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 .
M

Michael T

Circular Logic?

Okay - let me propose this logic flow:

1) All humans are fallible.
2) Systems are designed by humans.
3) Systems are fallible.

(We could discuss the proposal that, theologically, there was one infallible human - but I'm not going there...)

In Deming's equation, the person cannot be separated from the system - therefore, you cannot blame the person as a root cause of a non-conformance. However, all systems are inherently flawed because they are designed by humans --

So, my root cause is always human error.

My corrective action - remove all humans.

Let's see how much work gets done now... :smokin:

Aren't these exercises fun?

:biglaugh:
 
E

energy

What? Me worried?

Kevin Mader said:

1. Often, it means blaming the fallible human. Let’s face it: if we didn’t live in a time where the Management Philosophy wasn’t fixed on laying blame or ruling by fear, more folks would be like energy – willing to accept it.

2. By focusing on just improving individuals, we loose the forest in the trees and ultimately end up with the same level of quality, or worse.

3. Was Poor Joe influenced by another System Component that we overlooked? Or was it within himself to avoid the error, and if so, why didn’t he?

Regards,

Kevin

4.Or did the guy just build it in the wrong spot?

1. Blame the individual if he/she is at fault. You are assuming that there is a problem with the system. I'm telling you that is not always the case. It also has nothing to do with acceptance of a system that focuses (fear) blame on the employee for everything. Is that how it is in your company? I can assure you that it has been tried here and elsewhere and the employee has been deemed "innocent" due to no defined procedure and acceptance criteria, several times. And, you can't frighten me!
2. If the employee needs counseling, so be it. This forest and the trees thing is not applicable. Actually, I'm pretty good at identifying the problem trees in our forest. Some need pruning and some just have to be cut down so that the other trees might grow.

3. Joe may have been under the influence, but it wasn't a system component. He didn't avoid the error because he is human and no cost effective or amount of error proofing could help him. The only error proofing that I could think of, in some cases, is to have someone else do his/her job.

4. The employee built the windmill against the face of a granite cliff. But, someone gave him the plans, right? The system failed because they allowed an incompetent engineer to draw up the plans? More like, the wrong Engineer. :bonk: :ko: :smokin:
 
S

Steve MacDonald

I think therefore I have operator error?

I agree that every root cause could (or possibly even should)eventually end in operator error if the journey to that conclusion reveals truths that will aid in a fair and proper action. But should it always be called that?

Your arguments are all compelling. But I find myself drawn into the discussion (and at much risk) because while the debate may not hinge on this factor, we have to remember that the "operator" as a system variable, is also a person, and as such, will react to stimulas accordingly. (aka Morale)

(Maybe it's there parents fault.) Mr. Johnson, my names Steve MacDonald, and I'd like to audit your relationship to your daughter. She's having problems at work.

That system variable (I cringe to say this: feelings) should have relevance in this analysis in so far as realizing what it would be like to work in that environment, and its global impact on the company, and I would hazard, the entire oject of a quality system.

If we (I) hope to seek approval, assistance, (God forbid--an actual embracing of any quality system by anyone) in an environment where everything, regardless of the breadth or depth of the evaluation, results in some operator being fingered for everything that goes wrong we must certainly be mad.

What are the side affects to that kind of company (quality) culture? Operator error "implies" incompetance. It may be true but is it wise (tactful) to proceed in such a manner, or to espouse a system with such an emphasis, management sanctioned or not? Would you want to work there? Would you want your friends to work there? Your enemies?

I'm still new to this, and you'll proablt beat my a** for adding my two cents but there it is. (Ka-ching!)

