Is 'Operator Error' as Root Cause ever acceptable?

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bpugazhendhi

You said your son did so only once and then he learnt his lesson. Much the same way the workers also do. Unsafe working condition makes accident. Once bitten twice shy!
 

Jen Kirley

Quality and Auditing Expert
Staff member
Admin
You said your son did so only once and then he learnt his lesson. Much the same way the workers also do. Unsafe working condition makes accident. Once bitten twice shy!
Yes - it is a classic lesson about how a small action (or inaction) can have very big consequences.
 

harry

Super Moderator
Oh! Pick me! :mad:

:topic: My son totaled his car about three hours ago. He missed a country road turn while driving too fast and tweedling with his stereo or something.

Yeah, he's all right (thank the Maker). And he only did it once. But once was enough. Now he's walking......................
I saw the picture in your album - it is bad. Thank god, he's alright. If only these youngsters can show some empathy for their parents (I too have a son who love fast cars).
 

Jen Kirley

Quality and Auditing Expert
Staff member
Admin
I saw the picture in your album - it is bad. Thank god, he's alright. If only these youngsters can show some empathy for their parents (I too have a son who love fast cars).
Yes, very bad - He'll be a walking seat belt commercial now, I expect. That and airbags saved him. Sorry to derail the thread.
 
You said your son did so only once and then he learnt his lesson. Much the same way the workers also do. Unsafe working condition makes accident. Once bitten twice shy!
Well. . . "shy" or DEAD, if you are handling cobras, mambas, or kraits!:mg:

Mistakes in coal mines, deep sea oil rigs, steel plants, sulphuric acid plants, and many other industries can make you just as dead.


Questions:
Does true awareness of the danger make a worker more alert or more complacent?
Should fear of deadly consequences be a central part of training?

I've often asked myself if training programs which emphasize deadly consequences are more effective than the ones which don't. What do you think? Some examples which come to mind:

  1. smoking - viewing/interviewing cancer patients, viewing autopsies and diseased organs
  2. driving - viewing mangled bodies at accident scenes, morgues
  3. drug and alcohol use - seeing dead addicts and interviewing live addicts and surviving family members and friends
  4. criminal behavior - "scared straight" programs - visiting jails, interviewing prisoners
 
Last edited:

Helmut Jilling

Auditor / Consultant
Oh! Pick me! :mad:

:topic: My son totaled his car about three hours ago. He missed a country road turn while driving too fast and tweedling with his stereo or something.


Yeah, he's all right (thank the Maker). And he only did it once. But once was enough. Now he's walking.
  1. He knew he should be cautious on these country roads - it was close to home.
  2. The weather was perfect and no sun was in his eyes.
  3. No animal ran in front of him.
He was just experienced enough to ignore or mentally suspend, just for a couple of seconds, established rules of the road (slow down on those curves, watch the road, both hands on the wheel).

I think mishaps in the workplace happen much the same way: enough familiarity combines with momentary distraction to cause one thing to go wrong in a time and place where everything needs to go right. And, boom. One is doing the 5 Y's.
Well, thank God he's OK. He gets another chance (and, apparently lots of exercise...)

And add #4 - forgetting to focus at the critical points in the process where errors are most likely to occur. That same fiddling with knobs would likely have been a non-issue if on a stright part of road.

I liked to corner hard as a youngster, (I am sure I am better now...), but tried to always understand and practice that hard cornering times were not the times to sip coffee, change CDs, answer phones, etc.
 

Helmut Jilling

Auditor / Consultant
...The old "operator error" debate and misunderstanding. In ther earlier part of the quality movement, the stock answer was always "the operator made an error..." which led to an action something to do with "the operator was scolded... trained... shot at sundown... fired..."

That led to an effort to reduce "operator error" as an answer, because it rarely was actually the root cause, and when that was the answer, the investigation never discovered the true root cause.

However, that trend led to a point of view of some that "operator error" was never a legit answer. That is probably going too far, because there may be some cases where that really was sufficient. But, few and far between, and only after the other causes have been investigated.

Sort of like a homicide detective may conclude a fatality was accidental, but only after all more significant clues have been investigated and ruled out.
 

Jen Kirley

Quality and Auditing Expert
Staff member
Admin
Well, thank God he's OK. He gets another chance (and, apparently lots of exercise...)

And add #4 - forgetting to focus at the critical points in the process where errors are most likely to occur. That same fiddling with knobs would likely have been a non-issue if on a stright part of road.

I liked to corner hard as a youngster, (I am sure I am better now...), but tried to always understand and practice that hard cornering times were not the times to sip coffee, change CDs, answer phones, etc.
Yes, thank you. I am thankful too. Really.

Such things come with experience, one would think - learning when and where to not fiddle with stuff. But I also once read that most accidents occur within 25 miles from home (like this one). Familiarity is said to play a role, also just not being mentally engaged - yet or ever - because one is just doing a small errand or whatever.

We had just finished pressuring him to go apply for a job at a restaurant on his way to play music at his friend's house. He may have been speeding because he was mad about our nagging. People very often take unneeded risks when emotionally impacted. Some employers understand that, and invest in making services available to employees, like financial or personal counseling. The Navy tried to have a Personal Finance Counselor on board ships - I was one - to help sailors deal with creditors and reduce accidents and errors on the job.

And so we really are all too often one arm movement away from horror. What we do, when we're properly about it, is to reduce risk. Taking care is one important way.
 
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