Operator Error - Fact or Fiction?

Wes Bucey

Quite Involved in Discussions
#1
Here's my take:
"operator errors" come from two sources:
  1. intended error (sabotage)
  2. management failure to provide training, tools, and processes to eliminate the chances for confusion by operator, resulting in a nonconforming product.
Once you are able to eliminate intended sabotage from the cause, you are left (as Sherlock Holmes would say) with the answer, no matter how improbable to believe, that the management is at fault for not eliminating "opportunities for error."

Sometimes, management needs outside help in identifying and remedying the problem, but most often, the solution is to merely ask the workers, "what can we do to help you prevent making such errors?"

Good sources to look at for clues to possible glitches in your processes which can be eliminated include:
http://dept.lamar.edu/industrial/Underdown/org_mana/The_Red_Bead_Experiment.htm
http://www.campbell.berry.edu/faculty/jgrout/pokayoke.shtml
plus, google the terms "mistake proofing" and "Poka Yoke"

I hope this helps - come back and keep us up-to-date on your progress.
 
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Jim Wynne

Staff member
Admin
#2
Wes Bucey said:
"operator errors" come from two sources:
  1. intended error (sabotage)
  2. management failure to provide training, tools, and processes to eliminate the chances for confusion by operator, resulting in a nonconforming product.
This is a false dichotomy, based apparently on the fanciful belief that there are not times when it is impossible to eliminate human error, and there are other times when it is not fiscally responsible to do so.
Wes Bucey said:
you are left (as Sherlock Holmes would say) with the answer, no matter how improbable to believe, that the management is at fault for not eliminating "opportunities for error."
I fully believe that management is responsible for most process problems but even Deming estimated "only" 85%. If that number is accurate, do you ascribe the remaining 15% to sabotage?

In my opinion, two of the greatest myths in manufacturing are that human error can be eliminated or consistently predicted in all manufacturing processes operated by humans, and that "zero defects" is a reasonable goal. When we formulate plans based on mythical presuppositions, we shouldn't be surprised when the unpredictable happens.
 
D

David Hartman

#3
QChas said:
Remember there are no "Oerator Errors" ..... only "Management Errors". If the procedures are not adequete change them. If they are then it is managements responsibility to make sure they are followed. Allowing the inmates to run things is not the answer!
Is it just me, or isn't there just a bit of irony in this statement as it is presented here?

If there is no such thing as "Operator Error", what "Management Error" contributed to the typo in this posting (or was it sabotage)?
:D
 

Wes Bucey

Quite Involved in Discussions
#4
JSW05 said:
[/list]This is a false dichotomy, based apparently on the fanciful belief that there are not times when it is impossible to eliminate human error, and there are other times when it is not fiscally responsible to do so.

I fully believe that management is responsible for most process problems but even Deming estimated "only" 85%. If that number is accurate, do you ascribe the remaining 15% to sabotage?

In my opinion, two of the greatest myths in manufacturing are that human error can be eliminated or consistently predicted in all manufacturing processes operated by humans, and that "zero defects" is a reasonable goal. When we formulate plans based on mythical presuppositions, we shouldn't be surprised when the unpredictable happens.
Good points. So, with your take on the situation, the original poster could eliminate about 85% of his current nonconformances by fine tuning the management functions, huh? That seems like an admirable goal to me!
 
Last edited:
R

Randy Stewart

#6
Interesting discussion.
Wes, how do we eliminate human error? Is it by eliminating the human then? If so would that be the human management for confusing the operator or the human operator for making a mistake?
Let's get back to the real world here. With all the training that the members here have had, do we still make mistakes? Is it our General Managers fault for not providing adequate training? Is it the fault of the university for not having adequate corriculum?
I think we are back to the argument where we blame the bartenders for people driving drunk, or we blame the fast food place because we eat too much junk.
I agree that management is responsible to ensure the operators have appropriate equipment, but I don't see where it is value added to have a second set of eyes to ensure they don't make mistakes.
 

Wes Bucey

Quite Involved in Discussions
#7
OK, OK! I was being a little facetious.
The point to be gleaned by reading between the lines of most of the posts here is that management's design of the process and the tools and training have an incredible amount of effect upon "error rate." Employees do not have the power to change the process - only management has that power.

If you are not familiar with Deming's Red Beads, you should be before trying to "correct" employee errors.

Often, managers are too myopic to see the process glitches which contribute to errors. They compound the problem by unilaterally determining ALL problems are employee or operator based. They never consult with the operators on "how" to change the process to eliminate opportunities for error.

In most cases, the situation could be alleviated by a REAL "root cause investigation." Major drawback: many managers do not perform root cause investigation in a systematic, scientific way and therefore never really get to the root cause of a problem.

Until a manager with authority has the AHA! moment (when he says "AHA! That's the reason things are not getting fixed!), nothing will improve and morale will continue to go downhill.
 

Jim Wynne

Staff member
Admin
#8
Wes Bucey said:
OK, OK! I was being a little facetious.
The point to be gleaned by reading between the lines of most of the posts here is that management's design of the process and the tools and training have an incredible amount of effect upon "error rate." Employees do not have the power to change the process - only management has that power.

If you are not familiar with Deming's Red Beads, you should be before trying to "correct" employee errors.

Often, managers are too myopic to see the process glitches which contribute to errors. They compound the problem by unilaterally determining ALL problems are employee or operator based. They never consult with the operators on "how" to change the process to eliminate opportunities for error.

In most cases, the situation could be alleviated by a REAL "root cause investigation." Major drawback: many managers do not perform root cause investigation in a systematic, scientific way and therefore never really get to the root cause of a problem.

Until a manager with authority has the AHA! moment (when he says "AHA! That's the reason things are not getting fixed!), nothing will improve and morale will continue to go downhill.
I agree with all of this. In fact, I think that perhaps the "sabotage" thing might not be that far off base after all. If management has designed processes that have been proven to work as intended, and employees have been A) trained in operation of the processes and B) imbued with a sense of the importance of following them, then casual failure to follow the process could be seen as sabotage--i.e., malicious failure to get with the program.

That would leave "innocent" error as the only uncontrollable factor, and in terms of numbers, those are relatively rare, and seldom repeated.

I have seen only one instance of a large company wherein the quality system is accepted by hourly workers as received knowledge, and people who don't follow it are brought in line by their peers. That's one way you can tell that the system is, well, systemic.
 
R

Randy Stewart

#9
OK, OK! I was being a little facetious.
Whew, for a moment there I thought Wes had been replaced by a Cylon. But that discussion belongs in the SciFi forum.:lol:
This is where the Plan, Do, Check, Act program is important. Management Plans the process, operators Do the process, supervisors Check the process and all Act on the results.
One more thought or comment here. I believe the important issue is to promote the sense of ownership with the operators. If you own it you take care of it. I think most of us have heard that phrase "nothing parties like a rental". I see that same "attitude" from operators who have no input on how their jobs are done. They don't own the process therefore they don't really care about the output. Give me my paycheck and let me go home.
 
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