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Root cause is never the person .... REALLY???

Discussion in '5S, 5Why, 8D, TRIZ, SIPOC, RCA, Shainin Methods...' started by ncwalker, Jan 14, 2016.

  1. ncwalker

    ncwalker Well-Known Member

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    Came up on another thread, but I am very curious as to the opinion here of the root cause and how it can never be a person. I frequently see quality and production at odds on this.

    To start the discussion....

    The Quality Department: If the process "allowed" the person to make the mistake, then the process is poorly designed. And it should be adjusted so that it cannot happen.

    The Production Department: REALLY??? Some of these people out here, I wonder how they actually make it to work from home. How many times do I have to show someone the right way before I say "they just don't get it...."

    Also - what if the person is having a bad day with a bad attitude and comes in to work pissed off and want to just do something rebellious?

    Also - where does making everything completely bullet proof end? Continuous improvement is a noble goal. But someone has to pay for it. At some point, cost of the next improvement step is not justified by the results. THAT's a slippery slope. But it is there and can't be ignored.

    Also - what happened to good old "responsibility for your actions?" And "work ethic?" And "craftsmanship?" Maybe I am a cranky old man - but YOU KIDS DON'T WORK LIKE WE USED TO!!! :)

    Also - Why are we so lazy at trying to make the workers job easier, better, safer ... instead of making it mistake proof?

    Isn't saying "root cause can NEVER be the employee" sort of extreme work-place political correctness? In a court of law, "the person" damn sure can be guilty. We do not say "society failed him, we have to fix society." Or do we?
     
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  2. hogheavenfarm

    hogheavenfarm Well-Known Member

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    Sometimes the RC can be fixed with a simple CA - terminate said problem.

    Yup - not the current face of quality, but is true on occasion, I think that it is discouraged because it just provides an easy way out for RCA. (We retrained the operator, we added an inspector, etc.).

    "...Top Ten List of Unacceptable Corrective Actions
    10.The Employee was Counseled.
    9.Operator Error -- I Retrained Him.
    8.That Employee No Longer Works Here.
    7.We Had to Use Temps This Summer and Now That it is Autumn, they're All Gone.
    6.We Put Our Disciplinary Process in Place.
    5.We Sent Two Inspectors and Sorted the Product in the Customer's Facility.
    4.We Feel the Customer Applied Our Product Incorrectly -- Not Our Fault.
    3.Replacements Are on The Way.
    2.We Added More Inspectors -- It Won't Happen Again.
    1.I Fired His Butt.
     
  3. Marcelo Antunes

    Marcelo Antunes Active Member

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    You yourself mentioned the reason. Root cause of a problem is used to correct the cause of the problem, not to point who is guilty due to the problem happening.
     
  4. Golfman25

    Golfman25 Well-Known Member

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    You're 100% correct. At some point, there is diminishing returns. It's the difference between theory and reality.
     
  5. ncwalker

    ncwalker Well-Known Member

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    hhfarm - great list. Also great point. Refusing to allow it does keep people from taking the "gimme putt" answer on corrective action. I can see how that would morph into a climate of "it's never the operator."

    Marcelo - but can't the operator be the problem? I say that they can. But agree you should also not knee jerk just go to "operator error" as the source.

    Golfman - Yep. And boy, WHEN do you stop. I am curious how many of these recent recalls were someone thinking "eh, good enough...." We need us a p-value of when THAT decision is OK. :)
     
  6. Andy Nichols

    Andy Nichols Moderator Staff Member

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    I look at it this way. The company recruited the person. If, for whatever reason, the person doesn't "get it" and makes mistakes (or whatever you'd like to call them), it's on the company...Management should ensure they are sufficiently capable, competent and motivated to get the job done right, providing a well implemented process to achieve a satisfactory result - or move them on (in or outside of the company)...
     
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  7. Bev D

    Bev D Moderator Staff Member

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    ncwalker - I'm not sure of your point regarding error-proofing and "when do you stop". Takata airbags, GM fires, Ford roll-overs all injured very few people and the 'rate' of injury death was quite small yet we look at those things as abhorrent acts of poor quality by these organizations. can you clarify your position on error-proofing?

    As for 'holding people accountable' and 'guilty in a court of law', these do work and are necessary when the actions are deliberate and even of malicious intent. The saying about the operator never being the root cause (stemming most famously from Deming and his 14 points) does not apply to intentional and malicious acts. It applies to true errors and mistakes, NO ONE is perfect nor can they be. too often it is in fact the system, the operator is just a symptom of a poor system. A hiring process that will hire any body (summer help) and not adequately train and qualify an operator for a position needs to be changed. A system that repeatedly tells the operator that quantity is valued over quality will get operators who create poor quality, that system needs to be changed to change the operator behavior. Would you walk up to a piece of equipment that is producing defects and yell at it to 'just do a better job'? and yet as a quality manager for over 30 years I have seen this over and over again when it comes to operator 'behavior'. The argument that we aren't holding people accountable is misdirected: The phrase is in fact about holding people accountable - but it's about holding the right people accountable. We shouldn't hold the operator accountable for something that the supervisor or manager or leader is accountable for.

