Now, obviously this event is not directly related to safety,
as no one was injured, nor were they likely to be injured. However, the story
is pretty similar to one you hear a lot following an accident or incident –
someone screwed up and we have to pay the price for it. If only the project
manager had paid more attention while setting up the schedule the failure would
not have occurred. Therefore we can say that the cause of the accident was
“human error”.
How do we deal with it? Well, the answer is obvious. If the
project manager had only paid more attention we wouldn’t be in this mess, so we
need to tell the project manager to pay more attention next time. Perhaps even
some discipline is necessary to let them know the consequences of their
mistake. We could dock their pay for the lost revenue from having an assessor
do nothing all day. That would show them. If only we could find a way to get a picture of them in the act that we can use in training to shame them and others
into doing the right thing, that might help them not make that same mistake.
Does any of the above sound familiar? It should, because
it’s the same basic way that most organizations respond when a failure occurs
and it can be traced back to some sort of mistake. The thing is that the above
seems like it makes sense. However, what you see depends on what you choose to
see. Or, as Erik Hollnagel says, what you look for is what you find,
particularly after an accident. Many are content with seeing a failure
event like the one above as another story of people not doing what they are
supposed to do. So we need to fix the people (the project manager in this case)
and the problem will go away. But if you choose to look at the event
differently a different lesson and a different set of interventions present
themselves.
To illustrate, let’s look at the same event, but let’s look
at the actions of the project manager in the context they were in. First off,
the client was the one scheduling the individual focus groups and they did not
finish the schedule until late Friday afternoon, the week before the
assessment. So the project manager had to construct the schedule for his
assessors over the weekend. This was no easy task, as the project manager had
to take the schedule from the client and ensure that each focus group had an assessor
assigned to facilitate and some of these focus groups overlapped and were miles
away from each other (it was a large site). So the project manager needed to
ensure that each assessor had time to get to their focus groups, and then put
this information into a format that was easy to understand.
Normally we have quality controls in place to check people’s
work, but special circumstances made this challenging. First, it was a weekend,
so most people were not available. Second, those that were normally available
over the weekend, were not this particular weekend, as a result of their family
dog passing away that Friday. Oh, and by the way, the project manager was
constructing the schedule after helping bury the dog that afternoon. So he was
doing complex work, while tired, potentially distracted, and without crosschecks
to ensure accuracy.
Finally, the assessors who arrived at the same focus group
could have realized that it is not normal to have two assessors in the same
focus group. So that could have alerted them to the problem, which they could
have then figured out that one them was supposed to be somewhere else. But the
two assessors happened to be those with the least experience with the client
and with the focus groups we do. In fact, one of the assessors was not even
supposed to be there, as we had informed the client that we had a limited
number of assessors available that morning, so we needed to limit the number of
focus groups scheduled, which may have been lost in translation. But the customer
is always right, so we pulled in an assessor who was unfamiliar with the
project at the last minute to accommodate.
Here’s the thing – it is true that if only the project
manager had not made the mistake then the failure would not have happened. But
the fact that we focus on that piece of the story and ignore everything else
should say something to us. Here’s some more “if only” statements that are
equally true:
- If only the client had not scheduled too many focus groups that morning, the failure would not have happened.
- If only one of the two assessors happened to be one of the more experienced assessors who were onsite they might have noticed the issue earlier and started asking questions that would have led to a better solution.
- If only the family dog didn’t pass away, the quality control programs may have been in place to catch the problem during the weekend.
- If only the client had delivered the finished schedule earlier, the project manager may not have had to construct the schedule over the weekend, when he was tired and likely to make a mistake.
- If only the supervisor had not gotten angry at having missed the first focus group, we could have accommodated a make-up for the one focus group and easily conducted the rest of the focus groups for that day as scheduled.
There are more “if only” statements we could identify. This
isn’t just a long, convoluted excuse (we apologized profusely and took full
responsibility to the client, making up the focus groups and making everyone
happy). Rather, what we are trying to show is two-fold. First, as Drew Rae says, when you tell the story of an event, especially a
failure event, like an accident, you are making choices. The choices you make
are how you tell the story, what facts you share (and what you don’t share) as
relevant, and who you highlight was important (and not important) to the story.
All of this affects what you get out of the story. If all you do is tell the
story of “human error” that involves a deficient person doing something stupid,
then it makes sense that you would be led to the conclusion that you need to
blame and fix that person. But if you choose to tell the whole story and
context, if you choose to see the world through the eyes of the people involved
(as much as it possible), a different picture emerges that leads to different
conclusions.
And our second point, is that is this has real world
consequences. Because if the second version of our story is true, the idea that
we can tell the project manager to be more careful next time and that this will
fix our problem is just silly. The project manager didn’t make a choice to make
the mistake, so tell him to choose to not make the mistake next time is like
telling your pet dog to try and do better at math next time. The project
manager felt terrible for his mistake already, so what is us making him feel
even worse going to do?
The point of choosing to tell the whole story of the event
is not to remove blame just for the sake of letting someone off the hook.
Instead, it’s about really solving the problem. By understanding the story you
can build in more defenses that actually improve your system. For example, if
part of the issue is related to inexperienced assessors, telling the project
manager to not make a mistake next time doesn’t make that situation better. It
also doesn’t fix communication issues with the client in terms of scheduling
needs.
So next time you are faced with a situation in your
organization where someone made a mistake, remember that you have a choice. You
can choose to focus on that one “if only” statement, or you can choose to see
the larger picture and you just might actually make your system safer in the
process.
No comments:
Post a Comment
Note: Only a member of this blog may post a comment.