Hidden Faultlines In Your Organization Find them FAST FIX them Forever Dr. Ted Spickler Quality and Business Services 412-777-2054 [email protected]

Hidden Faultlines In Your Organization

Find them FAST FIX them Forever

Dr. Ted SpicklerQuality and Business Services

412-777-2054 [email protected]

Bayer Corporate and Business Services LLC

Bayer Corporate and Business Services LLC2

Why Are We Here?

Organizations, like geological features, are subject to earthquakes - sudden upheavals that can later be attributed to hidden, underground faultlines that are sensitive to stresses and can, without warning, let lose with disastrous consequences.


Faultlines

Some of us have chronic problems that have defied previous attempts at resolution.

Old problems rear up out of the blackness and bite us again and again.

Meaning we never really fixed them the first time.


What Are We Going to Do Today?Examine techniques for uncovering faultlines.

Practice building logic tree’s, a key tool for uncovering Latent Causes.

Differentiate between Direct Causes, Symptoms, Contributing Causes, and Latent Causes.

Learn to build effective fixes to these problems.


When Something Goes Wrong: Typical reaction

Shoot the messenger. Jump to quick conclusions about why something

happened. Find someone to blame - THEN: Hang ‘em high! Review procedures with “bad” person. Re-train and discipline “bad” person. How about: blame the supplier! Better yet: “Blame the CUSTOMER”! Hope it doesn’t happen again.


We Need A Better ApproachFind out what really went wrong.How do the quakes happen?What can we do to prevent bad things like this

from happening again?Where do you find evidence for the hidden

faultlines?Utilize a systematic approach using tools that

avoid simple blaming.Develop practical solutions that fix it forever.


Finding the Faultlines

We have learned to look in these two places:

Customer ComplaintsISO audit Corrective Action Requests

(CARS)


COMPLAINTS

Individual complaints are like viewing the company using tunnel vision.

You can get trapped in the specific details of any one case.

Instead look at a broad range of similar complaints looking for patterns.

These patterns appear to be “families” of complaints. The underlying causes of these patterns are what we

are looking for. Doing this is easier if you have a comprehensive

customer complaint database.


ISO Corrective Action Requests

In a similar manner look into the requests for corrective action that are written as a result of internal ISO audits.

Are there relationships between complaints and CAR’S?

As with complaints, you need a database of CAR’S.


Steps in searching for that hidden FaultLine Work backwards from the visible symptom of a hidden

faultline. The visible symptom is evidence that you have a problem. The kind of problem we are interested in shows up multiple

times and sometimes in varying places with often a variety of symptoms.

You don’t know this at first because you start with visible symptoms.

Sometimes this backwards analysis uncovers just a local issue that hardly counts as a faultline.

In that case you find the cause of the problem and fix it.


Variety of Problem-Solving Tools

Fishbone Diagram (Cause and Effect). The Five Whys. Systematic Root Cause Diagramming Methods

Commercial systems (see bibliography) Computer programs and chart-based analyses.

Chronological timeline Logic Tree

“What’s Different” Analysis, also known as “IS/IS-NOT” (Kepner & Tragoe)

Be prepared to apply multiple tools as the circumstances dictate


Two “Models” for Uncovering Faultlines

Single Investigator Has a “virtual team” lurking in the background. Can use all the tools described later. BUT might be biased or jump too quickly to conclusions. AND might miss something hidden under the surface. May fail to come up with a good mix of corrective actions.

Team with Facilitator Expensive to get everyone together. Used when a highly visible problem really needs “big-time”

attention. Used when many departments “touch” the problem.


If You Need a Team ... Include people who know something about what

happened. But hold down the size of the team! 5 - 7 seems optimal

Want persons with different expertise and backgrounds. May want a vendor or a customer representative on the team if appropriate.

Some team members might feel guilty! The guilty-feeling persons should not be “spotlighted” - we

need information and not remorse. Hold “kick-off” meeting - carefully define the problem. Determine what sorts of information are likely to be

needed.