    As for error-proofing and craftsmanship etc, some of the first adaptors of error proofing were the US airforce and the airlines. Heads up displays, color coding warnings etc. were all put in place because even the best trained and most disciplined pilots make mistakes.

    also I know you were making a joke but I find it incredible that every generation says the same two things: I want my kids to have it better than I had it, but when they do they call them lazy and no good, just like their parents said about them.
     
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  8. MarkMeer

    MarkMeer Well-Known Member

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    If we recognize that everyone makes mistakes, and hence no human-involved process will ever be completely "bullet-proof", then it goes without saying that the system has to have a mechanism for determining which are "excusable" mistakes, and which are actually systematic problems.

    In general, the system should be looking for trends, rather than individual isolated infractions, no?

    Personally, (depending on circumstance, of course), I wouldn't necessarily take issue with these..

    (9) if a training deficiency was identified as the root-cause of the error, training process updated, and employee retrained, I don't see how this is "unacceptable".
    (6) again if it's identified that there's a lack of incentives/disincentives, and so these are put in place and result in better performance, what's the problem?
    (5&2) if insufficient time/resources devoted to a process is a problem, then what's wrong with reallocating resources as a solution?
     
  9. ncwalker

    ncwalker Well-Known Member

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    Andy - I am in your camp on this one. I go evaluate companies as part of my job. 80% of a companies trouble comes from management not reinforcing proper culture. Most of the workers "know better" but people do what is enforced.
     
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  10. ncwalker

    ncwalker Well-Known Member

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    Bev

    Pgh 1: Oooooooh. Heavy philosophy. The military actually has the term "acceptable losses" and "acceptable collateral damage." Is a human life priceless? In our hearts and minds we like to think so. But if every week I stepped in and took half your take-home pay and said "sorry Bev, I need this money to go save a life somewhere ...." and the person wasn't connected to you in a tangible way, how many times until you said "hold on a minute ...." You have family, whom you would (naturally) put first. "Those big auto companies should have done everything possible to save lives!!!" is the public outcry. OK. How many people are killed by texting and driving? We very much could pass a law where once a cellphone detected it was going over 5 mph, text/email would be disabled until it slowed back down. Heck, you could push that software out to every smartphone right now. That would inconvenience us, however. Why must a company do everything, but we as the public should be left relatively un-monitored to make the right judgement call?

    Pgh 2: Totally agree. And that's the root of it. One CAN hold the operator responsible if certain (rare) criteria are met. But I'm not the one who put the word "NEVER" in "it is NEVER the operator's fault." It's more a personal problem with me, I cannot stand superlatives in conversation. :)

    Pgh 3: I still maintain that there's a difference between designing to make life easier (heads up displays, etc) and designing to make sure it can be done without thought or concentration from the operator. I mean, if we are going to do that, plunk a robot down .... it'll be cheaper. And that's a point that the workforce (and I generalize) needs to get ... you don't want a robot to replace you? You better start demonstrating your flexibility and your willingness to learn faster that it takes to program a robot. (Which is getting harder ...)

    Pgh 4: Yep. Griping about lazy kids is in the fine print on the backside of a birth certificate. (I'm pretty sure, anyway. Lots of evidence pointing that way).
     
  11. ncwalker

    ncwalker Well-Known Member

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    MMeer - Very good points. I myself have had "had to train the operator" on an 8D from a supplier and I was OK with it. Looking back hindsight - how much did I actually DO to verify this, however. I just accepted it. (It was a strong supplier that seldom has issues). But ... I could have asked for the training material he was now using.... Or reports on how many operators had been trained until all required ones were .... Or statements from the operators that they understood the training ... Or quizzed them the next time I visited him ..... I didn't do any of the that. The NEXT problem had me distracted. I wonder - am I therefore not meeting what I am demanding from the operators? 100% focus and care ...????
     
  12. Bev D

    Bev D Moderator Staff Member

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    the issue is that usually these are not actually the root causes and therefore the 'solution' doesn't work. They are typically offered as a 'check the box' answer to a corrective action. the 5-Whys are supposed to get at that: why wasn't the operator properly trained? why is the operator careless? in only very rare occasions have I ever seen these types of responses be serious and the solution actually work. As for the "I added more inspectors" that would drive me absolutely batsh*t. lack of adequate inspection is not a root cause to anything. why was the defect created in the first place? that si the root cause that needs action. lack of adequate inspection is only an escape cause...
     
