Failure where the Root Cause was the Material Handler Not Following Procedure

qcman

Registered Visitor
#1
I had a failure where the root cause was the material handler failed to follow the procedure of comparing ID's of stock brought to a machine with what was set up and running at the machine. Parts look the same at this point except for a large ID stamped into the part. All loads,samples and work instructions were clearly and correctly marked and handler also has a copy of the daily schedule. He said he knew what part was going in but failed to notice what the machine was set up for. He follows procedures 99.9% of the time but this .01% may cost 10K. I don't like to use operator failure as a root cause but in this case I don't see it as anything but. Guess my question is are there times where we just except human error and that there is not *always* a corrective action for it?
 
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Randy

Super Moderator
#2
Re: Not following procedure

There is a series of commercials running on TV which I like because it stresses what I have always referred to as the only really uncontrollable variable in most endeavors and thats the HUMAN element (Hu). There is a great deal of truth in this when we think about it.

The only thing you can honestly do is, to the best of your or your organizations ability, stress and reinforce the importance of following requirements though whatever means are the most effective for you. That's it.

What we refuse, fail to acknowledge and accept is that as long as people are involved there is going to be deviation and the "F" word (failure). Even machines can fail because people create them (at least we do at this time in our history and this may change).
 

BradM

Staff member
Admin
#3
Re: Not following procedure

He said he knew what part was going in but failed to notice what the machine was set up for.

(Let me put my process cap on... ) How are you operators suppose to know how the machine are set up? Are there clear markers/postings? Is there a set-up document for the machine that is clear/understood by all? While this individual (by your accolades) is a very conscientious worker, will the next person be the same? Or, can your process be improved where it does not rely quite so much on individual characteristics, and standardizes the approach more? Have you walked through the process, and you feel fairly certain that the probability of this happening again is acceptable, for this and other individuals?

If your worker is as good as you say he/she is, and this one oversight cost the company that much, I think I would be having a power lunch to figure out simple but effective ways to minimize (alleviate) that happening again.

:2cents:
 

qcman

Registered Visitor
#4
Re: Not following procedure

Walk the process all the time and honestly it is very simple and well documented. Walk up to machine,look at sample part with tag containing job discription and part number,compare that to schedule in hand that list same info as part tag,if you know where parts are go there,check ID tag on load for correct part number and bring load to machine,if not sure whether job has been run out go to computer terminal and enter part number which displays part count at each step through out the process,if parts are ran out inform operator. This process takes place about 200 times a day plant wide.Do I think it can/will happen again? Yes. Problem is in this situation I am not seeing an error proof corrective.
 

Coury Ferguson

Moderator here to help
Staff member
Super Moderator
#5
He said he knew what part was going in but failed to notice what the machine was set up for. He follows procedures 99.9% of the time but this .01% may cost 10K. Guess my question is are there times where we just except human error and that there is not *always* a corrective action for it?
In my opinion, there is always a possibility of Human Error, and it can be a "Root Cause" but under normal circumstances, the Human Error factor can cause approx 5%-10% of the problem. The remaining percentage can usually be determined as a process error.

Since, the operator follows procedures 99.9% of the time, (I know some covers may not agree with me) I don't feel that a Corrective Action would be required. I understand that this .1% cost $10,000.

I might look at how the Machine could be identified to eliminate the possibility of this happening again (Mistake Proof).
 
D

Dean Frederickson

#6
After the material handler delivers the parts, why isn't there a procedure for the machine operator to verify that the correct parts have been delivered? It would seem that if you have same/similar parts that the operator would check the I.D. mark/stamp prior to running the newly delivered parts. Do this to avoid future financial losses. To answer your question yes I believe operator error was the root cause here if your material handler is as good as you say and this is a one in one thousand mistake I would change your work insructions or procedures to have a second verification/identification of correct parts by operator as a procedure or work instruction and use as C.A. / P.A. . Now you can use not having a second person check the part I.D. as the root cause a failure with the process.
 
Last edited by a moderator:
C

Cordon - 2007

#7
After the material handler delivers the parts, why isn't there a procedure for the machine operator to verify the that the correct parts have been delivered?
This seems simple enough, unless we are missing something. Operators should have a sense of "ownership" of his process and should be held accountable to ensure that he is running the correct parts. :2cents:

Flawed work process.
 

Gert Sorensen

Forum Moderator
Moderator
#8
Parts look the same at this point except for a large ID stamped into the part.
I'd be looking at our design procedure/and or the production lay out as well. If I were to evaluate this kind of product then I would be thinking about errorproofing in the design phase as well. Having basic items that can be used at the same equipment in different productions should something that could be evaluated by a risk analysis. You might look at Dell's way of assembling PC's for inspiration :cool:


All loads,samples and work instructions were clearly and correctly marked and handler also has a copy of the daily schedule. He said he knew what part was going in but failed to notice what the machine was set up for. He follows procedures 99.9% of the time but this .01% may cost 10K.
S... happens in production. If he's so consistent then one single failure should be forgiven. A lot of QA persons would like to have him at their manufacturing site :D
I don't like to use operator failure as a root cause but in this case I don't see it as anything but. Guess my question is are there times where we just except human error and that there is not *always* a corrective action for it?
Yup, I believe it can sometimes be the root cause, and basically the exercise here is to make it a learning experience for the involved parties here.
 
A

Aaron Lupo

#9
I had a failure where the root cause was the material handler failed to follow the procedure of comparing ID's of stock brought to a machine with what was set up and running at the machine. Parts look the same at this point except for a large ID stamped into the part. All loads,samples and work instructions were clearly and correctly marked and handler also has a copy of the daily schedule. He said he knew what part was going in but failed to notice what the machine was set up for. He follows procedures 99.9% of the time but this .01% may cost 10K. I don't like to use operator failure as a root cause but in this case I don't see it as anything but. Guess my question is are there times where we just except human error and that there is not *always* a corrective action for it?
I would take the individual out back and beat the living tar out of them!

Actually if you have a good system in lace for tracking little hiccups like this you should be able to justify that a corrective action is not needed. In my last place of employment we would track deviations and they would be reviewed monthly (or more frequently if needed) to see if there was a significant trend developing. If this is the first time it has happened or it has been an extended period of time since the last hiccup up I would just write it of as S#it happens and move on.
 

Jim Wynne

Staff member
Admin
#10
I have a simple question, and keep in mind that I'm one who believes that human error can be cited as a root cause in some cases. If the material is so easy to identify, why doesn't the operator make sure it's correct before processing it? One good way to mitigate human error is to add redundancy to the system, especially when it's fairly easy to do.
 
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