|
This thread is carried over and continued in the Current Elsmar Cove Forums 
|
|
|
This thread is carried over and continued in the Current Elsmar Cove Forums
|
The New Elsmar Cove Forums
|
 The New Elsmar Cove Forums
 Nonconformance and Corrective Action Systems
 Corrective Action Report-Root Cause
|
 UBBFriend: Email This Page to Someone! |
next newest topic | next oldest topic |
| Author | Topic: Corrective Action Report-Root Cause |
|
darwinbb Forum Contributor Posts: 10 |
posted 07 May 2001 01:37 PM
   
I worked as a QA tecnician in an ecoat paint facility in Southwestern Ontario, part of my job is to write corrective action reports whenever customers request for it. In one of my reports I wrote among others "operator error" as a root cause, our customer rejected the idea and ask me to find some other reason why the problem occurred. My question is( for those quality people out there) is an "operator error" not a valid root cause in a 7-D format corretive action report? IP: Logged |
|
Laura M Forum Contributor Posts: 299 |
posted 07 May 2001 03:22 PM
While "operator error" is a common response, most companies (B3) are starting to recognize that there is usually some other cause. Can you ask "why" was there an operator error? Possible answers could be: 1. "new employee" - so root cause may be lack of training with the C/A on the training program, or needed better visual aids for a new operator. or, 2. Operator instructions were not clear. or, 3. Bad part placed with good parts? Why? Lack of errorproofing. I think your customer just wants to make sure operators aren't getting blamed when there may be a "better" or quality "system" related root cause. If you can ask "why was there an operator error" - and not come up with an answer, you should still look into errorproofing as corrective action. That may satisfy the customer. Your thoughts? Laura IP: Logged |
|
energy Forum Contributor Posts: 228 |
posted 07 May 2001 03:51 PM
Operator Error is real. Show me someone who doesn't make errors and I'll show you someone who doesn't do anything. Inattentativeness, momentary lack of judgement, distraction and just plain stupid! We do everything we can to find a reason. It will never go away. Look at some of the posts mispelling.(mine too). While it may be considered minor and doesn't really matter, it reminds me that we are all human. One mistake of the key can create an order entry error. Customers who don't accept Operator Error as a valid reason are just bullies and enjoy the power trip. Inspection was developed for just that reason, and they make mistakes, too. So there! energy IP: Logged |
|
Marc Smith Cheech Wizard Posts: 4119 |
posted 07 May 2001 04:25 PM
True. It is real. How you address the 'problem' is what is important. For example, operator error on the space shuttle systems assembly, etc. is not acceptable. For any reason. Would you accept Operator Error by a technician performing structural tests on an older aircraft as a vaild root cause for a crash of that airplane? I don't think the flying public would accept a finding which says "Well, there will always be operator errors... We can't prevent them entirely." Not even 1 is acceptable sometimes. The first thing I want to know if I find operator error has been determined to be the 'root' cause for a nonconformance is has this happened before? Same operation? Same machine? Same shift? Same operator? Same part? Recurrence of operator error is a sign that there is a deeper problem. So - you're both right. But -- look closely at the entire context before you decide whether (or how much) operator error is an acceptable 'feature' of your business processes. [This message has been edited by Marc Smith (edited 07 May 2001).] IP: Logged |
|
Dan Larsen Forum Contributor Posts: 137 |
posted 07 May 2001 04:55 PM
Refusal by a supplier to accept "operator error" as a root cause to a CA is not new. I had a supplier tell me this seven years ago (a small company in Northern Michigan, as a matter of fact). Further, I'll admit to subscibing to this belief myself. Like Laura, I believe that if operator error is defined as the root cause, it really defines a management problem. Either the operator wasn't properly trained, was promoted without appropriate skills, or the process was not sufficiently mistake proofed. This is not to say that errors won't occur. But the role of manangement is to design processes and systems in such a way that the liklihood of errors is either minimized or the errors that could occur have insignificant impact on the product. I guess my question for darwinbb is this: If operator error was defined as the root cause, then what was the action taken to correct it? If the action was a reprimand to the operator ("Don't do that again!"), then the CA fails on two counts. If the action taken was training, then the root cause was a training failure. If the action taken was an example of mistake proofing (a process design change that will ensure the error can't happen again), then I'd buy the operator error argument.
