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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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    This conversation lacks snacks and beer. It would be MUCH better with snacks and beer.
     
  2. Jennifer Kirley

    Jennifer Kirley Moderator Staff Member

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    Root cause is not simply the person, but the reason why the person failed/decided to not follow the plan. Why, why, why... Remember my paper When Employees Don't Follow Procedures? Maybe it is time to attach it.
     
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  3. Bev D

    Bev D Moderator Staff Member

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    I suggest that comparisons to cars or wars or other geo-political events is a different beast than the business world. standard work, training, oversight, compliance etc. are all much stronger in a business than 'out there' in real life. While there are certainly some things to learn these don't usually serve as a very helpful analogy.

    I would also second Eric's referral to my post regarding clarification of the post title: The phrase is really about operators and not all 'people'. (How many times have you actually seen management listed as the cause on a corrective action?)

    I will also restate that the intent is to not accept 'operator error' as cause and retraining, reassignment, discipline as a corrective action without solid evidence. It's about looking beyond the reflexive 'check the box' answer to getting to a true casual mechanism that prevent re-occurrence. Even Deming allowed as some small percentage of defects were due to operator error. One of my favorite lines form the West Wing: every once in a while, there's a day with an absolute right and an absolute wrong, but those days almost always include body counts. Other than that, there aren't very many unnuanced moments.
     
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  4. BradM

    BradM Moderator Staff Member

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    The question on the table is "Root Cause is never the person". I say... yes, it can be. :) Driving a vehicle: Unless we are going to develop such robust processes that all drivers operate vehicles virtually using the same process, people will be the cause of accidents due to their behavior (follow too closely; distracted; speeding; intoxicated; etc.). We all know there are idiots out on the road with drivers licenses (how did they ever pass that test???) and borderline dangerous vehicles (how did they pass inspection???)

    However, in business, the goal (or at least it should be) is to minimize failures/defects; that's how you make more money than the 'other guy'. This is where Bev's clarification of operator comes into play. Too many times in the past, it's all too easy to blame an individual for a failure; instead of digging in and seeing where the process broke down. So I would say in business it's almost always not the person; with the assumption that the individual wants to do a good job.
     
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  5. Jennifer Kirley

    Jennifer Kirley Moderator Staff Member

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    If behavior can be corrected, it is behavior not simply a person. I object to saying a root cause is a person because being a person is not in itself actionable. Too often people are fired through knee jerk reactions to perceived shortcomings.

    I appreciate the latter part of BradM's description as added clarity.
     
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  6. Raffy

    Raffy Member

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    IMHO, Pointing finger to the guilty person is the answer, instead try to assess the current process if the person involved fits the system. Sometimes we need to adjust our procedures to answer this kind of problem.
     
  7. Golfman25

    Golfman25 Well-Known Member

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    So here is one. You have some type of specialized machine which requires a unique skill to operate. Not many people have that skill and it may take years to develop. You're late on orders because the machine is down due to the fact that the operator is habitually late. He knows he has you by the ____, so he has no incentive to get to work. He does it on his schedule.
     
  8. Candi1024

    Candi1024 Well-Known Member

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    That's a horrible business plan. What if this person is in a car accident tomorrow and couldn't work? Would you simply shut down the business?
     
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  9. Bev D

    Bev D Moderator Staff Member

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    OK - we've already said that there are times when the operator is in fact at fault. There can be malicious and truly incompetent employees and appropriate action needs to be taken. I would agree that this employee is malicious. But I would also say that to be in this position is the fault of the company and the employee is merely taking advantage of this. If you have a position that requires such a rare skill, you should compensate the employee adequately (supply and demand) and you should develop a training program to create the skill in more than one employee. The semiconductor industry did this in the 80s when it was clear that local operators with the skill to run the sophisticated fabrication equipment just didn't exist. I've been in that situation in more than one occasion and I always address it by recruiting and paying or training and paying.
    If this was my supplier telling me that the reason I couldn't my parts - or that my parts were defective because of this situation, I'd hold my supplier accountable for providing the skill at a level and quantity that would provide my parts on time in the specified quality level per the contract.
     
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  10. MarkMeer

    MarkMeer Well-Known Member

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    Agree with Bev D's response.

    However, for the sake of discussion this is certainly not an uncommon situation...particularly in the software-development field. No matter the policies for documenting/commenting code, ultimately the original developers become invaluable, as the cost of training someone to be familiar with the code/architecture continually increases over time (as the code becomes increasingly complex as it is developed).
     
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  11. BradM

    BradM Moderator Staff Member

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    Agreed. To coin St. Paul... "I do not understand what I do. For what I want to do I do not do, but what I hate I do." It's easy to state, as with any operational issue, "I'm not going to get into situation X..."; only to fail to prevent situation X. A good operations manager is worth their pay. Having someone who takes the time to review processes, training, age of systems, etc. to assure optimal operations is a lot of work.

    But that is work well spent. The better systems that are put in place so workers perform better, is a win-win for all.
     
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  12. Chris Brockway

    Chris Brockway Member

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    I like Tim Autrey's book. It delves into this question deeply, and while it's mostly safety based, the problem of human error also has importance in quality management.
     
