M Greenaway said:
We cannot build a fail safe system, it is a state of perfection that we will never reach.
But should we blame the operator and ignore trying to improve the system ?
At what point do we say 'our system is good enough - the operator should not have failed, it must be their fault' ?
Just borrowed this from a previous post:
Of course, you're right about using "human error" as the last result of the investigation. I've addressed this scenario before, but a nicer version is:
Data Entry error results in incorrect part is sent to the Customer. This is a slip of the finger on the keys. We call it "happy fingers"
1st Why? "I made a mistake"
2nd Why? I made an error. Don't you get it?"
3rd Why? "Look, haven't you ever made a mistake? What was YOUR reason? Go see my Supervisor."
Supervisor is asked the 5th "why?". "The guy made a mistake."
6th Why? "He made a mistake. What do you want, blood?"
There comes a time when you get frustrated with the amount of time that is spent to come up with a good CA/PA. The customer understands mistakes, gets the right part and orders something else. He/she doesn't have a problem with it. After all, some Customers (those who admit it) also have employees who make mistakes.
Most problems are explainable, but occasionally there is no clear answer so you become "creative" with cause/preventive action just so you can get on with life. I also feel if you have enough people to throw at a problem, it's easier. Most small companies do not have the resources. I'll stop here because it's my pet peeve and I become emotional when it comes to overbearing large customers who demand action on anything, regardless of significance.
I would only add that asking 5 or more "Why's" can result in being sprayed with a pest
icide when you have been told from the beginning that it was a mistake. For those who would advocate "idiot proofing" the process, I say that it is not very compassionate to instruct HR to amend that hiring process to make sure that that they don't hire idiots!