Informational Nonconformances and Defects - Operator Error, System Error, or both?

In the event of a NC or defect, what/who is at fault?

  • "The system" is always at fault.

    Votes: 8 13.3%
  • "The system" is at fault ~ 90-96% of the time.

    Votes: 19 31.7%
  • "The system ~ 80%", operator ~ 20%.

    Votes: 21 35.0%
  • It's about even.

    Votes: 12 20.0%

  • Total voters
    60
  • Poll closed .
Elsmar Forum Sponsor

CCaantley

Involved In Discussions
Oh dear. Throw the hapless employee under the bus...
I don't disagree. My bosses tend to blame employees first and foremost.

PM - "Why did you let that drill break in the CNC?"

Operator - "The CNC head just dropped! (Counterweight chain broke)"

PM - "So why didn't you stop it?"
 

Ninja

Looking for Reality
Trusted Information Resource
PM - "Why did you let that drill break in the CNC?"

Operator - "The CNC head just dropped! (Counterweight chain broke)"

PM - "So why didn't you stop it?"
Me: What did the drill cost? What estimated cost would PM or periodic replacement of the chain cost? When the head dropped, was it a safety threat to the employee? Did it risk significant damage to the machine? What other parts of the machine should also be considered for review/service/replace and how often and what cost?
 

CCaantley

Involved In Discussions
Me: What did the drill cost? What estimated cost would PM or periodic replacement of the chain cost? When the head dropped, was it a safety threat to the employee? Did it risk significant damage to the machine? What other parts of the machine should also be considered for review/service/replace and how often and what cost?
Exactly.
 

Sidney Vianna

Post Responsibly
Staff member
Admin
The response we got when asking what happened was "I don't know, I f-ed up." It wasn't the first mistake the shipping clerk made, but it was the biggest. The higher ups decided to find a new shipping clerk.
Obviously, I have no idea of what the true root cause of this wrong shipment is, but in the past, I have become aware of a few similar cases which the root cause investigation led to the (surprising?) fact that people doing menial jobs were totally illiterate and hid that from the employer for ages. Some, even worse, were illiterate and had terrible vision, so, even pictorial aids were useless to assist them with their work.

So, in that case, the system fault was failure to screen illiterate candidates and candidates with vision impairments during the hiring process.
 

Jim Wynne

Staff member
Admin
We need to think about what's meant by "The system is at fault." Although it seems obvious, it's not so simple. There are times when the system is indeed at fault, but changing it isn't economically feasible. If the failure level is very low and the impact of failure is negligible, it might make no sense at all to change anything. This won't prevent benighted customers from asking for corrective action, of course. On the other hand, it's possible to guard against human error to the extent that it's economically responsible to do so, but human error will still occur. In any system where human influence is necessary, human error is inevitable. It's all about deciding when it's economically responsible to do something about it.
 
It also occurs to me, triggered by Jim's post that problems which get to a customer aren't always as bad as they might seem. It can be the case that the manner in which an organization responds to their customers when things go awry is a huge confidence builder - they now know that if/when something doesn't go to plan, you are responsive to their needs. It helps build relationships, which is often overlooked.
 

John Broomfield

Staff member
Super Moderator
It also occurs to me, triggered by Jim's post that problems which get to a customer aren't always as bad as they might seem. It can be the case that the manner in which an organization responds to their customers when things go awry is a huge confidence builder - they now know that if/when something doesn't go to plan, you are responsive to their needs. It helps build relationships, which is often overlooked.
Andy,

Excellent point.

I absolutely agree with the wisdom of managing the relationship with customers carefully and closely through good times and well before bad times.

Managing the fulfillment of customer needs and requirements is a vital process. It may usefully refer to or include protecting the customer’s intellectual property when working as a contract manufacturer.

BTW, needs may be seen as undefined requirements.

John
 

CCaantley

Involved In Discussions
Obviously, I have no idea of what the true root cause of this wrong shipment is, but in the past, I have become aware of a few similar cases which the root cause investigation led to the (surprising?) fact that people doing menial jobs were totally illiterate and hid that from the employer for ages. Some, even worse, were illiterate and had terrible vision, so, even pictorial aids were useless to assist them with their work.

So, in that case, the system fault was failure to screen illiterate candidates and candidates with vision impairments during the hiring process.
I really hadn't thought of that.

It also occurs to me, triggered by Jim's post that problems which get to a customer aren't always as bad as they might seem. It can be the case that the manner in which an organization responds to their customers when things go awry is a huge confidence builder - they now know that if/when something doesn't go to plan, you are responsive to their needs. It helps build relationships, which is often overlooked.
It was a quick fix to get our customer the correct parts, and they weren't overly upset about it. It just hurt our external PPM a whole lot.
 
