AS9100 - Moving beyond operator error as a root cause

 

AS 9100 aerospace quality management systems in clause 10.2 ask organizations to determine the causes of a non-conformity and then to take action to prevent recurrence or the occurrence of similar non-conformities in other parts of the system. As QMII works with clients in a consulting capacity or where we support clients for their internal audits QMII has often noticed the use of operator error as an identified root cause. As process-based system consultants and believers we encourage our clients to look beyond placing blame on the individual and blaming the system. Does ‘operator error’ then quality as blaming the system?

Most organizations that manufacture aerospace parts are required to be certified to AS 9100. Certification is granted to those that demonstrate that their system has been documented and effectively implemented in accordance with the AS 9100 standard. Organizations that conform to this standard need to demonstrate they have a process to identify non-conformities and then to address them within an agreed timeframe. There are many methodologies used to conduct root cause analysis with the simple 5 whys being easy to explain but perhaps not very effective unless used as a decision tree analysis or cause and effect analysis process.

Certain AS 9100 industry gurus are against the term ‘root cause analysis’ as they claim that companies then only focus on one root cause and so they opt for causal analysis. The bottom line being that for every non-conformity there may possibly be more than one cause. Further the question arises if the operator error is a direct cause of indirect cause. In some cases, we have observed organizations stop at operator error and look no further. Even in such cases let us say we accept the root cause as identified. For the users of the system know their system better than QMII as the consultants. The organization in these cases would be better of from conducting a trend analysis over time to identify the number of cases of operator error. In one case there were 115 instances of operator error as the identified root cause over a period of 8 months and no trend analysis done or efforts made to look beyond this.

By resorting to the root cause as operator error we in essence are implying that either our process controls are weak or that the training program implemented was not adequately assessed for effectiveness. After all per clause 7.2 of AS9100 we are to ensure that only competent personnel are performing duties related to meeting customer requirements. Further clause 8.5.1 now even asks organization to consider means to error proof their system as part of risk-based thinking.

AS 9100 risk based systems must begin to look beyond operator error and encourage operators to appreciate the risk of being distracted when working on critical items or a critical process.