When it comes to your business, there are a lot of things you can do to improve performance and avoid potential accidents. But sometimes, accidents happen despite our best efforts. If an accident does occur, it’s essential to have a corrective action plan in place so that you can quickly address the issue while preventing it from happening again. There’s no question that a corrective action plan can be daunting. But with the right partner, you can develop an effective corrective action plan that will help improve your organization’s performance!

Here at Fisher Improvement Technologies (FIT), we have over a decade of experience helping our clients improve their safety records. We specialize in root cause analysis and developing corrective action plans that can make a real difference. We’ll work with you to understand the problem and create a plan that addresses the root cause of the issue. Don’t wait. Reach out to Fisher Improvement Technologies today!

When it comes to workplace safety courses, Fisher Improvement Technologies is the best in the business. We have a team of experts who develop workplace safety training programs that are designed to reduce human error. Our courses are based on real-world examples and case studies, so you can be sure that you’re getting the most accurate and up-to-date information. Keep reading to learn more about why our workplace safety training courses are second-to-none, and sign-up for one of our virtual workshops today!

Do you need to improve your workplace safety? Are there accidents occurring that are eerily similar to ones you’ve experience in the past? If so, our Advanced Root Cause Analysis Workshop at Fisher Improvement Technologies is the perfect FIT for you and your team. This workshop is designed to help you find and fix the root causes of accidents and safety incidents in the workplace. Keep reading to learn more about the benefits of taking this workshop, and contact us today to get started.

Hello followers and colleagues. I hope this finds you all staying well and using some of our time to reflect and energize for the future. This Robservation is difficult. I entitled it “how fast is too fast,” but it is more about the speed at which we try to manage risk, errors, and defenses.

Hi, and welcome to the next Robservation. In today’s discussion, I want to talk about one of the major roadblocks to effective organizational problem solving, even as deep as incident analysis.

We have been talking a lot recently about how leader language and behaviors shape an organizations’ ability to improve. I even heard a recent podcast that talked about how the organization in question had pushed HOP principles out to the field, but the leadership wasn’t actively engaged. That, by the way, is one of the Top 5 HOP deployment errors and has been for years. Those of you who know us well know that we at FIT don’t even engage beyond the initial Senior Leader contact unless the leaders show substantive changes in what they know, and what they do, related to deploying and integrating HOP concepts.

A term we have heard a lot of lately in business, and in life that describes our current times is VUCA. It stands for Volatility, Uncertainty, Complexity, and Ambiguity. I think we can all agree that whether we are staying at home or essential workers on the front lines, these four terms in the aggregate pretty well describe what we are living through

For decades now, we have been told how important employee engagement is. Companies do surveys, and they do corrective actions if the surveys say employee engagement is too low, they give refreshers on how employees should engage… it goes on and on. What I want to talk about today is LEADER engagement, more specifically, how leaders engage to ensure that there are shared visions and values set amongst the leadership and the workforce.

Dan O’Brien was as close as you’ll ever get to a sure bet for winning a gold medal at the 1992 Olympics. At the 1991 World Championships, he’d posted the top score in five of the ten events comprising the men’s decathlon. In contrast, none of the 26 world-class athletes competing against him won more than a single event. Sportswear giant Reebok’s confidence in Dan was so high that they spent over $25 million on an advertising campaign following his path to Olympic glory. Imagine everyone’s surprise when Dan didn’t make the US Olympic Team!

During the Olympic Team trials, Dan was winning by a comfortable margin heading into the pole vault. A successful vault at the initial height of 14’ 5 1/4” would have landed him in second place overall with two events remaining. Not a bad place to be, considering the top three finishers would make the team. Surprisingly, Dan waited until the bar reached 15’ 9” before making his first attempt. That’s the height he routinely opened at. Heck, he’d even cleared 16’ 1” during warm-ups earlier that day.

