Get at the Core

Abstract:Human error as a root cause of a performance or manufacturing error often does not truly reflect the true root cause of the problem. Thus, formulating a corrective action plan based on providing additional training is often a waste of time and resources. By shifting the focus of an RCA from "human error" to the actual causes of human error, more meaningful changes to the production flow can be made which can minimize the impact of human …

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I agree completely with the premise that human error is rarely the root cause of a failure. I suggest that the root cause not stop with "noisy, distracting environment". Continue to ask "why?" - "Why is the environment noisy and distracting?" until the cause is outside the company's control, the information needed cannot be acquired, the team determines the benefit of going further does not justify the cost, or the the right person in an organization holding all the information needed to make a decision, decided to take a risk that did not turn out well.
--Alan Berow, 10-06-2017

Great job Devin! The company I now work for uses "Human Error" as RCA for 90% of the CA/PA root cause. This article hits the nail on the head I have been preaching since I joined. I am requiring all personnel involved with corrective actions to read this article.

Thanks Again,

Charlie Poirier
--Charlie Poirier, 09-05-2017

Thank you for providing this article. Too many times we get stuck with Human Error as a root cause and I like how this redirects our CAPA efforts at the reasons a person might make an error. I've printed this for all employees to review, of course giving credit to the Author and the Magazine.
--Judy Love, 08-29-2017

Excellent article, a propos since the trend in the last few months is about human errors and accountabilities.
--Max Lyoen, 08-21-2017

Excellent article and a must read for all QEs/QA Managers/Supervisors. Dont blame the employee. The management must setup the process/system for SUCCESS not let them fail. PREVENTION is the key. PFMEAs and Control Plans are helpful in this endeavor
--sjsoukup, 08-12-2017

--Chris, 08-09-2017

If a process is working well, is robust and dependable in the first place, it won’t matter how an employee feels when they start their shift because the tooling and processes will eliminate most noise and variances so that the output is consistently the same. Management needs to re-invest into its tooling and upgrade. My bet is this is the root-solution.
--S. Weld, 08-09-2017

This article is a good reminder to keep diligent at deeper root cause rather than pushing retraining.
--Catherine Doran, 08-09-2017

Hi Devin,
Often the corrective action to the true root causes of nagging problems that are typically tagged as "human error" requires tooling/equipment/facility upgrades in the tens or even hundreds of thousands of dollars - changes that cannot be made immediately or even at all. Any suggestions on interim mitigations for root causes with solutions that are not easily implemented?

Amanda Forsythe
--Amanda Forsythe, 08-08-2017

Dear Devin,

Thank you for raising such an important topic! I believe that many quality professionals would recognize similar situations from their past or current experience, related to, let's call it, re-training pitfall (vs digging to the true root cause).

There is a single point that I would ask a clarification to: in place where AQLs are mentioned, shouldn't these be read as 2%, 9% and 1% accordingly (98%, 91% and 99% seem to be too high to be tolerated by any industry)?


Alexander Kholodov
--Alexander Kholodov, 08-07-2017

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