Steve (Waiting patiently for his beating)
 
E

energy

No beating

Steve,

I have asserted all along that someone has to screw up to bring about the investigation of what went wrong and it was reported. I also said that the system is agressively assessed, first. The employee's mistake is always viewed as a system weakness. Only having determining that the system has worked for everyone else and is not in need of modification, does it make sense to call it what it is. Human error. It happens. To shade it as something else, out of compassion for the worker bee, is dishonest and serves no purpose except to avoid the real reason. If I accepted the idea that all errors I commit are due to system failure, I'm ducking responsibility for my feck ups! That's English. :vfunny: "I made the mistake because I'm so busy due to a lack of sufficient resources which would allow me to work at my own comfortable pace." Or, "Maybe I need some training in Time Management". These are stretches and amount to excuses for not accepting what is common to all of use (Those who admit it). People make errors and sometimes they are huge.
One more time, my issue is with those that never accept human error as a possibility and refuse to call it that for root cause. It does become an "incompetency" issue if the mistakes are made repeatedly, by only the same person. For the occasional slip up, employee error, IMO is acceptable root cause.
Example: We recently had an error that resulted in a Sales Person
released an incorrect order. Subsequent discussions with the Customer revealed the miscommunication. The person said, "I have a thousand excuses, but none of them are good enough. I just fecked up". What do you do? He cut 15 orders that day, according to the established system, and botched one.
Somehow this thread has turned into "abusing" the poor employee without looking at the system. Not so. It's just candy coating previous posts that insist the system is at fault thereby poo pooing "Operator/employee error" as an accepted root cause.

I, for one, enjoy your posts. Never be worried about getting beat up. Contrary to some beliefs, nobody is smarter than the next one here in the Cove. It's just a matter of cutting through the smoke and mirrors! Abbracadabbra?. Presto! I'm gone.:agree: :smokin:
 
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Kevin Mader

One of THE Original Covers!
Leader
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Mike,

Weather systems...now there is a confusing system to dissect!!

energy,

I'm not sure my comment on fear came out the way I meant to state it. Where fear is prevalent, folks are often overly defensive, even when they don't need to be. My guess, based on your comments in this thread, is that you will take the blame easier than most. My feeling is that your comfort level (pain threshold?) is higher than most.

4.) I was thinking about a windmill placed in an open plain. It sits next to a small home and was erected by the homeowner, a farmer noless.


Kev
 
D

db

error and incompetence

My boss says I am the best example of the Peter Principle that he has ever witnessed. Did he make an error, or am I incompetent?
 
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D

D.Scott

LOL Dave

That depends on whether or not you have stopped climbing.

He may be meaning you are good at whatever you are doing and still haven't risen to the top.

Remember it is the "Peter Practice" that elevates you past the level of your incompetence then demotes you. As long as you are still working on the "Principle" part, I would say you have nothing to worry about.

Who knows, it may be your boss who is about to experience the "Practice" end.

Thanks for the laugh. Have a nice holiday.

Dave
 
E

energy

I'm not sure

The Peter Principle was first introduced by L. Peter in a humoristic book (of the same title) describing the pitfalls of bureaucratic organization. The original principle states that in a hierarchically structured administration, people tend to be promoted up to their "level of incompetence". The principle is based on the observation that in such an organization new employees typically start in the lower ranks, but when they prove to be competent in the task to which they are assigned, they get promoted to a higher rank. This process of climbing up the hierarchical ladder can go on indefinitely, until the employee reaches a position where he or she is no longer competent. At that moment the process typically stops, since the established rules of bureacracies make that it is very difficult to "demote" someone to a lower rank, even if that person would be much better fitted and more happy in that lower position. The net result is that most of the higher levels of a bureaucracy will be filled by incompetent people, who got there because they were quite good at doing a different (and usually, but not always, easier) task than the one they are expected to do.

db,

Sounds like he is saying that you are "maxed out". As for being demoted, this says you're all set. You have achieved the highest level of the bureacracy...but not to worry. Your boss is at the pinnacle, which makes him the Peter Principle Peter, so there's still room for you to climb to another level of incompetence. :vfunny: Have a happy.

:ko: :smokin:
 
J

jaimezepeda

It has taken me a couple of days to wade through this thread and I decided to vote for choice #2 - system is at fault almost always. I work for a service organization where automating much of the work is not feasible. We (my employer and the customer) trust competent employees to carry out their assigned tasks as they have been trained.

Jaime
 
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