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Hidden Fault lines In Your Organization. Find them FAST FIX them Forever Dr. Ted Spickler Quality and Business Services 412-777-2054 [email protected]  Bayer Corporate and Business Services LLC. Why Are We Here?.

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hidden fault lines in your organization

Hidden FaultlinesIn Your Organization

Find them FAST FIX them Forever

Dr. Ted Spickler

Qualityand Business Services

412-777-2054 [email protected]

 Bayer Corporate and Business Services LLC

why are we here
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.
  • 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
What Are We Going to Do Today?
  • Examine techniques for uncovering faultlines.
  • Practice building logic tree’s, a key tool for uncovering LatentCauses.
  • Differentiate between Direct Causes, Symptoms, Contributing Causes, and Latent Causes.
  • Learn to build effective fixes to these problems.
when something goes wrong typical reaction
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 approach
We Need A Better Approach
  • Find 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
Finding the Faultlines
  • We have learned to look in these two places:
    • Customer Complaints
    • ISO audit Corrective Action Requests (CARS)
  • 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
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
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
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
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
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
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
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.

a lesson in assuming16
A Lesson In Assuming

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.
a lesson in assuming19
A Lesson In Assuming

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.


how to construct a 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
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?”
    • “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 tree
“Speeding” Logic Tree

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

building the logic tree
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 tohappen?”.
  • 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”.
speeding logic tree26
“Speeding” Logic Tree


Need to investigate why he was “Not aware that

speed limit was 25”

speeding logic tree27
“Speeding” Logic Tree

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

try a simple example

Try a Simple Example

Take these eight statements and identify the symptom of the problem - then draw the events and conditions in a Logic Tree Chart.

eight statements
Eight Statements:
  • Did not see debris
  • Driving to work
  • Left by previous car?
  • Got a flat tire
  • Looking backward to pass car
  • Debris shredded tire
  • Slow car in front
  • Debris in road
case of the shredded tire
Case of the Shredded Tire

Case of the Shredded Tire

after the logic tree is constructed
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
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

Definition of Latent:

“Present but not visible or Active”



searching for latent causes
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
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
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
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
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
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 actions
Corrective Actions
  • After 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.


The Case of Something That went Wrong?

  • “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”
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”.
the case of the missing bar code label
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.”
a less than effective latent cause and corrective action
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.”
  • 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.”
the case of the scrambled boxes
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 ofthe technician which resulted in these orders being labeled inappropriately.”
next step
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
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

On changing procedures ...

“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 Designof Everyday Things, by D. A. Norman, 1988, Doubleday.

“Procedures are the scar tissue of past mistakes”

Sherry Poriss, Performance Review Institute, Warrendale, PA

now you try it
  • The Case of the Capsized Ferry
    • Get into teams
    • Review 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)
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.

Chronological Timeline Tool
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.”

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

Need Another Why
sometimes the tree doesn t help much
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

“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 analysis59
“What’s Different” Analysis
  • Break the problem down into:
  • Look for a pattern in the “difference” comparison.
  • Based on Kepner and Tragoe “IS/IS NOT” analysis
example excessive leaks in unloading hoses
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
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
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.
    • Hoses that cooled down had couplings that shrank away from the hose material allowing for slight leaks.
    • Inadequate unloading procedure that failed to take into account the affect of changing temperatures on hose coupling.
    • Apply same hose swap with other customer site.
corrective action
Corrective Action
  • Develop corrective actions with the team or “virtual team”
  • Monitor corrective action implementation
  • 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
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
Silos vs Processes
  • Vertical organizational silos handling a process, but who is the process owner?

Silo 1

Silo 2

Silo 3


process mapping68
  • 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 mapping69
  • 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 raci
  • Although 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 tool
  • RESPONSIBLE: 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?
raci charting
RACI Charting
  • 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 definitions cont
Role Players are the positions in the organization that have a task to perform.



























RACI Definitions (cont.)

Role Players:

  • Activity:
    • An action or decision that is one of several sequential steps in the completion of a business process.
analysis of raci chart
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
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.
corrective actions for behavior
Corrective Actions for Behavior

Determine what’s needed, i.e.

resources, training. Remove


Can’t Do

If root cause is determined to be

“human error” or simply a case of

people not doing what they are

supposed to do. Conduct a Root

Cause Analysis for Behavior.

Develop and communicate clear

and agreed-upon RACI.

Doesn’t Know

To Do

Ensure the right things are being

reinforced, especially when there

are competing behaviors.

Won’t Do


Need Mistake Proofing

typical corrective actions can t do
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
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
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
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
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
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
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
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
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
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 slips88
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
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
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 types91
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
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
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 ofConstraints 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”.