When making your non-conformance (problem) statement, be sure to choose words that will get the response that you’re looking for. Stating a non-conformance as, “The operator did not follow the procedure” will set the root cause analysis back 30 years. Statements that identify a person as the problem will only end in disaster. Statements like this cause defensiveness and turn the focus on finding someone to blame. A better approach is to ask, “What is the weakness in our system that allowed this to happen?” This question will reduce resistance and get the focus where it should be: on the system itself. Once we make it less personal we can get to the root cause.
What Are My Options?
An alternative to ‘The operator did not follow the procedure’ might be, “The procedure to inspect the fromulgator at stage 6 has not been fully implemented”. Or, “The requirement to carry out inspections of the fromulgator has not been met at all stages”. Or, if the operator has found a better way to do it and your document control process is so complicated that it hasn’t caught up yet, try, “Current documentation does’t match current practice”. This shifts the focus onto the system, where it should be.
This approach creates an opportunity to review the whole workflow to see if the inspection is actually needed or if this is not a value adding activity. State the problem in a way that opens the door, not closes it. Refer to non-conformances as ‘nuggets of gold’ and act that way!
Determining that the root cause is ‘operator error’ might be the case occasionally, but remember the research that concluded that yes, operators do make errors, but it’s about 6% of the time. If your RCA finds ‘operator error’ the cause more than 6% of the time, a bit of polish is needed on your process. Even if this IS the case (the operator did make a mistake) it may be helpful to acknowledge that front line people can only deliver what your system allows them to. They cannot make a silk purse out of a sow’s ear (to coin a long lost phrase!). Find out what they need to get the results you’re looking for – at least word your non-conformances in a way that leads down that path!