Operator Error: Is that really the root cause?

HPISC. Resource Library

Content Area: Cause Analysis – Human Error

Item: Operator Error Article

Operator Error – Root Cause of Performance Problems?


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.

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Comments Welcomed.


Resource Tools also available:

Resource Tool –  Performance Causes

Resource Tool – Performance Improvement Checklist


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