  13. Bev D

    Bev D Moderator Staff Member

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    I take this more as a political rant than a quality discussion. :) Of course we must make business decisions about the cost benefit of mistake proofing and no one is saying that all mistakes must be prevented. BUT most mistake proofing is actually very inexpensive. If we truly understand the cost of poor quality we will realize that most (not all) mistake proofing does increase the bottom line.
     
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  14. ncwalker

    ncwalker Well-Known Member

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    Well it is a bit of a political rant, of course. The intention of the thread was to get people thinking beyond the bumper sticker length statement "It's NEVER the operator's fault."

    This, however, made me chuckle....

    Can I come work where you work? In automotive, we have no chance of hearing it because LOW PIECE PRICE is screaming REALLY LOUD. Oooh. And JIT. Let's have next to no inventory because that saves money ... That we then spend ten-fold in expedited shipments. :)
     
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  15. MarkMeer

    MarkMeer Well-Known Member

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    It could be argued that the idea there is always a systematic "root cause" independent of human accountability is inherently flawed, because the system itself is designed, approved, and implemented by people. Even if you drill down to a systematic root-cause, further "whys" would raise questions of "who approved this?", "are THEY qualified?". Ultimately, the true "root-cause" is always going to be a human factor, no?

    (As we are on political rants... ;))
    But isn't this the way much of society operates? There is are cost-benefits and logistics to consider. Sure, we know the "root cause" of plane hijackings is not insufficient inspection of passengers. ...and yet we're perfectly willing to accept increased passenger scrutiny as a mitigating measure...
     
    Last edited: Jan 14, 2016
  16. Bev D

    Bev D Moderator Staff Member

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    ncwalker: I'm very aware of hwo blessed I am to work where I work. I worked for large companies and your ability influence is very low. I am currently at a medium sized company and I can influence how we approach quality. Were not perfect but we are moving in that direction...
    I too dislike extreme sayings like "never", and Deming didn't say never, he said the vast majority was managemetns fault not the operator's fault. But I've found that to change habits we must 'cut-off' the habitual path and 'force' the person to think differently. "An object in motion will stay in motion on it's current path unless a force is applied to change it". Our obligation in this case is to know when those rare cases of operator intent have occurred so we can properly guide the team to the correct solution.

    Mark: Yes of course at the heart of every systemic problem there is a human being, but the phrase is about the operator on the line who too often takes the blame for the supervisor, manager or leader's failings to do the right thing.
    Also, societal problems are not a good analogy for what we should do in business. yes you are correct that too often people reflex back to increased inspection as a corective action but in physics problems (far different from malicious and evil people) we can get to the physical root cause and prevent recurrence. As quality practitioners that is what we need to do, not buy in to the same old tired approaches that simply don't work.
     
  17. Bev D

    Bev D Moderator Staff Member

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    By the way the TSA has a 96% failure rate of catching bombs and weapons when challenged by homeland security.
     
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  18. Marcelo Antunes

    Marcelo Antunes Active Member

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    It depends on what you exactly mean with the operator being the problem. You mean the operator being the root cause of the problem, meaning, by removing the operator, the problem will go away? This would only make sense in the context of making the process automatic instead of manual (meaning, you would remove the human part of the process).

    If you mean the operator being the the problem as if the process was correct but the operator is not a good operator, this would call back to what some people already commented that, why then is he an operator in the first place? Another part of the system should have checked that.
     
    Last edited: Jan 15, 2016
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  19. hogheavenfarm

    hogheavenfarm Well-Known Member

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    "...You mean the operator being the root cause of the problem, meaning, by removing the operator, the problem will go away?..."

    Precisely. This does happen, for a variety of reasons, not related to management or the system. People sometimes snap. They have issues outside of work that they enact during working hours. I once worked in a place that had a deal with the State to employ ex-felons and disturbed people. Many functioned perfectly, but sometimes they didnt. The problem was with the operator, and removing them solved the problem. The only option open to the company was to not employ these people, many of whom desperately needed jobs and worked very well. Many times people bring home problems to work and just "lose it", or simply lose concentration. Is this a management issue or a personal one?
    Sometimes (albeit rarely), the operator is the problem.
     
  20. Marcelo Antunes

    Marcelo Antunes Active Member

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    Still not clear to me, you mean removing the operator and substituting him for another operator? Again, this is a problem of the process that defined that type of operator met the requirements for the process, not the operator himself. If he is not suitable, he should not be allowed to perform. If the problem occurred with one operator that snapped, as you mentioned, it's a very specific problem, and really, it does not need a corrective action, only a correction (changing the operator). If this happens a lot, it's a problem of the process that defined that this type of operator would be ok.
     

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