Root Cause Analysis - Is Insufficient Understanding an acceptable Root Cause?

E

eturns

#1
We have just had our stage 2 TS16949 audit and have major non-conformities that need closing out within 60 days.

I know that normally operator error etc would not be an acceptable root cause, however as this is our first assessment to a new standard is insufficient understanding an acceptable root cause?
 
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RoxaneB

Super Moderator
Super Moderator
#3
Re: Root Cause Analysis

We have just had our stage 2 TS16949 audit and have major non-conformities that need closing out within 60 days.

I know that normally operator error etc would not be an acceptable root cause, however as this is our first assessment to a new standard is insufficient understanding an acceptable root cause?
As Golfman said, it would be helpful if you could share the finding because we don't have the full picture at this moment.

That said:
  • If your organization has made it this far, I doubt a lack of knowledge regarding the standard is the real issue.
  • "Operator error" is usually about a failure regarding the product, not the standard.
  • Why was the operator unable to meet the requirements of the standard or the process...this is probably your real root cause.

I remember an external auditor once asking our operators "What is your quality policy?" Three of them, out of the handful asked, were unable to answer and we were issued a finding. In my opinion, the question was the wrong question asked. Some people are better at memorizing stuff than others or some people panic at the idea of a "test" (aka audit). It would have been better to ask "How do you impact Quality" or "How do you impact the organization's ability to make what the Customer wants".

We don't know - at this moment - what the details are regarding the finding but you should consider the situation around it.
 

Marc

Hunkered Down for the Duration
Staff member
Admin
#4
... is insufficient understanding an acceptable root cause?
While I agree with the others, ask yourself: "Why was there insufficient understanding?" (I.e.: What was the cause of "insufficient understanding")

Root Cause Analysis requires you to go further in your investigation which is why "operator error" isn't acceptable. My opinion obviously, but I wouldn't accept "insufficient understanding" as a root cause for a major non-conformance in a Stage 2 TS16949 audit.

Also see: Problem Solving
 

Golfman25

Trusted Information Resource
#5
I am not sure I would phrase it as insufficient understanding as much as a possible different interpretation of the standard.

I had an audit which was full on non-conformances because we interpreted the standard differently. For example, he hit us on "process map" even though there is no such requirement and we had what amounted to an equivalent method of showing relationships and interactions. The best root cause I could come up with was that we saw things much differently than he did (as opposed to "clueless auditor" :)).
 

Marc

Hunkered Down for the Duration
Staff member
Admin
#6
Yeah - I used to see "interpretation of the standard" issues come up during audits from time to time. Elsmar started as QS9000.com in January 1996 because of the problems of QS-9000 auditor interpretations. ISO 9001 "interpretation" issues were much less of a problem, but ISO 9001 clause interpretations, too, came up from time to time.

In this case, as you said above we need to know more about the actual writeup the original poster is asking about.

Then again, it being a Stage 2 audit any major inconsistencies / differences in interpretations of requirements of the standard should have already been addressed and reconciled. I worked with companies in quite a few ISO 9001, QS-9000 and TS 16949 (and a few ISO 14001) implementations and registrations and never saw a major non-conformance during a registration audit.
 
P

PaulJSmith

#7
In line with the other responses here, the real question should be "WHY" was there insufficient understanding, especially at this phase of the process. I think this will lead you closer to the true root cause.
 

Raffy

Quite Involved in Discussions
#8
When I was working in Manufacturing, Operator Error is very common.. However, we always look for improvement and not rely too much on the human aspect...sometimes operator or people commits error because there is lacking in the system, it could be a procedure, a process, or how we perform work.
Best regards,
Raffy :cool:
 

Paul Simpson

Trusted Information Resource
#9
When I was working in Manufacturing, Operator Error is very common.. However, we always look for improvement and not rely too much on the human aspect...sometimes operator or people commits error because there is lacking in the system, it could be a procedure, a process, or how we perform work.
Best regards,
Raffy :cool:
Hi, Raffy. I missed this first time around but was browsing the forum (as you do!). The question of human error has been rattling around for years and I recently produced an article for Bywater on the fallacy of human error.

It is interesting that pretty much everyone who has responded agrees that we have to improve systems and give people our best chance of them doing a good job.
 

Mike S.

Happy to be Alive
Trusted Information Resource
#10
There are a lotta threads on human error on this forum.

My thought is, human error as a root cause does exist. It is rare, and is probably blamed 10 times more often than is appropriate, but it does exist.
 
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