Interesting Read Human Factors as Root Cause

Edward Reesor

Quite Involved in Discussions
#11
I don't believe "operator error" would be accepted by an auditor looking through our CAPA records. As stated above, you have to dive deeper to address why there was operator error.

One of my guilty pleasures is watching endless re-runs of the (Canadian) TV show Mayday (different titles in different countries). Because it deconstructs aviation disasters, it reveals the multi-faceted approaches to system failure. Despite being one of the safest industries in the world, it reinforces why we need to ask "why" many times before we unveil the root cause of the issue.
 

Ninja

Looking for Reality
Trusted
#12
Been re-reading "The Martian" recently and one interaction seems apropos:
A man stranded on Mars with no means of communication...interaction paraphrased...

How many radios did we send?
Four
So how could this happen?
Total lack of imagination...we never imagined a person would be on Mars without a ship to leave on. Never saw it coming. When the ship left, four radios became one...and it broke.

Human error will always be with us...zero is unattainable, and always will be.
But zero is by far the best target to shoot for...
 

Miner

Forum Moderator
Staff member
Super Moderator
#13
Many errors are caused by conditions that exacerbate the probability that the error will occur. Eliminating these conditions may not totally eliminate the error, but will reduce the frequency of occurrence. The attached images list a number of these conditions.
 

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Bev D

Heretical Statistician
Staff member
Super Moderator
#14
Interesting list - it from a safety perspective and this is highly analogous to human errors that result in defects. many on the list are causes that could be lumped into one resulting behavior - not paying attention. One thing that I found missing in the list is the system that that operators must operate under and the latent 'accidents waiting to happen' that trip up those who aren't paying attention and even some who are. posting a sign or monitor or equipment part that is lower the top of the head of the tallest operator AND is in a direct travel path. two parts of very similar shape size and color sitting next to each other on an assembly station.

employees makes mistakes and errors because they can. it is management's job to take away the latent defects in the system.
 
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