IP: Logged |
|
senergy unregistered |
posted 07 May 2001 08:35 PM
hey guys, I'm not arguing with Laura M. We have history! I'm also not talking about the space shuttle. They triple, if not quadruple inspection points on all operations to prevent errors. I'm referring to the small shop making brackets for a wire harness for aircraft, maybe a small machine shop fabricating a fitting for an airhose on board a ship. They all are important, but the wild goose chase some of these big companies will send you on just to satisfy some 4,000 employee company's idea of cause and corrective action is not justified. They have the personnel who can spend a week looking for the boogie man, and he/she won't be missed. If it's the same part, same excuse, well look deeper. If it's not, do your best to find the cause and get on with life. I still think that most of this stuff is directed from the bully pulpit. Yup, this is energy working at home, so I crafted a similar user name. Can I use my user name on my home computer or am I commiting "Operator Error"? energy IP: Logged |
|
Jim Evans Forum Contributor Posts: 45 |
posted 08 May 2001 08:39 AM
I am one of those that will not (under any circumstances) buy "operator error" as a root cause of a problem. It tells you nothing about the nature of the problem other than an operator was involved. Laura is correct in that you need to ask why (as many times as needed) to get to the root cause. Even in the second scenario that Dan cites if the correction was to mistake proof the process then the design of the process that allowed the operator to insert a part in bacwards (or whatever the problem) was the root cause. Tradionally "operator error" has been the dumping ground for all sorts of problems that company managements did not want to accept the responsibility for because it was their systems that were at fault. I would say that most companies that I deal with will not accept "operator error" as a root cause. Best Regards, Jim Evans IP: Logged |
|
Michael T Forum Contributor Posts: 16 |
posted 08 May 2001 09:39 AM
Ok.... I guess I have to play devil's advocate here.... If we say that "operator error" is not an acceptable root cause, how much can we "mistake proof" the process before it becomes financially untenable? Cheers!!! Mike IP: Logged |
|
energy Forum Contributor Posts: 228 |
posted 08 May 2001 09:58 AM
If you don't care for the term "operator error", you really wouldn't enjoy "unknown". We used it when there was no way to pin down the cause. Talking with all personnel in the loop, no legitimate cause could be determined. We had 15/18 operations where nicks and scratches could have ocurred. Nobody in the process could point to the cause. We used "unknown", with separating the parts with dividers to eliminate normal handling. That's alot more honest then blaming an Operator. If it's Operator Error, that's the cause. With 40 operators, and not always the same one responsible, it's hard to believe it's a training issue. You can say it, but that don't make it so. It also has to be mentioned that the company's PPM defects didn't even show on the customers' quarterly report. So the customer had to change to report to show units on the graph to a max of 10. Then we can see 5 pcs rejected out of thousands shipped. Think about it. 1500 pc order with one pc having blurred part marking. Another 2000 pc order with a scratch on it. This with an approved sampling plan for final inspection. The amount of time required and the futility of determining who, what and where, just doesn't "add value". Most importantly, the orders kept coming. It's not a perfect world and some customers that know you provide superior product are aware of it. Once more, Customers that demand full blown investigations in light of the conditions I mentioned, employ way too many Quality Geeks with not enough work to do. They are just feathering their nests and beating their inflated chests because as the Customer, they can. I want to add that the average cost per part is about $2 or $3 each, with the customer continuously trying to nickel and dime that cost down. Some parts aren't even a $1. Give me a break! [This message has been edited by energy (edited 08 May 2001).] IP: Logged |
|
Dan Larsen Forum Contributor Posts: 137 |
posted 08 May 2001 01:56 PM
Energy, In your example, I don't know that the cause is unknown as much as the source. The cause is high potential for mishandling; your solution was appropriate for the problem. I also sympathize with you regarding the PPM issue. In fact, it can be frustrating when customers issue CAR's over what seem to be petty issues. There seem to be quite a few companies that issue CA's for every reject or concern regardless of the significance. When this approach is used, it diminishes the impact that a CA should have, the result generally being that root cause analysis suffers. Personally, I think CA systems are one of the most misused systems in ISO and QS. I guess that's one reason they tend to be such a hot topic. IP: Logged |
|
Sam Forum Contributor Posts: 244 |
posted 08 May 2001 05:36 PM
