Operator-error attributed as terminal root cause
483 likelyFDA consistently cites firms that stop the investigation at 'operator error' without identifying the system condition that allowed the error. This pattern reliably draws a 483 for inadequate root cause investigation.
Aspen Pharmacare (paraphrased) · FY2023
FDA Warning Letter to Aspen Notre Dame de Bondeville (FY2023) — case reference on file
FDA noted the firm's investigation concluded with operator error as the cause without addressing why the procedural design, training adequacy, or shift staffing allowed the error to occur unchecked. The agency required a CAPA addressing systemic factors, not just retraining of the named operator.