Operator-error attributed as terminal root cause
483 likely21 CFR 820.100(a)(2) requires investigation of the cause of nonconformities. FDA cites firms that close investigations at 'operator error' without identifying the design or procedural condition that allowed the error.
Medtronic (paraphrased) · FY2022
FDA Form 483 — observed during inspection
FDA observed that CAPA records concluded with 'operator did not follow procedure' without an analysis of whether the procedure design, training program, or workstation layout contributed. The agency required the firm to broaden investigations to the system level.