Gather Information

Interviews, copies of procedures, copies of logs, charts, test results, reports, photographs, maintenance records, audit reports, process flow charts and diagrams.

Has this happened before? Retrieve reports from earlier investigations.

This is why archiving investigations in databases is useful! Do not assume anything - fill in the details with facts. Expect the unexpected - look for the surprise!


A Lesson In Assuming

Bill owns a company that manufactures and installs car-wash systems. Bill's company installed a car-wash system in Frederick, MD. These are complete systems, that include not only the car wash itself, but also the money-changing machines.



Lots of money turned up missing - was it the manager? Or had someone stolen the key from the manager to make a copy?

Bill just couldn't believe that his people would do that, so they set up a camera to catch the thief in action. Well, they caught him on film!


It was not just one bird; there were several working together. Once they identified the thieves, they found over $4000 in quarters on the roof of the car wash and more under a nearby tree.




No matter what the circumstantial evidence may be, don’t jump to conclusions until you have all the facts. In this case, the new owner made the assumption that since:

a) Money was missing on a regular basis.b) The machines were not being broke into (no damage).c) The only other keys would be the dealer or one of the dealer’s employees.

that it must be theft by the dealer or a stolen key.

WRONG!!

Key Tool for Identification of Hidden Faultlines:

The Logic Tree


How to Construct a Logic Tree

For training purposes we will play around with a trivially simple case:

First define the PROBLEM by examining symptoms: “We lost 20 hours of production” “The customer’s plant had to be shut down” “An employee broke his leg” “My son was ticketed for speeding”

Search for the “pain”, where does it hurt? The problem has a “so what” dimension, check: why do we

care? The cost of a ticket is an “OUCH”! The possible increase in insurance premiums HURTS! Your son has run afoul of the LAW [not a good thing].


Construct the Sequence of Events and Conditions Begin with the “bad thing”. Ask: “How did that bad thing happen?” or “What

immediately preceded the problem event to directly cause it to happen?”

EXAMPLE: “My son was driving his car” AND “His speed was 35” AND

“The speed limit was 25” AND “A Police Officer observed him”.

Think in terms of “events” and all of the necessary “conditions” that conspired to cause something bad to happen. In this example, the two events and two conditions had to all be present to lead to the end result.


“Speeding” Logic TreePolice officer observed

Event

ANDSpeed Limit was 25

Was ticketed Condition

for Speeding ANDEvent Speed was 35

Condition

ANDDriving hiscar

Event

Each box contains a single item. Avoid statements like: “Driving his car at 35”.


Building The Logic Tree The structure looks like a sideways tree. It spreads out with multiple “limbs”. Develop each limb of the tree by asking “What caused this

to happen?”. Capture events and conditions necessary to describe what

happened - working backwards. If you don’t know the “why”, terminate that branch with a

“?” mark. You may need to research that limb further. Eventually each branch ends.

Judgment is required here. Don’t terminate a branch prematurely (you may miss a significant organizational fault, but on the other hand don’t keep going back forever to the “origin of time”.


What the Logic Tree Looks Like:


“Speeding” Logic TreeAssigned to that location

Event

Police Officer Observed In position to see himEvent Condition

Speed Limit was 25 Local OrdinanceWas ticketed Condition Condition

for SpeedingEvent Speed was 35 Not aware that

speed limit was 25Condition Condition

Driving his Had to go to workcar

Event Condition

?

Need to investigate why he was “Not aware that

speed limit was 25”


“Speeding” Logic Tree

Local OrdinanceCondition

Not aware that Did not see Inattentionspeed limit was 25 speed-limit sign

Condition Condition Condition

Had to go to work

Condition

The root cause here might be attributed to “Inattention”. BUT: why the “Inattention”?

Try a Simple ExampleTake these eight statements and

identify the symptom of the problem - then draw the events and conditions in a Logic Tree

Chart.


