expertanswe

Error elimination
Q: What’s the best way to reduce human
error in production?
Submitted via the QP reader survey

A: The old adage “to err is human; to

forgive, divine” works well in social interac-
tions, but in the industrial world, human
errors can be costly and occasionally result
in fatalities.
The lives of a flight full of passengers
may depend on an airplane pilot’s alertness
and attention to detail. The same attentive-
ness is necessary for transactional pro-
cesses in banking and finance; otherwise,
organizations may go bankrupt due to
human errors.
Remember W. Edwards Deming’s 85/15
rule that says 85% of the problems in any
operation are within the system and are
management’s responsibility, while only
15% lie with the worker.1 The same thing
holds true for human errors. Eighty-five
percent of so-called human errors could
be prevented by designing an effective
system.
Human errors may be due to:
• The system. whole—person, method, machine, material, Given that you can’t foresee all the pos-
• Lack of skill, knowledge or experience. measurement and environment. There is sibilities, learning from past experiences is
• Carelessness. no guarantee all possible opportunities can key to reducing human errors. And that’s
• Willful sabotage. be foreseen, but assembling the right team not just your own experiences; it also
How many times as a quality pro- with the right experience will help identify includes the experiences of your suppli-
fessional have you seen human error most opportunities for error. ers, customers, competitors and even
assigned as the root cause and “retrain It’s also necessary to learn from past organizations from completely different
the operator” as the corrective action? errors and examine the opportunity for a industries.
Has this ever worked? There is a time and similar error to occur in your system based The Japanese have a devoted body of
place in which proper training or retraining on an underlying root cause. There may be knowledge on this subject called poka-
can help reduce errors. But I’ll get to that a tendency from the team to discount past yoke—also known as error-proofing or
shortly. errors as completely different situations mistake-proofing—that is a collection of
Most of the situations in which an that aren’t applicable to the current one. standard solutions for finding and removing
individual could commit an error can be On the surface, that may seem to be the a system-induced error in an industrial or
foreseen during the design of a process via case. But the root cause may be one and manufacturing setting. Several situations in
a comprehensive review of the system as a the same. which this may be applicable include:

8 QP • www.qualityprogress.com
rs
An emphasis on doing it right the first time
can play a key role in reducing human errors.
• Designing nonsymmetrical parts.
• Creating features such as drill or dowel
holes to prevent variations in a sym-
metrical assembly.
• Designing fasteners of the same thread
size to prevent the application of incor-
rect torque.
• Designing parts that combine two ele-
ments—such as a washer head and a
screw.2
The initial cost of developing a system to
prevent errors may be low or high depend-
ing on the situation. You will need to weigh
the severity and probability of the error to
justify the need.
For situations in which it is cost prohibi-
tive to design a system to prevent errors,
you can use a qualified and competent em-
ployee with the right attitude to significantly
reduce those errors.
Besides designing a system to prevent
errors, it’s possible to reduce the num-
ber of errors if the workload is planned
in a way that distributes it evenly among
your employees, thus reducing stress and
fatigue.
Organizational culture and an overall
emphasis on doing it right the first time
Conformance question
Q: Recently, a new firm began auditing our
organization, and I’m noticing differences in
requirements compared with our previous
auditor. At the closing of an annual surveil-
lance audit for a three-year certificate, if a
nonconformance is issued at the closing
meeting:
• What is the expectation for response to
the auditor for a minor nonconformance
and a major nonconformance?
• How many days are expected for the
initial response for each?
• How many times during the next 12
months should we expect the auditor to
revisit the site to verify corrective action
for each?
Deborah Magoon
Grand Rapids, MI
A: Clause 8.2 of ISO 9001:2008, internal
audits, does not specify or prescribe any
time limits. Clause 8.2.2 only requires the
management for the responsible area—the
process owner—to take corrective action
without undue delay.
With regard to audit follow-up visits,
this depends strictly on the registrar or
other auditing body. Some auditing bodies
will follow up on closed corrective action
reports during their next scheduled surveil-
lance audit. This allows enough time for the
organization to evaluate the effectiveness
of the corrective action taken.
In most cases, the auditee is required
to complete the correction action report
identifying the root cause and the cor-
rective actions taken to prevent a recur-
rence. This information is assessed by the
auditing body to confirm that a root cause
was identified and that the action taken
matches the root cause. This is normally
done in the form of a desk review.
Due to the costs involved and other
logistics, it’s rare for any auditing body to
want to come out to verify each corrective
action taken. This is usually something for
the internal audit staff to perform as part of
its audit activities.
Bill Aston
Managing director
Aston Technical Consulting Services
Kingwood, TX
Bibliography
International Organization for Standardization, ISO
9001:2008—Quality management systems—Requirements.

can also play a key role in reducing and

preventing human errors.
Govind Ramu
Senior manager, quality systems
Keep It Simple
Organizations don’t need to wait for an external source to
SunPower Corp.
identify their shortcomings. Those who want to take the initiative
San Jose, CA
and start the improvement journey can get the tips they need
Reference and note
to conduct an effective internal audit in Process Driven Com-
1. Mary Walton, The Deming Management Method, Perigee prehensive Auditing by Paul C. Palmes, now available in the ASQ
Books, 1988.
2. These examples and others can be found at
Quality Press bookstore (http://asq.org/quality-press/index.html).
http://facultyweb.berry.edu/jgrout/pokayoke.html.

February 2012 • QP 9