In this series, I’m covering five principles that will help organizations like yours avoid repeating bad days, such as those experienced by Bill Murray’s character Phil Connors in 1993’s groundbreaking comedy Groundhog Day. They are:
1. Find the REAL source of the problem
2. Don’t assume the problem is isolated
3. Identify solid long-term fixes, rather than band-aids
4. Implement fixes promptly and correctly
5. Ensure fixes remain in place until no longer needed
Today’s blog will touch on Principle #3: Identify solid long-term fixes, rather than band-aids.
Several years ago, a manufacturing company shipped product to a customer with surface defects exceeding the allowable tolerance. The team tasked with determining how and why this occurred quickly learned that this ‘escape’ of non-conforming product was just the latest in a series. The organization’s response to those prior occurrences generally consisted of warning whichever quality inspector hadn’t caught the defects that they’d better inspect closer and harder, as well as telling their co-inspectors to do the same. This approach, which obviously wasn’t working, didn’t account for the fact that the inspectors, being human and all, we’re only capable of detecting about 75-80% of the defects that were just large enough to exceed the limit. And that’s under optimum conditions, which these weren’t. The team found that the lighting on the inspection table didn’t meet minimum standards for visual inspections AND the inspection was being performed in a distractive environment right next to a high traffic walkway AND the inspectors were zoning out due to performing repetitive inspection tasks for extended periods AND the inspection table wasn’t indexed such that the inspectors knew when the cylindrical product had been fully rotated and all surfaces inspected. More importantly, the team found that far more attention had been given to sanctioning the inspectors than on finding and eliminating the source of the defects that were challenging them. Surgery was needed to address this repetitive problem, not band-aids!
I’m leading with this story, not because it’s so unusual, but rather because it typifies how many organizations respond to their incidents. When I ask attendees at my workshops to share their organization’s most common corrective actions for incidents triggered by human acts, I consistently get these three answers regardless of what industry they work in: 1) sanction the individual involved in the incident; 2) modify the work instructions; and, 3) retrain personnel performing the task. While it’s conceivable that these three actions might work in certain situations, they definitely won’t provide a one-size-fits-all solution for every problem an organization encounters.
Let’s explore the touchy subject of sanctioning. There’s really nothing wrong with sharing lessons learned with an individual whose action or inaction was a factor in an incident. Where we go wrong is believing that holding them accountable via some form of sanctioning will necessarily reduce the risk of recurrence. At least 90% of the human acts that trigger incidents are errors, with most involving situations where the individual fully intended to comply with applicable rules but made a mistake while carrying them out. In this case, sanctioning equates to warning someone to never repeat an act that they never intended to commit in the first place. How effective do you think that will be? Even in the case of conscious deviations, sanctioning the individual won’t do much for reducing the risk of recurrence if systemic issues drove their choice. For example, a worker at an automobile manufacturing facility once told me that he and his co-workers routinely took short cuts because strict adherence to the rules governing their tasks would result in failing to achieve production quotas, which they all perceived was the most important thing to management.
If we are truly going to reduce the risk of incident recurrence to acceptable levels, we have to expend the effort to understand what the source of the problem is and apply solid long-term solutions. To resolve that repetitive product quality issue, let’s find and fix the source of the surface defects so that we reduce the number of shots on goal that challenge the goalies (inspectors). Let’s also fix the systemic issues that are reducing the effectiveness of the inspectors, such as resolving the insufficient lighting. But…if management isn’t ok with imperfect humans only catching 75-80% of defects that slightly exceed the limit, let’s automate the inspection process to take human inspectors out of the equation entirely.
I’ve partnered for several years with Fisher Improvement Technologies (FIT) to develop Cause Analysis approaches that integrate solid methodologies with the practical application of HOP principles. We’d love to help if your organization wants to avoid reliving the same problems. Please visit www.improvewithfit.com to learn more about the products and services FIT offers, including how to enroll in our upcoming Cause Analysis Workshops. You can also contact me directly via LinkedIn or by sending an email to firstname.lastname@example.org.