Eight Statements:

Did not see debrisDriving to workLeft by previous car?Got a flat tireLooking backward to pass carDebris shredded tireSlow car in frontDebris in road


Case of the Shredded TireCase of the Shredded Tire

Got a flattire

DebrisShreddedTire.

Debris inroad.

Did not seeDebris

DroveOverDebris

Left bypreviouscar?

Lookingbackwardto pass car

Slow carin front


After The Logic Tree is Constructed ...

Identify Direct Causes.Key events or conditions (e.g., “ran over debris”)

that led directly to the undesirable event.Appear to the untrained person as the “root cause”

but is not. Identify Contributing Factors.

They have an influence on the problem, but if they were not present, the event could still have occurred.Example: Talking on the cell phone


Now Look Deeper:

Identify Latent Causes.Affect not only this incident but

influence spreads over a wide area and could generate many other similar incidents. The process of checking for access to the

passing lane

Definition of Latent:

“Present but not visible or Active”

“Dormant”

“Quiescent”



Searching for Latent Causes

One reason for identifying Direct Causes and Contributing Factors is to avoid calling them Latent Causes.

Direct Causes and Contributing Factors affect this particular case.

Fixing these factors is sometimes called “Containment”.Latent Causes will generate new problems of a similar

nature at a later date. Addressing Latent Causes leads to “sustaining”

corrective actions.


Finding a Latent Cause

In the speeding example, “Speed was 35” is a Direct Cause to “Ticketed for speeding”, but not the latent cause.

Latent Causes underlie Direct Causes.Latent Causes are at the end of the cause-and-effect

chain yet still within the control of the organization.Although the Direct Causes lead directly to the

problem, the Latent Cause sets up circumstances to bring about the Direct Causes.


Test for statements identifying latent causes

If a statement merely summarizes a bit of factual information about something that took place it is not a good latent cause statement.

Example: “Pipe broke”This is an accurate statement describing what

happened. BUT the statement does not “drill deep” enough beyond describing what happened, hence it is not identfying a latent cause.


Latent Cause Tests:

Events are not typically latent causes. Latent causes are more likely conditions that allowed events to lead to the (usually) undesired effect .

Think in terms of inadequate systems, processes, and procedures.


Other Tests for a Latent Cause Statement

If you were to remove the latent cause, or fix it, or change it so that the influence it had before is gone...the problem should go away permanently.

Sometimes it might take fixing or removing more than one “thing”, in that case you have more than one latent cause.

One of the causes is “necessary” but not “sufficient”.This shows up as fixing the problem under certain

circumstances but not all circumstances.


WARNING: Symptoms are not latent causes.Symptoms partially describe the problem.Symptoms tell you something about what’s wrong.BUT Fixing the symptom rarely stops the problem from

happening again. “We are having processing problems at the customer

site, and their filters are showing evidence of a solid contaminant in our product.”

The solid contaminant is a only a symptom of the underlying cause.

Ineffective corrective action: “They should switch to larger filters.”


Corrective ActionsAfter the Logic Tree chart is completed:

Check each box and ask if there is anything that can be done about it.

Build a corrective action list from these ideas.

Corrective Actions should: Be practical and achievable. Reduce the likelihood of problem repetition. Be compatible with other departments or functions. Be accountable in terms of persons and time.

Be sure you have done something about the Latent Causes and the various contributing factors.

EXAMPLE

The Case of Something That went Wrong?


Examples of Actual Investigations


EXAMPLE

“For the want of a nail, the shoe was lost; for the want of a shoe the horse was lost; and for the want of a horse the rider was lost, being overtaken and slain by the enemy, all for the want of care about a horse-shoe nail”. Benjamin Franklin, Poor Richards Almanac


EXAMPLE OF AN INEFFECTIVE LATENT-CAUSE ANALYSIS

Complaint: “Five skids are misidentified. Labels exhibit code 160200 instead of 160280”.

Latent Cause: “The latent cause of this error is that the label was not generated with the correct code”

IS THIS CORRECT?