Back in the day of, MIl-Q, We used the term "random failure" Has a nice ring to it. At times, no matter how hard you try you cannot determine the exact cause of the failure. But then agin this is not an acceptable answer either; is it? CA is a vicious cycle, on the one hand I get a CA request from my counterpart at another company and complain about the paper work; I in turn receive defective product from a supplier to which I promptly request a CA. And on and on. We need to do a better job at addressing the CA system, maybe stand out side of the box and take another look. IP: Logged |
|
Al Dyer Forum Wizard Posts: 622 |
posted 08 May 2001 06:41 PM
Although it has been awhile (1992), the last time I used the term "operator error", I was called to G.M. Headquarters in Warren to "discuss" the response the the SQA. I still hurt! At the very least respond, as said before, with something like "random occurance" and be prepared to back it up with data and further actions. As to intentional "operator error", on some level I don't think we will ever be able to get rid of it, only reduce the occurance. There will always be disgruntaled people and they will even bypass the built in preventive measures and traceability to make their point. It's our job to minimize these actions. I think there is a bigger point here and that is to have an up-front relationship with the customer at all levels. There are many times I have visited a production line and because I had a relationship with the operators, they would call me over and point out a "possible situation" and then get rid of the product in question. No harm, no foul, until I got back to the plant. ASD... ASD... IP: Logged |
|
Q rex Forum Contributor Posts: 14 |
posted 09 May 2001 04:02 PM
Is the mean time between failures concept useful here? If we're going to realistically claim operator or, e.g., machine, error, and need data/statistics to back it up, does this work? Sort of a risk management spin on it? Root cause was error by Operator A. Is he within the lines on mean time between errors? Yes, then operator error acceptable as root cause; no, then investigate why his error rate is out of spec. Or not... Rex IP: Logged |
|
Al Dyer Forum Wizard Posts: 622 |
posted 09 May 2001 05:23 PM
Q rex: I like the idea of using MTFB, but I see it being very difficult to quantify such subjective data as "operator error". I see it as not very cost effective when you take into consideration the numerous studies that would have to be performed. i.e. A study for each operator on each process, part, failure mode, gage used etc... Any ideas on how it could be used in a cost effective manner and keep customers happy? MHO Keep up the thought provoking posts! IP: Logged |
|
Laura M Forum Contributor Posts: 299 |
posted 10 May 2001 07:19 AM
OK - one client was in the process of "beating up" an operator when I arrived yesterday. Apparently a significant quantity of bad product was produced. This extremely dedicated, high attendence employee did not perform some quality checks. He noticed a problem, but "thought" they were OK. Unfortunately he took it upon himself to make that call. However....this was the first run of a new product after qualification. The Quality Engineer did not "verify" that the instruction for a regular production run were understood. In my opinion, and what I told the owner, was that this was entirely a management issue. If the QE was not in the department during a start-up, looking at product himself, providing assistance if needed, then the operator was left on his own to make a decision. Could the operator have used better judgement? Of course, but root cause was not operator error. I agree, you can errorproof yourself out of business, but not all errorproofing is expensive. Simple, visual controls usually work. IP: Logged |
|
energy Forum Contributor Posts: 228 |
posted 10 May 2001 08:43 AM
quote: I may be guilty of the same thing internally. We recently purchased a great CA program, and, to get people used to reporting problems I created a problem detail reporting form. So as not to slight anyone, I am currently entering all into the database. All the problems involve Customer Complaints, Supplier issues and internal data entry mistakes. Some personnel use this as a vehicle to beat up on a co-worker. My problem is that 80% of the problems involve data entry errors. These are definitely operator errors. One poor individual may process 200 orders per week, but every week I receive a report where something went wrong with the 1 or 2 orders that results in us having to provide free freight, discounts on the next order, credit memos, etc..These cost the company money. On the flip side the individual makes a lot of money for the company. I don't issue CAR's at this time because we are in the startup mode with this program. Is there a way to classify this type of problem other than "Operator Error". Actually, I call it order entry error, but it's the same thing. "Error". I know we have the option of determining the magnitude of what gets reported, but quite honestly, it makes up the bulk of the problems reported. Any ideas or suggestions from this talented group are always appreciated. [This message has been edited by energy (edited 11 May 2001).] IP: Logged |
