21 Feb, 2017 | Auditing, IATF 16949, ISO 14001, ISO 9001, OHSAS 18001, Root Cause & Problem Solving

As professionals with responsibility for developing management systems and for auditing them we often come across instances where the service delivered isn’t what it should have been or we have problems with product quality. As good professionals we investigate and identify root cause as ‘human error’. How real is this and how can we deal with these errors and stop them from hurting us?

Firstly, it is too easy to come up with human error as a root cause for failure – so much so that some customer industries including automotive will not accept it as being a final cause for a supplier failure, the logic being: people only make mistakes because they are allowed to!

To understand real root cause you need to understand the nature of errors – often impossible in the heat of a customer complaint. People do make mistakes – rarely will you find an example of someone deliberately delivering a poor product or service – but there is normally a good reason why a mistake was made. An individual may be distracted or under pressure to keep up with delivery schedules. Process documents may be unclear or authority levels not sufficiently defined.

To resolve these issues needs further investigation and to do this you will have to have the confidence of the people involved. The area is huge and is a minefield. As with all complex systems to be able to understand how errors occur you need to look at a range of different aspects:

Leadership – how do your organisation’s leaders exemplify desired behaviours and the importance of satisfying customer requirements so people understand what is required of them?
Communications – how do you communicate organisation expectations, including customer requirements; how well do you listen to what employees are telling you about their jobs?
Competence – how do individuals within your system demonstrate they have the skills and knowledge required to do the job?
Empowerment – how are people authorized to develop and manage areas of their work?
Recognition – how are people’s efforts appreciated and good practice rewarded?

If you are able to answer the above questions satisfactorily then you will be a long way towards establishing a quality culture that seeks out and eliminates root causes currently undiscovered and assigned to human error. There is guidance available from ISO TC 176 on people aspects of management systems, a vital area and often neglected, in the form of ISO 10015 and ISO 10018 and they are both being revised as we speak. There are some great examples around of earlier work including quality circles and the more recent self directed work teams at the heart of Lean manufacturing and service.

W. Edwards Deming said that 85% of all quality problems are management problems – if you accept this then you are part way to accepting there is no such thing as human error.


Paul Simpson
Bywater Associate
Providing consultancy and training on quality strategy and implementation.