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Errors Are Human Nature; Negative Events Result from System and Process Breakdowns

  • March 2020
  • Number of views: 4861
  • Article rating: No rating

Paul Idziak
Management Services Committee Member
Shermco Industries, Inc.

Are we doing everything we can to support our employees, or are we looking to assign blame when things don’t go right?

We have all heard the buzzphrases like “finding your why” and “human performance.” While not new, consider looking at this area from a different perspective.

Fallibility
Humans are fallible. Merriam-Webster defines “fallible” as, “liable to be erroneous; capable of making a mistake.”

Yes, that is right. Everyone can make a mistake, but sometimes by a stroke of luck, that mistake may not always result in an event, such as a plant shutdown, injury, vehicle collision, or worse.

How can we protect against fallibility? Simple. We use specific tools and procedures that ensure everyone is systematically following all the required steps. These tools include, but are not limited to, job hazards analysis, daily and post-break tailboard meetings, walking the site and asking questions to ensure that everyone understands the expectations and, most importantly, a daily close-out meeting.

Don’t Throw the Baby Out with the Bathwater
Each of us probably remembers a day when an error occurred that resulted in a negative event. But how many of us can remember the senior leadership participating in the event review (root cause) meeting and accepting a large part of the responsibility for the occurrence?

Eighty-four to 96 percent of all error events can be directly attributed to three main issues: 

  • Organizational: Falling into the “It’s the way we do things around here” trap.
  • Programmatic: Incorrect programs that were most likely written by a committee that never stepped foot inside the facility.
  • Process: The procedure is outdated and requires a more in-depth review.

Leaders must step up and accept responsibility for error events, no matter how minor.  The difference in a small event and one that is catastrophic can merely be a stroke of luck or being in the wrong place at the wrong time.

By now you’re probably thinking one of three things: 

  • "We can never eliminate all events.” 
  • “We would never fall victim to this type of situation because we train our employees to take action against the precursors that lead to these error events.”
  • “We have never experienced a significant event.” (my personal favorite)

You are probably all correct but, the next time you’re in the field, try asking the employees how their activities are going. See if they have experienced any recent near misses or concerning issues.  Be prepared for the answers, as they might surprise you.

Training Is the Biggest Problem . . . Or Is It?
We all brag about our training programs and show statistics that indicate we do more training than our competitors, and that’s why our employees have not had any error events. Then, if events start piling up, we attempt to defend ourselves by saying, “We are placing all the employees involved through additional training, and we will perform field verifications to ensure they understand this time.” 

That’s great, but consider this: 

  • Most serious error events involve experienced and well-trained employees.
  • If we are doing all of the training we say we are, then more training isn’t going to help.
  • People are fallible, so how is training going to prevent the employee from making a mistake?

Think about it: If the worker was trained three months ago on the proper use of a lathe or crane, and today a critical step in the process was missed, will sitting through retraining solve the problem? I think not.

We need to engage the involved workers and  thoroughly inquire as to why the event occurred. Then, we should ask ourselves, “Did I contribute to this event? How could I have helped prevent it?”

The Answer May Surprise Us
As leaders, we need to remind ourselves that employees want to do a good job, and human error is a product of a deeper organizational issue. It is our responsibility to find those issues and repair them at the forefront.



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