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Is 'Operator Error' as Root Cause ever acceptable?

R

Richard Pike

To what extent does pride stop employees from using their procedures?

John
Do you mean "because you are supposed to know" you dont refer to the instructions. Like a guy who refuses to get a map out when lost!

Or do you mean "you want to do it your way" and dont like to follow instructions from others? because you know better!
 
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John Broomfield

Staff member
Super Moderator
Do you mean "because you are supposed to know" you dont refer to the instructions. Like a guy who refuses to get a map out when lost!

Or do you mean "you want to do it your way" and dont like to follow instructions from others? because you know better!
Could either of these prideful reasons result in employees not using their procedures?
 

AgnieszkaSz

Involved In Discussions
We have a problem currently with operators not following the instructions - the problem occurs in project-driven production (not serial or even short series, mind), so the assumption was taken that poka-yoke will not be cost effective. I could argue this, comparing the poka-yoke costs with bad quality (internal and external) costs - but never mind. I see a big problem - how we could effectively transfer a huge amount of knowledge? This is a complicated hand assembly. Operators are demotivated by seeing an instruction of, say, 10 pages. And there are dozens of them, appropriate for specific products, components or operations.
That can be one reason of not following the procedures, too. When people asses the process of GETTING TO INFORMATION too tiresome and time-consuming; although the information is available.
 

John Broomfield

Staff member
Super Moderator
We have a problem currently with operators not following the instructions - the problem occurs in project-driven production (not serial or even short series, mind), so the assumption was taken that poka-yoke will not be cost effective. I could argue this, comparing the poka-yoke costs with bad quality (internal and external) costs - but never mind. I see a big problem - how we could effectively transfer a huge amount of knowledge? This is a complicated hand assembly. Operators are demotivated by seeing an instruction of, say, 10 pages. And there are dozens of them, appropriate for specific products, components or operations.
That can be one reason of not following the procedures, too. When people asses the process of GETTING TO INFORMATION too tiresome and time-consuming; although the information is available.
Agnieszka,

Agreed, using the 10 page work instruction to hammer the official plan into the brains of the operators probably will not be effective.

If the problem is not costly enough to invest in mistake-proofing then why not ask the operators to develop their own plan of assembly in the form of photographs, diagrams, cartoons, audio clips, video clips and other media?

They may also come up with inexpensive mistake-proofing ideas.

Perhaps require new operators to create their own version of the plan/instruction to evaluate and verify their understanding from the training in the whys and hows of the assembly process and its controls.

Is the team self-directed so the process is monitored and evaluated for ongoing conformity of the process and effectiveness of the plan/work instruction?

Enable progress this way and the operators may motivate themselves to use their aids to getting the assemblies assembled faster and right the first time.

John
 
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R

Richard Pike

Agnieszka,

Agreed, using the 10 page work instruction to hammer the official plan into the brains of the operators probably will not be effective.

If the problem is not costly enough to invest in mistake-proofing then why not ask the operators to develop their own plan of assembly in the form of photographs, diagrams, cartoons, audio clips, video clips and other media?

They may also come up with inexpensive mistake-proofing ideas.

Perhaps require new operators to create their own version of the plan/instruction to evaluate and verify their understanding from the training in the whys and hows of the assembly process and its controls.

Is the team self-directed so the process is monitored and evaluated for ongoing conformity of the process and effectiveness of the plan/work instruction?

Enable progress this way and the operators may motivate themselves to use their aids to getting the assemblies assembled faster and right the first time.

John
Now that is constructive ! :applause:
 

Helmut Jilling

Auditor / Consultant
We have a problem currently with operators not following the instructions - the problem occurs in project-driven production (not serial or even short series, mind), so the assumption was taken that poka-yoke will not be cost effective. I could argue this, comparing the poka-yoke costs with bad quality (internal and external) costs - but never mind. I see a big problem - how we could effectively transfer a huge amount of knowledge? This is a complicated hand assembly. Operators are demotivated by seeing an instruction of, say, 10 pages. And there are dozens of them, appropriate for specific products, components or operations.
That can be one reason of not following the procedures, too. When people asses the process of GETTING TO INFORMATION too tiresome and time-consuming; although the information is available.
What I see in your post is trying to solve a problem where you have not determined the root cause. Unless you determine WHY they are not following it, you can only guess at solutions. More research is needed why they are doing these things, then make solutions to solve those causes, while involving them in defining the solutions. For example, if the instructions are too complicated, if that is the root cause, then work with them to make them less complicated. But, ISO says start with the root cause, not by guessing solutions.
 
S

samsung

Operators are demotivated by seeing an instruction of, say, 10 pages. And there are dozens of them, appropriate for specific products, components or operations.
That can be one reason of not following the procedures, too. When people asses the process of GETTING TO INFORMATION too tiresome and time-consuming; although the information is available.
In addition to what others have advised, you may find this illustration useful which, I know, will not solve the problem but can provide an insight into the practical difficulties that people face while following the prescribed procedures and patterns.
 
M

Michael T

Time to resurrect this lovely little thread because I'm stumped.

Situation: We received a request for Corrective Action due to a picking error. We haven't had a picking error in over 3 years. There were 6 pieces on one line item that were mis-picked for a total value $9.60.

Procedures are clear, employee is more than adequately trained... I can find no hole in the process... he simply grabbed the wrong part... instead of grabbing 6 pieces of part ABC, he grabbed 6 pieces of part BCD which are very close in size to part ABC.

I can't go through and find out how many PPM's that equates to... there is no way to track that data. As these parts are not high volume parts nor high value, management is not going to go for installation of some elaborate bar coding or RFID system.

My question for this august body of quality folk... What is my root cause other than a "Picking Error" and what could I possibly write as a corrective action other than "counseled employee"?

Your advice is greatly appreciated!!

Cheers!!

Michael
 
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