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Is 'Operator Error' as Root Cause ever acceptable?

Helmut Jilling

Auditor / Consultant
I have a case where we have molded well over a million parts with zero defects for over six months. Several defective parts were found at our customer and we have determined that the reason the parts escaped was that a trained operator, who has done the job correctly for months, failed to scrap the required number of start up shots were the defect - short shots occurs.

He admits he did not follow procedure.

The occurrence of shorts at a start up cannot be eliminated, it is essential that parts not be saved until start up parts are purged.

IS the root cause operator error?
If it is not, how do you mistake proof this type of situation?
Wouldn't "a trained operator, who has done the job correctly for months, failed to scrap the required number of start up shots were the defect..." be a more useful root cause than simply "operator error?"

Admitably, it begs the question of "why," but it is a more useful statement than "operator error."
 
A

AirdrieQPA

There we go, I agree with this. I work for a defense contractor, and we repair F18 avionics, and I am also a retired Warrant Officer from the air force. We do a lot of research into every flight safety incident or potential incident. This will burst many bubbles here but in Flight Safety (remember folks I have been in this business now for 32 years) we do cite operator inattention as a root cause. Before any technician is allowed to complete work on there own the training and qualification sign off process is extensive, Military training records and qualification and skill requirements are very in depth. Flight Safety has determined that 'Brain Farts' do occur, and the fact that operator error has been cited does not mean the Flight Safety team was lazy and chose this assessment as a dumping ground. When we are calling an incident the result of error you can bet we shook the whole training tree to see what else fell out. In the end operator error is a very real and valid assessment. And yes mistakes in my field can be very costly, and they are very real, but they do happen, and there is great tragedy involved and I have lost friends due to operator error. You will never be able to convince me that operator error is not real and not valid. Companies that won't accept operator error as a reason are also companies that would pass failing school kids through the system as they want to be seen as telling someone they are not trying hard enough. That is just passing the problem on to some one else.
 

Jen Kirley

Quality and Auditing Expert
Staff member
Admin
There we go, I agree with this. I work for a defense contractor, and we repair F18 avionics, and I am also a retired Warrant Officer from the air force. We do a lot of research into every flight safety incident or potential incident. This will burst many bubbles here but in Flight Safety (remember folks I have been in this business now for 32 years) we do cite operator inattention as a root cause. Before any technician is allowed to complete work on there own the training and qualification sign off process is extensive, Military training records and qualification and skill requirements are very in depth. Flight Safety has determined that 'Brain Farts' do occur, and the fact that operator error has been cited does not mean the Flight Safety team was lazy and chose this assessment as a dumping ground. When we are calling an incident the result of error you can bet we shook the whole training tree to see what else fell out. In the end operator error is a very real and valid assessment. And yes mistakes in my field can be very costly, and they are very real, but they do happen, and there is great tragedy involved and I have lost friends due to operator error. You will never be able to convince me that operator error is not real and not valid. Companies that won't accept operator error as a reason are also companies that would pass failing school kids through the system as they want to be seen as telling someone they are not trying hard enough. That is just passing the problem on to some one else.
This is a very good contribution to the discussion. :applause:

What's needed is to avoid taking a short cut when arriving at the determination of "operator error" as root cause. The question posted by the error-proofing camp (which I am a happy member of) is "Ought this person at this point in the process have the ability to make a decision that can result in loss?" If a decision can be avoided through clarification, standardizing, staging, color-coding or some other method of ensuring little deviation due to a mental process is possible, then the "happy error-proofing campers" feel that's good.

Some processes can't be regimented. Some can be standardized, but the process people considered it regimentation. Some medical professionals balked at the notion of checklists in operating rooms until the data came in: appreciably fewer people left surgery with a sponge or utensil left in their gut. That principle may have been behind the pre-flight checklist too.

But I agree not everything can be controlled this way. We just need to understand what rightfully ought to be, and what rightfully ought not to be; and when thinking is required over standardization we should make sure we do all we can to allow the thinker to think clearly and arrive at the correct decision. We can do that with immediate things like adequate rest, and programmed approaches like Command Finance Specialist (to help service people in credit troubles).

