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Is 'Operator Error' as Root Cause ever acceptable?

M

Michael T

Are these similar parts, can they be located on different shelves/locations, this would eliminate the human element.
Yes... these are similar parts. They are arranged by P/N on the shelves based on diameter. We utilize these parts when we fabricate hose assemblies and we sometimes sell these parts to fabrication shops when they want to fabricate their own hose assemblies. Logistically, it wouldn't make any sense to locate them on another shelf. It would make picking parts ourselves difficult.

Cheers!!!

Michael
 

Helmut Jilling

Auditor / Consultant
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
I think the root cause is right in your own post, as Phil Fields already inferred:

...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.

If they are similar, and next to each other, there will be a possibility to mix them. Either separate them, mark them, make an extra step of awareness because they are similar, put an extra sign up...these are potential actions. The first ones are more robust than the latter ones...
 
M

Michael T

I think the root cause is right in your own post, as Phil Fields already inferred:

...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.

If they are similar, and next to each other, there will be a possibility to mix them. Either separate them, mark them, make an extra step of awareness because they are similar, put an extra sign up...these are potential actions. The first ones are more robust than the latter ones...
Thanks Helmut... Can't separate them... the bins are already marked but the parts can't be marked... I'll look into a secondary review prior to release for shipping.

Cheers!

Michael
 

Bev D

Heretical Statistician
Staff member
Super Moderator
well, in general a 'second look' isn't going to help much. especially with such a low occurrence rate. that's why most people are advocating moving the bins away from each other. (remember that the important part of bin location is to minimize the travel distance of the picker so very often there are few reasons to have physically similar parts next to each other)

Another option is to use color coding of the bins by some categorization that makes sense.

But since the effect and occurrence rate of this particular failrue is so low it may be helpful for us to know who isssued the corrective action? Was it a Customer or an internal person? Some 'problems' are so small that they are not worth addressing especially if your organization has other higher impact problems.
 

Helmut Jilling

Auditor / Consultant
Thanks Helmut... Can't separate them... the bins are already marked but the parts can't be marked... I'll look into a secondary review prior to release for shipping.

Cheers!

Michael
If the root cause centers on they are very similar and close together, then the antidote (action) needs to deal with the "very similar" or the "close together" part. Something to break that. Or, persuade the customer the risk is low since it happened once in several years.
 

Jim Wynne

Staff member
Admin
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
I don't know why everyone is so bent on blaming the system all the time, especially when a reasonable person says that he's looked at the reasonable options.

The only rational course of action is to politely tell your customer the truth: that the nature of the occurrence is such that formal CA isn't warranted, but that you'll be on the lookout for similar things in the future. If your customer poo-poos rationality, be irrational and make something up, because you can be sure that the problem isn't the picking error but the customer's own lack of insight.
 
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SteelMaiden

Super Moderator
Super Moderator
In this case I would write the investigation pretty much the way that you stated it here. No picking errors for three years, cost of these recent errors less than $10. You made the employee aware of the mistake so he would know. Due to the infrequency of the problem and the relatively minimal cost you will send the customer a replacement(s) but no further corrective actions will be performed at this time. Picking errors will be monitored to provide assurance that this was an isolated problem.:2cents:
 
M

Michael T

In this case I would write the investigation pretty much the way that you stated it here. No picking errors for three years, cost of these recent errors less than $10. You made the employee aware of the mistake so he would know. Due to the infrequency of the problem and the relatively minimal cost you will send the customer a replacement(s) but no further corrective actions will be performed at this time. Picking errors will be monitored to provide assurance that this was an isolated problem.:2cents:
Thanks Steel & Jim... I was leaning towards that approach. The only other alternative I could see is requiring the individual responsible for picking the parts measure the first one before pulling all parts. It just felt like swatting a fly with a sledge hammer given the dollar value vs the cost to implement a corrective action as well as the infrequency of the mistake.

I'll write it up that way and see if the customer will accept it.

Thanks again!

Cheers!!

Michael
 
Q

QC Rick

Remember that 100% inspection will not give 100% assurance that 100% of your products are 100% good. What it means is, 100% inspection in itself is not to be a feeling that "All is well".
The more rigorous this inspection becomes, the more problems it itself creates.
It is more about good process control, proper and scientific checks established at stages that give a good end output, and a scientifically established sampling plan to inspect that assures quality.
It should be Quality Assurance and not Quality Control.

jerry_Malaysia (2010)
100% error free is not possible, for ever.
You simply can not write a CA on human error. It's, illogical.
 
I'm kind of a "picky" guy [pun intended] - I presume from your description the parts are similar in configuration and size.
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.
Maybe the part numbers are also similar.

Do you have many parts similar in size and configuration? Are they in bins close to each other? Do you have a mistake proofing process (other than counting on a super alert order picker?)

Having been the idiot who pulled a dozen 3-inch lag bolts from the local self-service hardware store when I really wanted 3-1/2 inch bolts, I can empathize with the order picker, especially after I got up on the ladder and put the first bolt in, only to find it too short.

Despite the apparent small cost of the error, the real cost is in the soft costs of handling the error and the loss of confidence from a customer who expects perfection.

If it were my operation, I'd relook at my inventory layout and see if there were other opportunities for mistakes.

When I returned to my hardware for the correct bolts, I made one small suggestion they adopted the same afternoon - they put up laminated rulers and gages on each shelf of screws and bolts and nuts for customers and clerks to check on the spot without having to search around for a measuring instrument. (Incidentally it cut down on folks putting parts back in the wrong bins.)
 
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