Operator Error - Not an Acceptable CAR (Corrective Action Request) Response



When I have written corrective actions, I have written them as honestly and to the best of my ability to explain them. I now have been told that if I write a corrective action where "operator error" has occurred and the operator has been re-instructed, this is no longer acceptable.

Our management says this is just "rubber stamping" a corrective action.

Comments please. What do I do now? How do I defend this position when it is the truth?


operator error.

The environment that you work in, Is there a union involved?
Operator error within a union environment is a grey area and, If this is the case for you then, I would re-word your NC report to include all possibilities such as task element and ergonomic re-assessmnts, including training issues and the possibility of more than one opperator performong the task (Between shift work assessment).


You could be in a tough spot.
We have had some other threads on the board dealing with the validity of operator error as root cause. I would suggest doing a search to see what the other threads have to say.

For myself, I am not a big fan of operator error as a root cause. However there may be times, especially on internal issues, where it is legitimate. Wallace brings up some good points about addressing other issues such as ergonomics etc., but sometimes it just comes down to poor performance. If management doesn't like to admit that operators can make mistakes, ask them if they prefer operator stupidity any better for a reason. Or how about expressing it in terms of Process capability. "The process failed do to a deterioration in capability. Source of deterioration has been traced to the main control unit (in this case human) which will need to be repaired, or replaced."

If your management is dead set against operator error in all cases, then they had better be prepared to spend some big bucks idiot proofing every operation in the place.

Well enough of my rambling vent...

Questions to ask.
How long has this person been on the job? (experience/training)
Has anything changed in the task? (training)
Has anything changed in the environment? (ergonomics)
Has anything changed in the materials used? (process inputs)

If the person has been doing this job long enough, and no changes have occurred on the process then you are left with operator error.



Management audit.

Are you performing a 1st, 2nd or 3rd party audit when you report your finding regarding operator error?
JKRH made a good point regarding expressing the outputs of your findings as process capabilities.
The culture of an organization is a good indication of internal and external commitment to QMS issues and, your finding of operator error may be the truth yet, auditor ethics whether they be internal or external must IMO adhere to an accepted code of ethics, I have allways refrained from giving my opinion even if my opinion is true and accurate during an audit.
I would suggest that you use the task element approach developed by Allan J Sayle refering to Management audits, this entails assesing Person, Item, Equipment, Information and Service, you may wish to report the persons' Competence, Training, Identification, Motivation and Attributes, Understand that this approach is NOT within the scope of ISO9001 yet, I have come to realize that this approach is a very efficient and effective method of allowing management to see the big picture regarding the most important part of any process THE PERSON who performs the task.

Kevin Mader

One of THE Original Covers!
Two thoughts:

1) If you believe in Dr. Juran’s 85/15 or Dr. Deming’s extension of that at 94/6 (I have seen videos where he goes as far as 98/2), then the cause for the problem is System related and not Individually related.

2) Even if it is traceable to an individual, then I ask if the process of nonconformance is stable and predictable (i.e. people make mistakes and sometimes do stupid things). If the cause is ‘common’ and not ‘special’, then I think that the CAR may have been issued erroneously.

Most CARs are for system generated problems and as such, require system adjustments to correct. Correcting people (and so noting this on a CAR) may lead to temporary success (hiding problems or unusually high short-term focus), but system fixes lead to real improvement. Using the 5-Why approach should lead folks to system causes or program oversights, thus making a dent into the problem when corrected.

Just some thoughts…



Apreciation of the system.

You have said what I should be saying, Thanks for getting me back on track :eek:
Appreciation of the system is what we might want to concentrate on for the education of the workforce regarding what may be an evident operator errror. I'm interested in the route that we are taking here, JRKH mentions the use of process capability to bring to managements attention the performance capability of the operator, At my place of work we use ISPC (In station process control), This measures all of the task elements that I mentioned previously and, We can all see the stats, My problem with this method of control is that, If there is no formal system in place and no appreciation of the system (Education) then, there can be no phsycological approach to operator motivation (Measure of Morale). :frust:
I mentioned in a previous thread that organizational culture may be a good measure of the root cause of operator error. What's your take on this dbulak?


I appreciate the advise given here. Thankyou again as always. But another question on the same subject. Is it then ok to use operator error when filling out a customer corrective action. Management has vetoed this also.


operator error.

You are definately passionate about the operator error finding and, I believe that's a good thing, providing that you are able to communicate the operator error with the appropriate evidence and, wording it in such a manner that doesn't express judgement upon the operator.
Tha fact that you may have witnessed operator error is important to your findings and, you may want to concentrate a CAR on the training and development of the operators, Ofcourse if you have witnessed operator error that may lead to a safety issue, Then I would indeed report it to management imediately. I take it that your findings are recorded and filed?


Make life a little easier for yourself. Get management involved in these decisions by scheduling a team problem solving process.

E Wall

Just Me!
Trusted Information Resource
Operator Error

While I do believe this happens...if you have 'many' operator error occurances then you are truely not getting to the root of the problem.

5 Why's? Keep asking and asking and asking~! Maybe there needs to be an SOP with the specifics that are missed frequently. Or, there could be a problem with your training or evaluation processes. All get the drift?

Good Luck, Eileen
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