HPISC. Resource Library
Content Area: Cause Analysis – Human Error
Item: Operator Error Article

Abstract:
More often than not, operator error is the root cause for a deviation and retraining is the corrective action. What’s wrong with using operator error as the root cause? Actually, a lot of unwanted consequences.
Conducting an analysis using 4Ms, man, machine, methods and materials, enables companies to conduct a true root cause.
Take Aways:
- 4 Ms Fish Bone Diagram for Training RCA
- 4 Possible actions to pursue as Corrective Actions
Additional List of Resources
Typical Requester:
This article appeals to a wide audience within Quality Assurance and Regulatory Affairs.
How Used:
- Compliance Trainers love to use this article to help explain why repeated use of Operator Error sends the wrong the messages to Regulatory Agency.
- Root Cause Analysis teams refer to the fish bone diagram to frame the training questions to ask when investigating a failed training transfer event.
Comments Welcomed.
Resource Tools also available:
Resource Tool – Performance Causes
Resource Tool – Performance Improvement Checklist