Thread starter Similar threads Forum Replies Date
Tagin Evaluating nonconformances for escalation using Bayesian methods? Statistical Analysis Tools, Techniques and SPC 2
G Differences - Nonconformances vs CAPA, Corrections vs Corrective Actions ISO 13485:2016 - Medical Device Quality Management Systems 16
R Extension of product nonconformances - Construction project Nonconformance and Corrective Action 7
I Audit Nonconformances - Can reported corrective actions be incomplete? ISO 9000, ISO 9001, and ISO 9004 Quality Management Systems Standards 8
J EU ISO 13485:2016 Recertification Audit - Effect of 10 Minor Nonconformances EU Medical Device Regulations 2
W Closing of Stage 2 Audit Nonconformances AS9100, IAQG 9100, Nadcap and related Aerospace Standards and Requirements 3
M User Errors and Product Nonconformances Nonconformance and Corrective Action 22
K Notified Body - Minor Nonconformances - They have withheld all certificates General Auditing Discussions 3
Q Several Nonconformances with same Root Cause with just one CA ISO 9000, ISO 9001, and ISO 9004 Quality Management Systems Standards 15
V 21 CFR 820 Compliant way to use Kaizen to address Nonconformances Nonconformance and Corrective Action 9
N Nonconformances in the Construction Industry Nonconformance and Corrective Action 6
T Perishable Tooling Supplier - Nonconformances and Metrics AS9100, IAQG 9100, Nadcap and related Aerospace Standards and Requirements 5
H NADCAP Audit Nonconformances - Vacuum Furnace Load Sensors AS9100, IAQG 9100, Nadcap and related Aerospace Standards and Requirements 1
L Internal Audit Nonconformances - Your opinion? Internal Auditing 8
M Supplier Nonconformances - Key Points to ask a Metal Stamping Supplier Supplier Quality Assurance and other Supplier Issues 7
L Insurance to cover for nonconformances ? Misc. Quality Assurance and Business Systems Related Topics 2
T Defining Nonconformances in a Service Organization ISO 9000, ISO 9001, and ISO 9004 Quality Management Systems Standards 6
C ISO 9001 Nonconformances an how to handle them ISO 9000, ISO 9001, and ISO 9004 Quality Management Systems Standards 4
N Second Registrar Visit to Confirm Major Nonconformances Fixed ISO 9000, ISO 9001, and ISO 9004 Quality Management Systems Standards 11
L Definitions for Minor & Major Nonconformances ISO 9000, ISO 9001, and ISO 9004 Quality Management Systems Standards 15
F Response to ISO 13485 Audit Minor Nonconformances ISO 13485:2016 - Medical Device Quality Management Systems 6
M Seven Document Review Nonconformances General Measurement Device and Calibration Topics 9
J KPI for time to close NCs (Nonconformances) Quality Manager and Management Related Issues 17
R Internal Audit Cancellation when Nonconformances are Found Quality Manager and Management Related Issues 13
J Question about GM special requirement - Open Major Nonconformances IATF 16949 - Automotive Quality Systems Standard 2
K CAPA Training for Process Nonconformances Nonconformance and Corrective Action 2
A Nonconformances and Rework in a Machine Shop Nonconformance and Corrective Action 6
Fender1 Nonconformances that do not require Corrective Action Nonconformance and Corrective Action 21
C Who does the Analysis of Nonconformances and other Data Analysis? Nonconformance and Corrective Action 23
T NonConformances as a Tool to Measure Employee Performance Nonconformance and Corrective Action 21
A Surveillance Audit Result - Multiple Audit Nonconformances ISO 9000, ISO 9001, and ISO 9004 Quality Management Systems Standards 5
B Suspension of ISO 9001 Certificate - Major Nonconformances Identified ISO 9000, ISO 9001, and ISO 9004 Quality Management Systems Standards 24
B The Distribution that represents the Severity of Nonconformances Nonconformance and Corrective Action 2
L Non Conformance Register (aka Tracking Nonconformances and Corrective Actions) ISO 9000, ISO 9001, and ISO 9004 Quality Management Systems Standards 8
J How many Major Nonconformances could let the Audit be Terminated? General Auditing Discussions 9
R ISO 13485 Surveillance Audit Nonconformances and Report Help Needed ISO 13485:2016 - Medical Device Quality Management Systems 9
A ISO 14001 Surveillance Audit Nonconformances ISO 14001:2015 Specific Discussions 6
J Corrective Action Timeframe for Internal Nonconformances Nonconformance and Corrective Action 14
R Is it useful to adapt PFMEA's with nonconformances? FMEA and Control Plans 4
P Boss doesn't want Nonconformances called Nonconformances in Internal Audit Reports ISO 9000, ISO 9001, and ISO 9004 Quality Management Systems Standards 72
C System Root Cause and CA (Corrective Action) for ISO 13485 Audit Nonconformances ISO 13485:2016 - Medical Device Quality Management Systems 3
M Can a KPI (Key Process Indicator) be created against Nonconformances? Nonconformance and Corrective Action 8
J Certification Body follow up on clearing Audit Nonconformances Registrars and Notified Bodies 4
M NCR and Cost Collection - Capturing nonconformances in the field Nonconformance and Corrective Action 1
Q CTC (Critical to Customer) vs. CTQs (Critical to Quality) Nonconformances Nonconformance and Corrective Action 6
A Escalating Minor Nonconformances into Major Nonconformances ISO 9000, ISO 9001, and ISO 9004 Quality Management Systems Standards 9
D NCRs (Nonconformances) allowed during ISO 9001 Recertification Audit General Auditing Discussions 21
P Is Blaming Operators for Nonconformances correct? Quality Manager and Management Related Issues 62
C CB Client Contract Agreement - Identifying nonconformances - AS9100 Registrars and Notified Bodies 7
R Are these Audit Nonconformances? AS9100, IAQG 9100, Nadcap and related Aerospace Standards and Requirements 9
Similar threads


















































Top Bottom