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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.