You’ve probably already guessed what happened. Dan missed all three attempts at 15’ 9” and finished in 11th place overall. He later said, “If I had to do it again, I would still come in at 15’ 9”, just like I do every day in practice. I believe that’s a safe height for me. I believe I can go out and make it every day. Except today.”

Today’s blog will wrap up this series on successfully resolving issues the first time around, thereby avoiding reliving bad days like Bill Murray’s character Phil Connors in the comedy Groundhog Day. We’ve covered the first four principles below…so on to #5!

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

Organizations tend to have short attention spans. Once we’ve stopped the bleeding from one crisis we’ll move on to the next, often forgetting to keep the tourniquet tightened. And now our old crisis reemerges as a new, sometimes larger one. I saw this happen at a manufacturing company for which I was performing a cause analysis on a costly product quality issue. Procedure changes the company implemented in response to a prior occurrence had been removed during a subsequent revision by an individual who was unaware of their origin and intent. While the quality issue was caught internally the first time around, defective products had escaped to a customer this time and created a much bigger problem for everyone!

Let’s continue our series on the following principles for resolving issues the first time around, thereby avoiding the unpleasant experience of weatherman Phil Connors in the best comedy ever made (in 1993, anyway), Groundhog Day:

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 elaborates on Principle #4: Implement fixes promptly and correctly.

One of the more unpleasant situations an organization can experience is having an incident recur. It’s particularly disheartening when the incident recurs AFTER we’ve identified Corrective Actions for the previous occurrence but BEFORE we’ve implemented them. It’s like we’ve left our front door cracked open for a moment and something undesirable wandered in!

It’s a given that Corrective Actions robust enough to permanently reduce the risk of incident recurrence can rarely be implemented overnight. For example, an equipment modification can take months to design, approve, install, and test. Even a seemingly minor procedure revision can take days to roll out if numerous individuals on multiple shifts will need to be trained on the changes. Since we can’t just wave a magic wand and instantly make things happen, we’ll need to pick Corrective Action due dates that make sense based upon three key factors: 1) the level of effort required to develop and implement the action; 2) the risk posed to the organization if the incident recurs; and, 3) the existence of equivalent or greater risks that are competing for our organization’s limited resources. Careful consideration of these three factors necessitates the active involvement of management and impacted stakeholders when developing the Corrective Action plan, rather than simply relying on the team who completed the incident’s cause analysis to come up with solutions.

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!

Welcome to episode 10 of the ELC podcast. I am your host and intentional leader, Rob Fisher, coming to you from the AEROhp.com Studios in the FIT Center for Excellence, here in Concord, NC!

Welcome to episode 9 of the ELC podcast. I am your host and intentional leader, Rob Fisher, coming to you from the AEROhp.com Studios in the FIT Center for Excellence, here in Concord, NC!

Welcome to episode 8 of the ELC podcast. I am your host and intentional leader, Rob Fisher, coming to you from the AEROhp.com Studios in the FIT Center for Excellence, here in Concord, NC!

For this series, I’ve drawn inspiration from the comedy Groundhog Day, which was released by Columbia Pictures in 1993. In this classic movie (classic to me, anyway), cranky weatherman Phil Connors finds himself reliving the same bad experiences over and over.

In my first installment, I introduced the following principles that enable organizations like yours to put problems behind them the first time, thereby avoiding Phil’s experience:

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 #2: Don’t assume the problem is isolated. But first, a brief story.

Way back in the 1980s, I was making my rounds aboard a US Navy submarine when I ran across something that just wasn’t right. Specifically, a putty-like substance was visible in the overflow port for the purifier, which used centrifugal force to remove impurities from lubricating oil. The resulting inquiry determined that a drum containing paint hardener had been delivered to the boat along with drums of lubricating oil, and the crew had subsequently transferred its contents into one of our four oil sumps. After samples confirmed that the paint hardener had migrated to a second sump, both affected sumps were drained and flushed. Problem solved, right? Well…unfortunately no. During the next plant start-up, a turbine began spinning a whole lot faster than it was supposed to. An alert shipmate promptly tripped steam to the turbine before it catastrophically failed, much to the appreciation of those of us who probably weren’t quick enough to dodge shrapnel. It turns out that a pipe connected to one of the ‘bad’ sumps hadn’t been adequately flushed, allowing some of the contaminants to enter the ‘good’ sump supplying the turbine’s control system when a cross-connect valve was opened.

