System Failure Vs People Failure - Risks and Accountability

[Howard Atkins]

I saw the following yesterday.
The process produced a non conforming part, the operator found it and reported it on his production log and continued to produce. The whole roll of some 300 meters of roll bonded metal became scrap.
The system worked, they are now trying to understand why the process did not get stopped. The operator has authority to stop!

 

[Claes Gefvenberg]

...the operator found it and reported it on his production log and continued to produce. The whole roll of some 300 meters of roll bonded metal became scrap.

Doh! I have a feelig that most of us can come up with similar tales... I know I can.

The system worked, they are now trying to understand why the process did not get stopped. The operator has authority to stop!

Er.. I'm not sure I agree about the "system worked" part, but I see what you mean. The question is as you say why the work continued? All that was achieved was scrap metal, unnecessary machine wear, and time and revenue lost. I can think of several possible reasons, like for instance:

The operator may have been officially authorized to stop the process, but inofficially recieved a very different message. Perhaps he didn't dare to pull the brakes? What if he or some coworker recently got flogged for unneccesarily stopping the process?

He may have considered the defect insignificant. Did he know the intended use of the product, and how the defect would affect it?

Whatever the reason, this is a commmon problem.

/Claes