Stop blaming people for broken processes
Something goes wrong. It happens more times than we would like to admit, particularly I’m manufacturing where there are so many moving parts to keep aligned. A batch is scrapped. An order is late. A machine is set up incorrectly.
What happens next?
Quite often, we look for someone to blame.
Who did it? Who was responsible? Who needs retraining?
And sometimes, of course, people do make mistakes. But before we jump to conclusions, perhaps we should ask a different question, because in my experience, if you think the root cause is human, then you’ve probably not looked hard enough.
What is it about the process that allowed the mistake to happen?
I've spent years working in manufacturing, and I've seen how easy it is to focus on the individual rather than the system they work in, it can be a tempting and seemingly simple fix. How often have you seen retraining as the corrective action? It rarely addresses the root cause.
An operator uses the wrong machine setting. But are the correct settings clearly documented? Are they easy to find (visual management people)? Has anyone checked that everyone understands them? Are there different versions floating around the factory? Annotations in pencil?
The plan for the week is missed. But did everyone agree the plan from the start? Were material shortages flagged in time? Are the priorities clear across all departments?
A quality issue keeps recurring. But have we genuinely understood the root cause, or have we simply reminded people to be more careful?
Telling people to be more careful isn't a root cause analysis.
It's just ticking the box.
If the same problems keep happening, then its time to change what you are doing - are you fixing the problem or simply treating the symptoms?
This is where Operational Excellence can help.
It's about looking at the whole process, understanding where things go wrong, and putting systems in place that make it easier to do the right thing consistently. We do this together, involving the people who are part of the process to make sure that nothing gets missed and any improvements actually work for them.
That might mean clearer standard work, better visual controls, improved communication between departments, or mapping the end to end process to find out what’s actually going on.
It doesn't mean removing accountability. People still need to take responsibility for their actions. In fact, sometimes it actually means adding in MORE accountability.
Accountability works best when people have the right tools, information, training and processes to succeed.
Another benefit is that when people aren't worried about being blamed, they're more likely to speak up when something goes wrong. That's when you start uncovering the issues that might otherwise remain hidden. It also helps if you have a great mechanism for two way communication in place.
So next time a mistake happens on your factory floor, try asking three questions before looking for someone to blame:
What was supposed to happen?
What actually happened, and why?
What can we change to prevent it happening again?
You might find that the person you thought was the problem is actually the person who can help you solve it.
