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Sunday, September 21, 2014
The Best way to learn about Error -
It is a given that if a Qualitologist wants to improve quality, one of the first things to do is reduce error, and to reduce error, one needs to understand who causes error, why they cause error and what we can do to help turns things around. Turns out that may not be so easy.
Yesterday I had the opportunity to attend a workshop seminar put on by the Canadian Society for Safety Engineering who had invited Sidney Dekker. I have written of Sidney Dekker before. By academic background and training a psychologist, and by avocation a pilot, and by profession a thinker and writer and speaker/presenter on Error.
Dekker has honed a fine craft as a speaker/presenter. He is fast and edgy, personable, with more than a a touch of cynicism and sarcasm. Presentations are more a flow of consciousness than a formal focus on a topic. But it works out OK if you can stay on board.
The Dekker message is the error is complex, with the system contributing a lot, maybe most of the fault. If the system was better, there would be fewer errors. That is a message that I can live with, mostly, but not completely.
Dekker has come up with an interesting notion. If a standard or an instruction or a standard operating procedure says to do A, and the worker decides that it is better to do B, the difference between A and B is not called a “non-conformance”, rather it is a reflection of “resilience”. That is to say that if the worker chooses to go his own way, to break ground to find another solution, that is a good thing. It reflect mostly on the inadequacy of the standard, or instruction. As he puts it, there is the way the task is written and the way it is going to get done, that these two approaches may not be the same. In his view, there is great power in the young and new recruit learning at the foot of the wizened old-timer with a ton of experience. “I’ll show you how that really gets done”.
Well that certainly is interesting.
Now don’t get me wrong, my own philosophy and approach does not differ all that much. For example, from years of trying , I understand that one of the hardest things to do is write a standard and an SOP. An old exercise is to write an SOP on something like making a paper boat by writing the instructions on how to hold and fold the paper. It becomes pretty clear in a real hurry that given to 10 people you are very unlikely to get more than two boats looking alike, and those that do were likely a mistake. There are better ways to prevent chaos, for instance, pre-testing the SOP to see how many people understand what they are supposed to do (and keep in mind that in many worksites, there are many for whom English is a second language. So rather than work with traditional SOPs, consider supplementing with pictures and audio and video clips.
And I am pretty OK with writing flexible SOPs where the person has some choice in low risk steps. I don’t mean things like knowing how to find and hit the POWER OFF button, but if a step requires about a minute pause, but the requirement doesn’t have to be exactly a minute, then the SOP should not be framed around words of precision.
Also, I am a firm believer in the apprentice process, where junior staff are not just trained by a “teaching tech” as we call them in the laboratory, but that they sit side-by-side and learn for an extended period of time before being able to work on their own.
But I do have a problem with framing non-conformance as a positive (resilience). If someone does find a better way, there is a better approach for fixing the problem for everyone.
And I have a problem with Dekker’s notion that there are no people who are accident prone. They are not “bad apples” and they are not “morally suspect”, but they do exist. Some of them exist from silent incipient health issues that go unnoticed. Some are due to non-work related issues including family or time stress. Some may even be as a natural inclination that everyone else is wrong and they only they are right (that might even include me and others that I know and have met.) They may not only be a risk to themselves, but they may be a risk to others, and finding workable solutions can be a significant challenge.
But for me the bottom line on the workshop/seminar was that I came out at the end of the day with a ton of questions and challenges that will stimulate a lot of thought and action. And that is about as good an outcome as one can expect.