One of my all-time favorite movies is 1993’s Groundhog Day, in which Bill Murray’s character Phil Connors repeatedly relives the same day until he eventually gets it right. Phil has a luxury that we seldom get in real life, in that he gets to apply lessons learned from one bad experience to the next without having to carry over any of the consequences. A true do-over!

Here are five principles organizations and individuals should apply to avoid reliving bad experiences and dealing with their new, sometimes worse consequences.

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

Each of these principles lends itself to a lengthy discussion, so I’ll limit this blog to Principle #1: Find the REAL source of the problem.

People are better at day-to-day problem solving than we typically give them credit for. If something bad happens in the workplace or at home, we can often draw upon our knowledge and experience to correctly identify the immediate source of the problem without taking a deeper dive. Seat-of the pants analysis, which I refer to as CAS-U-AL Analysis, works fine for most problems we encounter in a typical day where being wrong results in little or no consequences. When it comes to problems that have moderate or significant consequences, or could easily have under slightly different circumstances, we need to increase the odds that we accurately identify its source(s) by performing CAUSE Analysis.

Hello, and welcome to the next Robservation. You know there is one phrase that, when I hear it, makes the hair stand up on the back of my neck, and here it is – “We’ve got good processes we just can’t get people to follow them!”

Welcome to episode 7 of the ELC podcast. I am your host and intentional leader, Rob Fisher, coming to you from the AEROhp.com Studios in the FIT Center for Excellence, here in Concord, NC!

Welcome to episode 6 of the ELC podcast. I am your host and intentional leader, Rob Fisher, coming to you from the AEROhp.com Studios in the FIT Center for Excellence, here in Concord, NC!

Welcome to episode 5 of the ELC podcast. I am your host and intentional leader, Rob Fisher, coming to you from the AEROhp.com Studios in the FIT Center for Excellence, here in Concord, NC!

Welcome to episode 4 of the ELC podcast. I am your host and intentional leader, Rob Fisher, coming to you from the AEROhp.com Studios in the FIT Center for Excellence, here in Concord, NC!

Welcome to episode 3 of the ELC podcast. I am your host and intentional leader, Rob Fisher.

Welcome to episode 2 of the ELC podcast. I am your host and intentional leader, Rob Fisher.

Welcome to the Essential Leadership Cycle podcast. I am your host and intentional leader, Rob Fisher, President and Director of Operations for Fisher Improvement Technologies. We have spent the last 25 years helping organizations and individuals. The Essential Leadership Cycle podcast is here to provide leaders information, insights, methods, and tools to ensure a highly reliable, sustainable, and resilient organization. Most of the podcasts will contain a story and then some things for leaders to try on their own. We will also feature specials guests to share their experiences.

In today’s Robservation, I want to give a little different view of something that I hear a lot of in the industrial world. That is a description of some organizations as having a “blame culture.” I have even heard it used to describe the reason organizations need to change (most often, I have heard it as a need to use this consultant or that consultant to “solve” our blame culture and “turn it around”).

Hi, and welcome to the next Robservation. Today I want to shift the focus a bit to the importance of integrating concepts. I know that first, we have to change our knowledge and change our paradigms, and then leaders need to start to change their language and behaviors based on this new knowledge.

Hi and welcome to our next Robservation…

You may have heard the famous quote, “a problem well defined is half solved.” Some attribute the quote to the famous inventor, Charles Kettering. Others attribute it to John Dewey, the psychologist, and philosopher. I learned the importance of the quote a little closer to home for me many years ago through my nuclear power background when Einstein was quoted as saying something along the lines of “If I had one hour to save the world he would spend fifty-five minutes defining the problem and only five minutes finding the solution.” I think what Einstein was also alluding to is that the quality of your analyses and solutions will be directly proportional to the quality of your understanding and statement of the problem.