I hope this makes sense.
 
T

TClose

Some response beyond "Operator Error" will be needed -- Ya' gotta have a fix. But I will say one thing along the lines of Micheal T's comment ... Once you have fully idiot-proofed your process, you will probabaly have idiots running your machines.
 
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Bev D

Heretical Statistician
Staff member
Super Moderator
Once you have fully idiot-proofed your process, you will probabaly have idiots running your machines.
that's a really clever saying but is unfortunately very misleading as it perpetuates many myths about error proofing. I would clarify that the real name for the activity is error-proofing. EVERYONE makes errors. if we equate making errors with idiots then we are all idiots.

Errors are unintentional actions. the intention of error-proofing is not to exclude or eliminate the skilled worker. In fact if we reduce or eliminate the ability to make errors or to prevent an error from creating a defect, we free up our skilled workers (and supervisors and engineers) to focus on real process improvements to our people processes and our physics processes. Chasing what amounts to human nature with fixes that are based in mythology, personal agendas or just plain lack of knowledge (such as disciplining the operator or 'retraining' them) is a waste of everyone's time.
 

Stijloor

Staff member
Super Moderator
that's a really clever saying but is unfortunately very misleading as it perpetuates many myths about error proofing. I would clarify that the real name for the activity is error-proofing. EVERYONE makes errors. if we equate making errors with idiots then we are all idiots.

Errors are unintentional actions. the intention of error-proofing is not to exclude or eliminate the skilled worker. In fact if we reduce or eliminate the ability to make errors or to prevent an error from creating a defect, we free up our skilled workers (and supervisors and engineers) to focus on real process improvements to our people processes and our physics processes. Chasing what amounts to human nature with fixes that are based in mythology, personal agendas or just plain lack of knowledge (such as disciplining the operator or 'retraining' them) is a waste of everyone's time.
Hats off to you Bev!! :applause: :applause:
 
T

TClose

Truthfully - the comment is meant as a warning, and the use of the term idiot is to make it more forceful. It came from my experience that operators get more disconnected from the process as more layers of inspection get added - including (and more typically) when the ultimate 100% automated inspection is incorporated. Detecting at the source, troubleshooting, awareness, and accountability all take a hit. Well thought out poke yokes plus visual feedback loops that integrate the operator work much better ... resulting in far fewer idiots running your machines.
 

Stijloor

Staff member
Super Moderator
Truthfully - the comment is meant as a warning, and the use of the term idiot is to make it more forceful. It came from my experience that operators get more disconnected from the process as more layers of inspection get added - including (and more typically) when the ultimate 100% automated inspection is incorporated. Detecting at the source, troubleshooting, awareness, and accountability all take a hit. Well thought out poke yokes plus visual feedback loops that integrate the operator work much better ... resulting in far fewer idiots running your machines.
Idiots are found at all levels!
 

J Allen

Involved In Discussions
We also see pilot error as a cause of a crash despite many hours of training, re-enforcement training, checklists, and other safeguards. An error can still be attributed to an operator. The review should be done to determine if one person can make this error, could another? Corrective action for "true" operator error is difficult to determine and apply. Poka yoke is not always a cost effective way to make something idiot proof. I wish some companys would take a more realistic approach to the C/A process then to get suppliers to write responses they think their customers want to hear instead of what really happened.
 

John Broomfield

Staff member
Super Moderator
We also see pilot error as a cause of a crash despite many hours of training, re-enforcement training, checklists, and other safeguards. An error can still be attributed to an operator. The review should be done to determine if one person can make this error, could another? Corrective action for "true" operator error is difficult to determine and apply. Poka yoke is not always a cost effective way to make something idiot proof. I wish some companys would take a more realistic approach to the C/A process then to get suppliers to write responses they think their customers want to hear instead of what really happened.
True, it costs a lot to redesign an aircraft's controls. Design shortcomings such as the co-pilot not being able to see what the pilot is doing to climb or descend in bad weather will be patched by more training until the cockpit is redesigned.
 
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