Tired of ROOT CAUSE = TRAINING?

Many organizations have a tendency to identify MOST of their nonconformances as ROOT CAUSE = TRAINING.  

In order to realize REAL improvement, organizations should avoid this practice.  Or at least, take it just a half a step further to really get into WHAT the supposed "training issue" really is!

It's true.  Many nonconformances are the result of an "operator error".  But the fact is, if the system allows the operators to routinely make errors, the system is not yet robust enough.  Can we ever prevent errors 100%?  Probably not.  However, we CAN IMPROVE our systems to make fewer errors.  How do we do this?

By digging further into exactly WHY an operator error occurs.  This requires a bold and brave approach to root cause analysis.  

Humans make errors.  There are some tools such as instructions, checklists and additional inspection to try to reduce these errors (or at least improve our chances of catching the errors before they escape).  But, these aren't the only tools that can reduce human errors.

There are a couple of additional areas to explore when it comes to operator errors.

The first we'll talk about is how to get people to do the thing the right way, every time.  Many times, a person will complete a task correctly 9 times out of 10, but fail on the 10th.  Why?  And how do we build a system that will reduce our risk of error?

There's some terrific tools and methodologies I've learned and applied from "Conduct of Operations" and "Operational Discipline" (CofO and OD).  The cool thing is, if you currently have an ISO-based management system, CofO and OD is also an integrated approach.  And while your organization may not need the depth and complexity of these methodologies, their principles can be invaluable in creating a more robust system. 

"Conduct of Operations (CofO) " defines execution of operational and management tasks in a deliberate and structured manner, leading to "Operational Discipline (OD)".  This is used in industries where safety and accuracy in operations are highly critical such as oil & gas, chemicals, nuclear power, etc.  The stakes are much higher for "operator error" in these industries.  So, there's a lot we can learn and apply.  It focuses on 4 main objectives:

1 - The formality and discipline of operations is adequate to conduct work safely and programs are in place to maintain this formality and discipline

2 - Sufficient numbers of qualified personnel are available to conduct and support
operations. 

3 - Adequate and correct procedures and control limits (including safety limits as
applicable) are in place for operating the process systems and utility systems that include
revisions for modifications which have been made to the facility. 

4 - The Integrated Work Management Process has been implemented to
ensure work is conducted safely, securely and compliantly.

Operational Discipline focuses on DOING THE RIGHT THING - THE RIGHT WAY - EVERY TIME.

The idea is to create a culture through training and education which values knowledge, formality, ownership and integrity.  Training programs emphasize the following:

DO THE RIGHT THING.  Level of Knowledge. Understand not just what you do, but why you do it. Continually seek greater knowledge about the systems, processes, and hazards in and around your workplace.

DO IT THE RIGHT WAY.  Formality. Treat your workplace and your role with respect, recognizing the seriousness of what you do and your role as a part of something bigger. Follow authorized procedures and expect the same from others. If you think of a better way, follow authorized processes to review and improve the procedures.

DO IT EVERY.SINGLE.TIME.  Questioning Attitude. Constantly ask yourself what could go wrong. Check for out-of-the-ordinary and learn to anticipate potential problems. Don't assume things are okay - verify.  Forceful Watch Team Backup. Backup your coworkers by looking out for what they may have missed and expect the same in return. Have the courage to care, intervening even when it makes you uncomfortable. If you see an issue, own it.  Integrity. Be reliable. Do what you say you are going to do, completing every task the right way, every time, even if no one is watching.

Sound familiar?  It doesn't matter whether your organization embraces Lean, Six Sigma, Agile or ISO based management systems.  ISO9001, ISO14001, ISO45001 and many other industry specific standards such as IATF16949 and AS9100, share these principles.  And companies are trending toward INTEGRATING these systems into a cohesive set of operating systems with consistent parameters to improve performance and reduce risk.  

So, this can work in supplement to your current system!  It's not something completely different or in opposition to whatever you're working with now.  To learn more about it, check out the standard at Conduct of Operations Handbook (doe.gov).

There's some great stuff in there that might help you take your exploration of reducing human error to the next level. 

The next thing is just to be more specific about why a mistake was made which resulted in an error in order to implement a more effective solution.

I recommend a deeper analysis whenever "operator error" is identified as a root cause.

• FIRST, is it REALLY the true root cause?
• If it IS, take the analysis further.  Whether you used "5Y", "Fishbone" or a simple "I Know Why" approach, it MUST go further to dig into exactly why the error was made.  
• What part of the system wasn't strong enough to prevent the operator from making the mistake?  Where is the disconnect between the system and the operator?  Some potential threads to explore might be:
  • Inadequate procedures
  • Inadequate communication of the procedure
  • Inadequate training program design
  • Inadequate training program execution
  • Inadequate enforcement of procedures

And each of the threads listed can be explored to drill even further into why the system is failing. 

• For example, "Inadequate procedures" might be caused by one or more of the following:  (HOW IS THE PROCEDURE INADEQUATE?)
  • Inadequate procedures
    • Lack of defined responsibility
    • Lack / inadequate job analysis
    • Inadequate coordination with procedure/process design
    • Inadequate employee involvement in the development
    • Confusing format
    • Contradictory / confusing requirements
    • Inaccurate sequence or missing steps
    • Key scenarios & reaction plan not covered

And if you can arrive at the deepest weakness of why you've identified the problem being the "Inadequate procedure", you can make a more effective correction. 

And once, you've made the correction locally on the specific procedure that was inadequate, you can take your corrective action further through the system.  You might:

• Review the rest of your procedures to see if any of them share the same weakness.
• Create criteria for future procedures that require all new procedures consider and clarify the list above.
• Review other noted nonconformances to see if similar errors are occurring elsewhere and make the appropriate corrections.
• Partner and engage with other areas to ensure processes are integrated.  For example, when a procedure is written, is it:
  • Adequately managed to ensure changes are properly communicated?
  • Is training immediately integrated when a new procedure is released?
  • How does the training process ensure that future employees are trained?
  • How is training effectiveness evaluated?  (This should be something like an audit of demonstrated competence.  Not only do the employees receive training, but do they retain and apply consistently the information?)

For more information on how to more clearly define ROOT CAUSE, use the form below to download a FREE template Common Root Cause List.  Use it for more effective problem solving and targeted corrective action.  HINT:  This Common Root Cause List will give the user an immediate "first three Why's" for problem solving!

If you'd like training for your organization on any of these concepts, we offer a variety of training solutions for your team.  No cookie cutter slide deck nonsense.  Our training begins with key concepts and principles, but each session is workshop based and will be customized INCLUDING ONE OR MORE OF YOUR ORGANIZATION'S REAL-LIFE PROBLEMS for your employees to explore!  Our customers rave about the effectiveness of our workshop approach.  Contact us today!

For an individual, try a weekly or monthly coaching subscription!  Again, we'll look at YOUR ORGANIZATION'S REAL-LIFE PROBLEMS with help from an experienced professional to help you more clearly identify true root causes and initiate better corrective actions to actually improve your results!

And remember, join me on my journey to always Keep Improving!