Welcome to the first Robservation of a new decade. We at FIT want to wish you and yours a happy, fruitful, and improved new year. I am also doing this Robservation from our new studio, where we will be starting the Essential Leadership Cycle podcast in early January.

When organizations try to solve problems, there are two things that I see them struggle with that tend to drive them towards ineffective analysis, conclusions, or corrective actions.

As I was listening to Todd Conklin’s recent podcast on “transparency,” I started thinking about some of the “HOWS” for making risk more transparent.

Well, it’s that time again. At least here in the US, we are in that sweet spot between Halloween and the new year. You know – when the retailers push holiday sales earlier and earlier, and all of the Christmas decorations start going up – and not just in the stores!

Hello, and welcome back to another Robservation.

Today I’d like to talk about taking some of what we learn at work about the positive impact of diversity and inclusion home to the family table. I have heard that some families struggle when they gather at the family table for celebrations.

Welcome to another Robservation.

Today I wanted to tell a story from a few years ago that highlights two things. First, don’t exclude people because you don’t think they are in the ‘target audience’ for error reduction and second, is the importance of triggers. In the early 2000’s FIT developed the method of using triggers, or clues to recognize vulnerabilities so that you can do something about it before it drives an error or incident. By recognizing the triggers, you can take action to manage a trap or performance mode in advance of it driving a bad outcome. Triggers have now become a norm in human and organizational performance and effective error management.

Welcome to the next FIT-losophy. FIT-losophies are insights into how and why FIT approaches errors and incidents in the manner that we do, to help you better understand and manage them in your organization. FIT-losophies have been developed using the information we have encountered in over 25 years of integrating human and organizational performance concepts into the day to day work in over 250 organizations worldwide.

Hello and welcome to another Robservation

Over the last 5 years, we have been working with Equilibria, who have spent over a decade collecting and analyzing information on how different personalities see and manage risk. By analyzing over 600,000 data points, we know fairly precisely how individuals with different personality tendencies react to changes in the system in very predictable ways.

Last week I found myself in a lot of pain and exhibiting some of the symptoms that I saw my mom go through the day she died. It scared me, and when I went to the hospital, they confirmed that my gallbladder needed to be removed immediately. I want to thank all the individuals involved in my care at Atrium Health in Concord, NC. You were awesome!

It wasn’t until recently that we started understanding that individuals tend to naturally pay more attention to safety attributes like work environment, people, equipment, processes, etc. based on their personality tendencies. Here are some simple definitions to get you thinking about personalities in a different way:1

This Robservation discusses some of the understandings and misunderstandings of safety, human and organizational performance (HOP) and the overlaps. Specifically, when an organization uses concepts like HOP and safety markedly improves (which is one of the natural outcomes if HOP is done right), what tends to be left are incidents that organizations put into the category of “isolated errors and incidents.” It baffles and frustrates organizations because they spend so much time and get such good results over a short period of time, and then they look around and people are still slipping and tripping, sometimes resulting in falls that produce injuries. Whether same-level falls or falls to a different level, the injuries result when some part of the body forcefully contacts the ground, or weor we twist, sprain, strain, or fracture a body part trying to reduce the impact of the fall. Unfortunately, once organizations get that first set of good results, they sometimes revert to applying blame to the individual for things like slips, trips, and falls.