ANOTHER EXAMPLE OF AN INEFFECTIVE LATENT-CAUSE ANALYSIS

“Customer profiles define shipping requirements. If the shipment arrived at the wrong temperature, it is because the temperature was not in the customer profile”.

HAVE WE FOUND THE LATENT CAUSE?


The Case of the Missing Bar-Code Label

Complaint Description Section: “Missing bar code labels - customer requires bar-code

labels on every box showing the part number.” Investigation Section:

“All messages are in place for customer to receive bar-code labels on their shipments. Order Entry tested a “dummy” order to make sure everything was in place for them to receive them on the next order and the test ran perfectly. We can only conclude this was a system-related problem that should not occur again.”

WAS THIS AN EFFECTIVE INVESTIGATION?


A Less than Effective Latent Cause and Corrective Action

Latent Cause Section: “Isolated incident that may have been a system-related

problem. All procedures are in place for customer to get bar-code labels. Test confirmed this.”

IS THIS A LATENT CAUSE? Corrective Action Section:

“Make sure before printing a bill of lading that bar-code indicator is set to “N” in other words do not bypass bar code labeling. This has been noted on customer profile.”

IS THIS AN EFFECTIVE CORRECTIVE ACTION?


The Case of the Scrambled Boxes

Complaint Description “Customer received sample with two different labels on one

box. One label read 248-1050 and the other label read 348-012002. The material ordered was 248-1050.”

Investigation “There were two orders from the customer scheduled to

ship. One order was for 100 pounds of 348-012002 and the other for 100 pounds of 248-1050. As the technician was processing the samples the shipping labels were attached to the wrong boxes. In essence it is inattention on the part of the technician which resulted in these orders being labeled inappropriately.”


Next Step…………..

Latent Cause Analysis “The latent cause was human error, affixing

address labels on two orders incorrectly.” “This is also a procedure short coming. We do not,

in detail, define the steps that should be taken by the technician to eliminate the potential for mixing sample orders.”


Following Step…...

Corrective Action “We have met with the technician responsible for

sample shipments, we reviewed the incident with the technician. This issue will be discussed with all technicians in the next team meetings.”

“The procedure covering the preparation and shipment of sample orders will be reviewed and updated as necessary to address this type of issue.”

On changing procedures ...

“Procedures are the scar tissue of past mistakes” Sherry Poriss, Performance Review Institute, Warrendale, PA

“Warning labels and large instruction manuals are signs of failures, attempts to patch up problems that should have been avoided by proper design in the first place.” The Design of Everyday Things, by D. A. Norman, 1988, Doubleday.


NOW YOU TRY IT ...

The Case of the Capsized FerryGet into teamsReview the facts of the case,What is THE PROBLEM?Build a Logic Tree with post-it-notes Identify key Direct Causes Identify Contributing Factors Identify Latent Cause(s)

Other Tools


Chronological Timeline Tool

The Logic Tree does not follow a timeline.Can be confusing.Building a timeline helps sort-out the order in which events took place.

Might offer some cause/effect clues.BUT is often multiple tracks with parallel lines which can itself be confusing.


For Simple Problems, A “5 Why’s” Analysis May Work

“Why is our production rate so low?” “Well, the preheater pressure is maxed out.”

“Why is the preheater pressure maxed out?” “Because the polymer melt viscosity is too high.”

“So why is the polymer melt viscosity too high? “Because the polymer melt temperature is low.”

“Why is the polymer melt temperature low?” “The second-stage reactor temperature is low.”

Why is the second reactor temperature low? “Because the process chemistry requires it to be low.”


Need Another Why“Why does the process chemistry require it

to be low?”“Hey ... if we go to this new catalyst we can run

the second-stage reactor at a higher temperature.”

Just hit upon a corrective action!BUT: Have we considered other factors?This is really just one branch of a Fault

Tree.


Sometimes the Tree Doesn’t Help Much

If you have a process with numerous inputs a variety of process variables and an unpredictable output, Logic Trees are not the best way to find out why the output is varying.

Example: “Product X is frequently off-spec in color. Color is influenced by temperature, pressure, production rate, and an impurity in the feedstock.”