  13. Jennifer Kirley

    Jennifer Kirley Moderator Staff Member

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    I so wish I did this more thoroughly before delivering informational sessions on ISO 9001:2015, using someone else's materials. :eek: It wasn't pretty.
     
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  14. Andy Nichols

    Andy Nichols Moderator Staff Member

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    Who keeps someone like that employed in such a situation? Where's the "plan B"? As Candi is saying, what if the person wasn't available? IMHO this example is not the same as being responsible for the root cause...
     
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  15. Tony Wardle

    Tony Wardle Member

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    :D
    :D:D

    Man ... Thats funny .... and of course I have heard it all before.

    Human fuzzy logic
     
  16. JDuhamell

    JDuhamell New Member

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    I've read all the comments and most of you live in a manufacturing utopia or your so far removed from production that you think everything is avoidable. The comments that no one goes to work to make a mistake and that everyone wants to do a neat job was laughable. We have the culture here that everyone can be trained, rehabilitated, and that we want to have a family environment so we don't like firing people...do you know what that "culture" really creates? A culture where quality isn't important and that operators can do whatever they feel like that day because there is no punishment; they get a paycheck no matter how many parts they scrap that day. And our customers feel it too. I'm very, very slowly changing that culture. About 50% of our operations is choice, and the only way to eliminate that choice is to replace the operators with robots. So there are a lot of times that we spend time and money poke yoking the hell out of a process and retrain, retrain, retrain when all it boils down to is the operator is worthless. The companies that I've worked for in the past that had really good quality and satisfied customers are the companies that had disciplinary actions in place - after so many times of screwing up, you were fired. When people jobs are on the line, everyone takes notice and start doing what they're actually hired to do.

    And you know why we have to put disciplinary actions in place? Because people nowadays lack work ethic. We live in a world where everything has become a dime a dozen and nobody values anything.
     
  17. hogheavenfarm

    hogheavenfarm Well-Known Member

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    I think you missed some of the earlier posts. Previously I stated "The problem was with the operator, and removing them solved the problem." Believe it or not, I agree with you that most posts seem to come from the "ideal" job where people want to do what is right. It has been my experience that these employers and jobs are quite rare, and instead I have to function in a less than ideal environment, recognizing that some people simply do not care , and that is not just employees, but employers too. I once worked in a place that literally ran on KPI's, one of which was turnover. I quickly saw an opportunity to reduce turnover and offered a comprehensive plan. Only then did I learn from the CEO that high turnover WAS THE GOAL. It was his way of keeping costs down, as new people could be hired at minimum wage and would leave long before they qualified for their 50 cent wage increase (after one year). We went through 130 people per year the entire time I was there. That turned over the entire floor staff and a bit extra every year. Far from being unusual, this attitude is common, at least in jobs I have looked at or worked in. So yes, the answers you may find here are idealized, and maybe companies like that exist, but there is nothing wrong with pursuing the ideal even in the face of the worst conditions. Quality is a way a life, not just a job, you will find you carry these ideals everywhere, thats ok, and how it should be.
     
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  18. MikeH

    MikeH Member

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    issue: a faulty part is delivered to a customer
    why1?: operators build parts away from drawing and faults are not detected before delivery
    why2?: parts are visually inspected and operators don't always detect the faults
    why3?: visual inspection is the most cost effective (<--important) means of part acceptance
    why4?: implementing other/secondary verification processes (ie poke-yoke) will raise operational costs and ultimately the operator will not HAVE a job if this line of logic is applied across every part (because that's root cause correction at its best)
    why5?: the production volumes are too low and the business is already "running on fumes"

    If I tell you why5 and why4 are fixed and can not be influenced...where does that lead the investigation back to?

    "measure the wrong thing and you get the wrong behaviors"...interesting point made above.
     
  19. Andy Nichols

    Andy Nichols Moderator Staff Member

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    Mike H: Your 5 Why doesn't read correctly to me. I have some questions: Only 1 part was faulty? Why 3 is nothing to do with Why 2, is it? Why 3 should question why operators build "parts away from drawing" (whatever that means)and, in fact why 3 is an "excuse" (pardon me for being blunt) isn't it? They don't build parts because they can't see them! They build parts which are faulty because the parts are created faulty, aren't they?

    Maybe revisiting the 5 Whys method might work!
     
    Last edited: Apr 28, 2016
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  20. Bev D

    Bev D Moderator Staff Member

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    Let me add that in addition to Andy's feedback, the 5Why doesn't branch. The inspection miss is an 'escape' cause. One can proceed down this path to determine why the inspectors are missing the defects: perform an MSA and determine their effectiveness, analyze the miscalls and determine if the process can be improved (maybe not 100% effectiveness but can you do better? you'll never know until you try).

    The missing branch would lead us to why the defects occur in the first place. In this branch I might start with what you mean by 'away from the drawing'.

    remember that the use of the word why is not a directive. in fact the phrases "how did" and "what prompted" are more effective because they keep us focused on facts instead of opinion, rationalization and justification responses.

    It is difficult to tell if you believe that this is an adequate 5Why or if you are providing a sarcastic 5Why that is really directed more at your company's lack of interest in quality?
     
    Last edited: Apr 28, 2016
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