Non-conformances due to Human Error

N

nurhakim

#1
Hi,

I would like to get your opinion regarding this. Recently we receive a complaint regarding packing defect which is-product was packed in different size boxes.
We investigate and come to conclusion that it was due to human error when no evidenced from QC & QA records showed that we experience such defects.

So our corrective action was retraining of operators. However it seems that customer is still not happy with the solution. How far do you think that this CA is acceptable and can satisfy the customer, with the fact that it will not reoccur in the future.

Thanks,
Nur
 
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Chennaiite

Never-say-die
Trusted Information Resource
#2
Hi,

I would like to get your opinion regarding this. Recently we receive a complaint regarding packing defect which is-product was packed in different size boxes.
We investigate and come to conclusion that it was due to human error when no evidenced from QC & QA records showed that we experience such defects.

So our corrective action was retraining of operators. However it seems that customer is still not happy with the solution. How far do you think that this CA is acceptable and can satisfy the customer, with the fact that it will not reoccur in the future.

Thanks,
Nur
Train your Operator thousand times or even more. Still on a given day such errors could happen, because Training plugs lack of awareness and not lapse of concentration which let us agree that cannot be completely eliminated. The best option is to make your process insensitive to lapse of concentration.
Some food for thought:
Why not standardize box sizes?
What business the different size box had in the location where you packed this product?
Why was it not detected before delivery?
Ask the operator, he might have some ideas too.
 

Hileen

Starting to get Involved
#3
Train your Operator thousand times or even more. Still on a given day such errors could happen, because Training plugs lack of awareness and not lapse of concentration which let us agree that cannot be completely eliminated. The best option is to make your process insensitive to lapse of concentration.
Some food for thought:
Why not standardize box sizes?
What business the different size box had in the location where you packed this product?
Why was it not detected before delivery?
Ask the operator, he might have some ideas too.
Is there a dedicated material list for the specific product that was packed? Were the different size cartons issued incorrectly from the store? Item numbers? Are checks in place to check all dry goods issued to production line prior to start- up of production?
 
R

RLewing

#4
Hi, Nurhakim

There might be several other things you could do - depending on your case, but the first question is: How much costs to the customer comes from this potentially repeating error? Is it worth additional preventive costs?

You might consider poka yoke (Mistake Proofing) by designing boxes that can only have the correct product and number (if possible). Or having "more eyes" - a separate person bringing in the products and the packing material, which then needs to be checked by the packer. Or having a separate out of the box audit (OBA) at the end, that is someone coming finally and opening and checking one random package.

But first, think of what is the cost of error?

BR Raimo
 
N

nurhakim

#5
Train your Operator thousand times or even more. Still on a given day such errors could happen, because Training plugs lack of awareness and not lapse of concentration which let us agree that cannot be completely eliminated. The best option is to make your process insensitive to lapse of concentration.
Some food for thought:
Why not standardize box sizes?
What business the different size box had in the location where you packed this product?
Why was it not detected before delivery?
Ask the operator, he might have some ideas too.
Hi,

thanks for your speedy thought, all boxes are well identified with size, it is just the matter of operators' awareness in picking up the correct product size to pack inside the correctly issued boxes.

In this case, of course, there is possibility that the workplace is not organized in such a way that the product can be well identified (e.g. labeling), thus causing this error.

But how far retraining can be the best solution, and customer are willing to accept it. So far other initiatives taken was-1) reorganize the work place, 2) labeling for identification 3) checklists for verification by the operators that they are using correct box and product.

Thanks,
Nur
 

harry

Super Moderator
#6
.............................. We investigate and come to conclusion that it was due to human error when ...................
Not sure about elsewhere but in Malaysia, this seems to be a favorite excuse probably because the operators are at the end of the queue of a finger pointing exercise.

which is-product was packed in different size boxes. .......................
This is evidence that there should be a few more 'whys' after human error


..................... However it seems that customer is still not happy with the solution. ...............
I think customers are not interested in what appears like a 'blame game' but would like to see some things done at the system level to prevent or at least minimize the occurrence of similar cases in the future. The other posts above do contain some good suggestions.
 
Last edited:

AMIT BALLAL

Trusted Information Resource
#7
Hi!!!!!!

Human error cannot be the root cause, as you need to work on error proofing so that errors cannot be made by a human. If anything goes wrong, it means system has failed somewhere (Not human).

If you think, "Operator was not aware about how to perform a specific task", then ask further why : " Why training was not given to the operator? ". Then you might get the root cause / if not ask further why to find out the final root cause.

I hope this might help!

Thanks,
Amit
 

ckillam3

Starting to get Involved
#8
What is the answer when the operator ignores the instruction or chooses to perform the task differently than the instruction?
 

AMIT BALLAL

Trusted Information Resource
#9
What is the answer when the operator ignores the instruction or chooses to perform the task differently than the instruction?
Ask why further: "Why he didn't follow the instruction / procedure?" Again, if you take action on cause: "Operator didn't follow the instruction", your problem won't get solved & will repeat again. It would be a disposition action, not a corrective action- as it is not the root cause.


Thanks,
Amit
 

somashekar

Staff member
Super Moderator
#10
Hi,

thanks for your speedy thought, all boxes are well identified with size, it is just the matter of operators' awareness in picking up the correct product size to pack inside the correctly issued boxes.

In this case, of course, there is possibility that the workplace is not organized in such a way that the product can be well identified (e.g. labeling), thus causing this error.

But how far retraining can be the best solution, and customer are willing to accept it. So far other initiatives taken was-1) reorganize the work place, 2) labeling for identification 3) checklists for verification by the operators that they are using correct box and product.

Thanks,
Nur
Retraining is a constant reinforcement, and as the world keeps on changing, what is good today may not be good tomorrow.
Retraining is always supportive, but a higher level corrective action is a system level corrective action.
Let us be sure that we are not here to eliminate human error, but to put in systems which helps people to do tasks (productive tasks) with minimum of induced errors.
Remember that if a boatman wants to sink his boat, there is no need of any hole in the boat which would sink it. A good boatman will certainly try to save the boat even if a hole appeares. Our corrective actions should plug as many holes as discovered securely and also see situations where a hole can likely happen in future and prevent it from happening.
 
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