Re: List operator mistake as the potential cause of failure
I strongly say all the problems need to be jolted down.
here we go....
Have a brain storming session, include operator,inspector,shift engineer,if possible manager aswell... make a note of all the possible reasons which may have lead to this problem..after its done eliminate the ones which may not have lead to this problem and then surely you will land up in having one major reason for the issue..and 99.99% of the times you find that there will be a loop hole in the system itself, I mean to say procedure not well defined, incapable operator working on the job, tools or fixtures not okay....and so on.... there should be a fool proof system or procedure or fixture...there should be room for the operator to assume things and work, everything should be crisp and clear....