Let’s revisit what some of the thought leaders have been teaching for a few years now related to safety as an OUTCOME. This opens the door to understanding that some safety outcomes are systemically preventable by the organization and some (<10% if you believe Deming and others) where the individual component is the primary driver. Either way, most of these incidents have a systemic element associated with the outcome, and the organization should make every effort to discover these systemic drivers. Organizations are typically not very good at understanding the difference, or at evaluating the circumstances of a bad safety outcome to determine the systemic drivers, including the individual components. It is not about fault or blame; it is about understanding the conditions and drivers that are associated with an outcome. HOP was never about making organizations ‘error-free.’ It is about preventing some errors that lead to outcomes, reducing the probability of other errors, or mitigating the consequences of the errors you cannot prevent. Initially, upon rolling out the concepts of HOP, organizations tend to see a downturn in the systemically driven incidents because the organization has better risk recognition and mitigation capability by using the concepts. Once the “low-hanging fruit” is understood, then the capability of humans within a system starts to be revealed. The human fallibility associated with distractions, multi-tasking, overconfidence, System 1 thinking, and others, then becomes more obvious. It’s not that it wasn’t there all along, but that the organization had so many other systemic drivers that needed to be discovered and taken care of, that they were always overshadowed as a primary contributor. Using a systems approach ensures that the organization learns everything they can learn, and doesn’t stop at the individual component, even when it seems like that is the easiest thing to do.

As it becomes warmer here in the US, we inevitably start to see the news stories about kids being left in hot cars. Let’s take a bit of a different view of this terrible situation and hopefully change the way people see it, approach it, and possibly change the way people try to fix it.

I like to communicate through stories. Here at FIT, we call it “teaching by storying around1.” Often the stories we hear from the people we are interacting with are far more powerful than what we experience ourselves. I am going to attempt to both share a story (names and specific locations avoided) and also capture what I hear people say and how I see them react about this issue so that we may take a bit of a different view.

As many of you know my background is both military and nuclear. And even though it has been a LONG time, I remember well that for most things we did we had to either discuss or document our ‘lessons learned’…“Did you file the lessons learned? Did you look at the lessons learned file? Did you talk about the lessons learned? Did you review the lessons learned?”

Hi, this is Rob Fisher with Fisher Improvement Technologies and welcome to Robservations. I’ve had several of these in the past and I wanted to take a minute to just chat about one that I see out there when people try to help others understand some of the techniques and technology behind what they’re trying to convey. Very often when these conversations happen one person is trying to convince another and they’re not really familiar with what the personality they’re trying to convince needs for information in order to be convinced.so what I like to do is set forth something called, “Is it reasonable to believe?”.

How do you change peoples minds about safety? How do you get people from where they’re at, to where you want them to go? Rob Fisher gives his thoughts…

Today we have a conversation with Rob Fisher, CEO and Director of Operations for Fisher Improvement Technologies. Rob talks about his involvement with HOP and how his life changed because of it.

Want another insight? CLICK HERE!

What is HOP? Rob Fisher, of Fisher Improvement Technologies shares his knowledge and insights on the subject of Human and Organizational Performance.

In this episode, we discuss what contributes to people not exercising stop work authority. Please comment below to continue the dialogue.

Here is a great article, written by one of our clients that deployed our Advanced Error Reduction in Organizations (AERO) technology. You can find out more at error-reduction.com.

Western Energy AERO Article

Want another insight? CLICK HERE!

This is the first of a new ongoing series called “Robservations.” These are intended to inform and start a dialog among professionals in the safety, quality, HOP and leadership fields. They are each based on things I have seen and experienced in my last 25 years of consulting in over 25 countries. I hope you will add to the conversation, and most importantly take some of the learnings to make your organizations and lives better.

This Robservation came out of personal frustration with the use of ‘filler words’ in life in general, but more specifically how I see them impacting our areas of expertise. I am looking forward to some of the future episodes.

Please join us on this journey – Rob Fisher, President and Director of Operations, Fisher Improvement Technologies

As we’ve discussed previously, error traps increase the probability that we may make a mistake. During and after the holidays, many of us get some well-deserved time off with our families and friends. When we come back to work, our risk to get hurt can actually go up!

Please enjoy this fun but serious look at how we may get hurt and ruin our holiday season. We hope you will share it with your peers and families to make this a safer and more joyous time of year.