Statistical techniques are required. If you have a long list of potential causes.

Not sure which ones need closer examination. The “What’s Different” tool is then useful.

“What’s Different” Analysis

Use this tool when it is not clear what changed to lead to the undesired effect.

Compare “problem” cases to “no problem” cases.


“What’s Different” Analysis

Break the problem down into:WHAT IS THE PROBLEM vs WHAT IS NOT?WHEN IS THE PROBLEM vs WHEN IS IT NOT?WHERE IS THE PROBLEM vs WHERE ISN’T IT?THE SEVERITY OF THE PROBLEM?

Look for a pattern in the “difference” comparison.

Based on Kepner and Tragoe “IS/IS NOT” analysis


EXAMPLE: Excessive leaks in Unloading Hoses

Customer complained that carrier hose fittings often failed hydrostatic tests at their facility.

Truck sent back to originating plant with customer complaint.

Yet hose fittings tested OK back at the terminal. Logic Tree working backward through series of events did

not pick up on any obvious causes. Special hoses and connections for that customer site? Poor unloading procedure? Incompetent unloading personnel? Inadequate unloading facilities?

Events and conditions seemed somewhat contradictory.


IS/IS NOT Analysis [Kepner & Tragoe] Look for instances where the problem does NOT occur. Compare to where and when it DOES occur. In fact the customer had another site where the leaks were

not occurring (IS NOT). Asking questions of the driver involved revealed a critical

DIFFERENCE between the two sites. At the no-leak site the standard practice was to have a

cleaned hose from the previous trip off-loaded and waiting in an interior location.

An arriving truck swapped hoses; they used the previous trucks hose to unload the arriving truck - the new hose was stored inside for the next load - NO LEAKS!


IS/IS NOT Questions lead to new insights: When leaking hoses from problem customer site were

tested later they had warmed up and did not leak. “Good” hoses left outside in the cold of winter showed

leaks. DIRECT CAUSE:

Hoses that cooled down had couplings that shrank away from the hose material allowing for slight leaks.

LATENT CAUSE: Inadequate unloading procedure that failed to take into account

the affect of changing temperatures on hose coupling. CORRECTIVE ACTION:

Apply same hose swap with other customer site.


Corrective Action Develop corrective actions with the team or “virtual

team”

Monitor corrective action implementation Verification.


Verification

Review the corrective action after sufficient time has elapsed since it was implemented.

Check that the corrective action was indeed implemented and still in place.

Determine if there have been any recurrences after the corrective action was implemented.

Don’t have tunnel vision -- if the corrective action was implemented because of a problem with Customer X, it is not effective if it occurs later with Customer Y.

If there is a recurrence, the corrective action must be deemed Ineffective and the investigation re-opened.


Some key tools for developing effective corrective actions

Process Mapping RACI Applied Behavioral Analysis. Cognitive Psychology of Human Error. ISO Standards.


PROCESS MAPPING

Often a latent cause is tracked to some malfunctioning part of a process.

Unfortunately processes work horizontally while management is designed vertically.

Who is in charge of a horizontal process? Who can take managerial charge of a process that

needs to be fixed? The answer is often unclear. Mapping the process with all stakeholders can force

the issue.


Silos vs Processes

Vertical organizational silos handling a process, but who is the process owner?

Silo 1 Silo 2 Silo 3

Process


PROCESS MAPPING

The action of mapping a process with the various “silo” owners present can lead to turf wars but it can also lead to agreement on who “owns” slices of the process.

Then you gain enough ownership to bring about managerial impact on the changes needed for the corrective action.

It helps to be building this “for ISO” - adds respectability to the mapping process!


PROCESS MAPPING

For the purpose of building a corrective action you need to define the process needing mapped.

Then identify the persons most likely to be process owners.

Bring them together and with post-it-notes construct the elements of the process paying particular attention to the information flow through the process.

Search for ways to change the process so that an undesirable incident is less likely to occur.