|
darwinbb Forum Contributor Posts: 10 |
posted 10 May 2001 10:26 PM
thanks for the response, i wrote my corrective action report without using the phrase " operator error ", it seems to me that our customer requires an elaboration of the root cause> This suit the customer very well, now I learned my lessons ......  IP: Logged |
|
Fire Girl Forum Contributor Posts: 41 |
posted 15 May 2001 03:35 PM
Wait wait! I need help.... I mean with NCR stuff. We recently had a customer send back a couple of bad parts. They don't seem to want to tell us how many bad ones they found. We 100% sorted 50000 (small) pieces and found one with the problems they were talking about. We can find no reasonable explanation. They aren't returning the parts, which makes me think that it isn't a very serious problem. However, they do want an 8-D filled out. I really don't feel that 'unknown' is a very good answer, but I got nothing else. Perhaps energy has a witty answer for me.... IP: Logged |
|
Sam Forum Contributor Posts: 244 |
posted 15 May 2001 05:21 PM
Fire Girl; 1 in 50000 looks like 20ppm. You may be the victim of a six sigma guru that wants to know why you cannot meet their requirement. Thus, the request for an 8-D. And you are right "Unknown" would not be "good enough". I went through the same thing with DCX. We had 2 parts failed in 47500 for the year which put us right on the edge for being an acceptable supplier. Answering all the questions on their 7 step was very important for our continued business. IP: Logged |
|
Laura M Forum Contributor Posts: 299 |
posted 15 May 2001 06:05 PM
How many more parts do you need to understand the problem? (Not meant to be smart a$$) 2/50,000 can be significant. We had a part that was used 6/car. Similiar PPM's were cited by the supplier. But with 6 per car, the ppm is 120 ppm at the vehicle level. How many more in stock to sort? If you can't root cause what you got, how will more parts help? I'd sort 100% for awhile, and brainstorm potential cause. Don't forget to update the FMEA! IP: Logged |
|
Al Dyer Forum Wizard Posts: 622 |
posted 15 May 2001 06:17 PM
FG, They sent 2, you found 1. You have a problem that needs to be considered. The next time you may receive the whole shipment back. What is your PPM with the customer? ASD... IP: Logged |
|
SteelMaiden Forum Contributor Posts: 28 |
posted 16 May 2001 09:06 AM
Sometimes it is difficult trying to get more info from a customer. While your company is seeing what it feels is a small percentage of bad parts, you have to concede that the customer is king. Get some people together and brainstorm this problem. Make sure to include some from the production end. They might be able to bring you some information as to if they've seen anything, were there process or equipment changes? Can you identify where in the run the defect happened or became apparent? Are the defects all in the same place, recurring regularly (even if it's one time a day on the last part or whatever)? I believe that occasionally you will come up with a problem that you cannot find a cause for. BUT...it is usually because of our limitations be they training, inexperience, lack of documentation etc. Everything in life has a cause, or many contributing factors. It is our jobs to identify them, or to define how far is far enough, when does it become unprofitable to continue to search. Good luck, I am sure that if you don't panic you can work through this. IP: Logged |
|
energy Forum Contributor Posts: 228 |
posted 16 May 2001 09:52 AM
Fire Girl, I don't have a witty retort, but I liked Sam's "random" failure/nonconformance or "isolated incident with low probability of re-ocurrence". They appear to just want an answer. As the customer they always have the option of not accepting your reply. If the interest appears to minimal, as you describe, you probably won't hear from them until the next snafu. But, as the current occupant of the bully pulpit, they may want more. Maybe the CAR person's dog got run over by a car or his wife left him, in which case, you're in what we call Dog Doody City. energy IP: Logged |
|
Jim Biz Forum Wizard Posts: 275 |
posted 16 May 2001 10:38 AM
Excellent discussion folks: Where would "Operator Aptitude/Attitude" fit - as an acceptable contributing cause? Reasonable source for variation? Regards IP: Logged |
|
Fire Girl Forum Contributor Posts: 41 |
posted 16 May 2001 10:56 AM
Ok. These mangled parts don't really look like something our tool could have done, so we really are baffled. The reason we would like to see all the bad parts is to see if there is perhaps some type of extra little telltale mark that maybe we didn't notice on the others. The one part out of 50000 is what we had in stock, they have more parts on site. The press stamps these parts off like 90, if it miss-hits 3 or 4 times, the operator is not likely to notice this. Usually the operator is running a few presses at once and checking his or her parts every 15 minutes or so in small bins before they are emptied into big bins. We have never seen this problem before. We are not QS 9000 certified although we do comply with many parts of the standard. Our customer is not either and they don't understand any of the paper work. They are getting the heat from their customer and they don't really know what to do. Looks like gravity is to blame again!! [email protected]*t really does flow downhill. Damn physics! IP: Logged |