NEED RACIAlthough you may build acceptance regarding

the process map there is still room for misunderstanding among the owners regarding exactly who is responsible for doing what.

The RACI tool helps clarify the details so that specifics of process interaction are precisely defined.

RACI stands for: RESPONSIBLE, ACCOUNTABLE, CONSULTED, INFORMED


RACI TOOLRESPONSIBLE: Who is the person responsible for

carrying out the process step under examination?ACCOUNTABLE: Who is the person accountable

for seeing to it that the person responsible carries out the task?

CONSULTED: Is there a position or positions within the organization who needs to be consulted about the task?

INFORMED: Is there anyone who needs to be informed about the execution of the task?


Identify all activities and decisions necessary to run the day-to-day process effectively

Identify: Who is Responsible (“R”) Who is Accountable (“A”) Who must be Consulted (“C”) Who must be Informed (“I”)

Document on charts for reference

RACI Charting


Role Players are the positions in the organization that have a task to perform.

Role Players:

Activity:

• An action or decision that is one of several sequential steps in the completion of a business process.

II

AA

CC

II

RR

AA

CC

II

CC

RR

RR

CC

II

RR

AA

CC

AA

II

AA

RR

RR

AA

RR

AA

CC

II

RACI Definitions (cont.)


Activities / DecisionsActivities / Decisions 1 A CActivities / Decisions 2 C RActivities / Decisions 3 A RActivities / Decisions 4 I A RActivities / Decisions 5 R AActivities / Decisions 6 I A C

Look For: No or too many

R’s No or too many

A’s Too few A’s / R’s Every box filled in Lots of C’s Lots of I’s

Analysis of RACI Chart


Get Feedback and Buy-In

Show the RACI chart to the representative groups of people covering the roles on the chart

Capture their comments and revise the RACI chart, if appropriate


HUMAN ERROR

There are circumstances where an undesirable event was partially caused by a person within the system who failed to do something that needed done.

Don’t just blame them! Judge how the failure occurred.

Use the following test: Didn’t know how to do it. Didn’t know to do it. Wouldn’t do it. Didn’t know they didn’t do it.


Doesn’t KnowTo Do

Corrective Actions for Behavior

If root cause is determined to be“human error” or simply a case ofpeople not doing what they aresupposed to do. Conduct a RootCause Analysis for Behavior.

Determine what’s needed, i.e.resources, training. Removebarriers.Can’t D

o

Ensure the right things are beingreinforced, especially when thereare competing behaviors.

Develop and communicate clearand agreed-upon RACI.

Won’t Do

Need Mistake Proofing

Slips


Typical Corrective Actions: Can’t Do

The “can’t” often relates to undeveloped skill or knowledge. Training (one of the knee-jerk automatic corrective actions) is the relevant corrective action.

Possibly “can’t” has more to do with unavailable tools or materials.

“Can’t” might even be involved with politics or a decision that someone is “not allowed” to do it.


What do you do with “Didn’t know how to do it”?

“Can’t do it” relates often to undeveloped skill or knowledge.

Sounds like training is needed. Possibly tool availability or use might be an issue -

computer example. Ask ISO:

6.2.2 Competence, awareness and training Someone needs to determine the necessary competence. Someone needs to offer the necessary training.


Doesn’t Know To Do Situations

When the root cause is due to individuals who can do the behavior, but do not know that they must complete the task, then use the RACI tool.

RACI defines the types of participation and involvement of all impacted team members.


What do you do with “Didn’t know to do it”?

The person responsible did not know they were responsible? The person accountable needs to straighten this out.

And check ISO: Update job description etc.

6.2 Human resources 9004 points to the “involvement of people….by defining their

responsibilities and authorities”


What do you do with “Wouldn’t do it”?

Put a gun to their head? Tell the boss?

(Bosses are not always effective) Application of Behavioral Principles can help.

Behavior affected by: Antecedents Consequences

Corrective actions can be centered around creating the right mix of antecedents and consequences.


Applied Behavioral Analysis

Solution based on a long history of psychological research.

The term “Behavior” is precisely defined. Behavior is measurement based. Studies show behavior can be triggered by incidents

preceding it called ANTECEDENTS. Behavior can be strengthened by the application of

resulting incidents following the behavior called CONSEQUENCES.


Won’t Do Situations

We address the individual who Won’t Do a task through a “Consequence Plan”.

“Won’t Do” usually means: A lack of natural positive consequences exist for task completion. Naturally occurring negative consequences exist for the desired

behavior. Answer:

Plan and provide positive consequences for the right behavior (to override the naturally occurring negatives.)

Analyze what’s being rewarded (from the performer’s point of view.)


Building a Consequence Plan

If they don’t do it there needs to be a consequence (or two…etc) clearly following the inaction that is recognized by the “non-doer” as undesirable [punishment].

When they DO do it there needs to be resultant consequences that have a positive, reinforcing effect.

Antecedents include clear messages that it needs to be done and this is why….etc.

Antecedents can instill a “belief” that doing it is a good thing.


What do you do with “Didn’t know they didn’t do it”?

“Asleep at the switch”? YES, The psychology of human error “Slips” are a class of human error involving

unawareness of the error. Occurs during skilful acts. An example could be typing errors Corrective actions do not include:

Punishment Re-training Reviewing procedures


Types of Slips

Capture Slip A pattern similar to another pattern (the desired behavior) is

triggered because it has a higher frequency of execution. Example: Calling the wrong number because you are used to calling it.

Associative Activation Slip Your actions are applied on the wrong thing, the intention is

correct but is misapplied. Example: The case of the wrong dog.


Types of Slips

Loss of Activation Slip The intent begins the action but short term memory is

suddenly loaded with something else and you find yourself part-way through an action but cannot remember why hence cannot complete the act.

Example: Why did I go upstairs?


Correcting Slips

Change the system under which the slip occurred. Redesign the way people interact within the system. Put into place immediate feedback loops. Design in checker routines. Re-program the computer. Include “Mistake Proofing” (Poka yoke)


More Human Error Types

Rule based errors A rule (known to be a good and true rule) is applied to the

wrong thing in the wrong setting hence causing a problem. Example:

RULE - If your car is going too fast, put on the brakes. But suppose you discover you are driving on ice?


More Human Error Types

Knowledge-based errors The situation is too far out-of-control for rules to work Rules were not constructed for this situation Instead you must figure out what to do from scratch based

upon your knowledge of the system. Unfortunately your analysis can lead you off-track and an

error is made. HELP? The more information you can provide the better


HUMAN ERROR: What Do Researchers Tell Us?

“Instead of blaming the human who happens to be involved, it would be better to try to identify the system characteristics that led to the incident and then to modify the design…”

“One major step would be to remove the term ‘human error’ from our vocabulary….”

“One conviction that seems to be shared by all members of the field studying human error…is a rejection of the conventional approach to error prevention, that of TRAINING and PUNISHMENT.”


FINAL MESSAGE

Search for patterns underlying a family of complaints. Improving corrective actions means looking further and

deeper than fixing the direct cause of a problem. Let ISO help cue that search for deeper places to look. Change the system instead of blaming the performers in

it. Identify and map out processes looking for ways to

improve the processes so the problem is less likely to recur.

Apply principles of behavioral reinforcement to susstain a true change in behavior.


THE END……………….References:

Guidelines for Investigating Chemical Process Incidents American Institute of Chemical Engineers (1992).

“The deductive approach starts at one point in time (the event) and looks backward in time to examine preceding events.”

See also “Current Reality Tree” tool described in Goldratt’s Theory of Constraints by H. William Dettmer (ASQ Quality Press, 1997)

“In building a Current Reality Tree, we work our way from Undesirable Events back through the chain of cause and effect to root causes”.

Documents

Hidden Faultlines In Your Organization Find them FAST FIX them Forever Dr. Ted Spickler Quality and Business Services 412-777-2054 [email protected]