|
Jim Biz Forum Wizard Posts: 275 |
posted 16 May 2001 01:04 PM
A machine that "Miss- hits 3 or 4 times" while running 90 can"t be operator error can it? - Only if you take the stand that the error of not catching it during the process is due to operator fatigue. Thinking I'd investigate "WHY is the machine miss-hitting?" Speed? Material? tooling? Then again I have had parts returned here that were dropped out of our packaging after shipment from our dock & ran over by a truck. Our customers sitll ask us to investigate how "we" did it. Regards [This message has been edited by Jim Biz (edited 16 May 2001).] IP: Logged |
|
energy Forum Contributor Posts: 228 |
posted 16 May 2001 03:35 PM
Jim, Aptitude is a training issue. Attitude is a human resource issue. Either way, according to the majority who have responded in this forum feel that, "employee" anything is not a good enough response. There has to be an underlying reason for the unacceptable event. To say the employee made a mistake, you ask why? I'm an idiot. Why? I quit school in the second grade. Why? Because I felt like it. Why? I could learn more by setting ants on fire with a magnifying glass. Why? Mind your own business. 5 whys and you dare not report any one of them as a reason for the N/C. Employee error is the cause. I stand in the minority. How about "Employee error" and now he/she doesn't work here anymore. These customer quality geeks may still insist that there must have been more that could have been done by the company to prevent this hapless individual from botching the job. A pox on them all!! IP: Logged |
|
Jim Biz Forum Wizard Posts: 275 |
posted 17 May 2001 07:26 AM
energy I don't disagree at all the "human factor" is certainly error prone - but unless I mis-read the thread fire girl has been informed of a "Problem/event" she hasn't seen before so I guess I'm trying to point to the fact that "Something" other than the operator has changed?Regards IP: Logged |
|
Sam Forum Contributor Posts: 244 |
posted 17 May 2001 09:11 AM
So, what can we do to eliminate this assinine method of communication? I have a thought,IMO. Maybe someone would care to expand on it. 1- Have a minimum of three suppliers for each type of product at all times. Item #2 is what we are trying to achieve. Afterall, we are all suppliers and we are all customers. Well any way I feel better. I can get back to completing this 7D. IP: Logged |
|
energy Forum Contributor Posts: 228 |
posted 17 May 2001 09:59 AM
quote: Jim, My last post was to address this statement, not Fire Girl's dilemma. She's between a rock and a hard place because of a over bearing customer that's enjoying the "power trip". IP: Logged |
|
Fire Girl Forum Contributor Posts: 41 |
posted 17 May 2001 11:32 AM
Let me elaborate. This part is new to this customer. We used to make this part for another customer. They never complained but that doesn't mean there weren't any bad parts. We are still trying to get PPAP approval from this new customer. They have had the documents for almost a year and they called last week and said our Certified Lab's certification expired! So we had to re-submit some stuff again!! Yes something has happened. Looking at the tool, there do not seem to be any problems with it. I still feel this could be an operator error. Chances are those few bad parts were made close together. The operator is supposed to be checking his/her parts before dumping them in bulk bins. I really think that freakish things sometimes happen and you aren't always going to have an explanation. Maybe on the space shuttle, yes, where there is a monitoring system for the effectiveness of the toilet flushing. I just think, humans built the dies, humans repair the dies and machines, humans run the parts and humans check the parts- you're just asking for trouble with a set-up like that. After all, we're not perfect, are we? Just this gal's humble opinion. IP: Logged |
|
energy Forum Contributor Posts: 228 |
posted 17 May 2001 02:19 PM
quote: keep the fires out, girl! energy [This message has been edited by energy (edited 17 May 2001).] IP: Logged |
|
Cheryl Forum Contributor Posts: 19 |
posted 01 June 2001 11:38 AM
Darwin, when you answered your Root Cause as operator error, did you verify? When defining and verifying root causes one or more causes can be considered the root cause depending on the problem description. Keep asking the question "what caused that" as many times until the TRUE root cause is established. I agree with you that operator error could have been one of the causes but not the true root cause. "What caused the operator error?" IP: Logged |
All times are Eastern Standard Time (USA) | next newest topic | next oldest topic |
  |
Hop to: |
Your Input Into These Forums Is Appreciated! Thanks!
Main Site Search 
