Fighting Mistakes with an Open Mind

As appeared in RxToday

Fallor ergo sum. I err therefore I am. (St. Augustine)

No one I’ve ever met who operates an automobile repair garage would leave wheel nuts loose because he/she didn’t feel like tightening them. But quite a few maintenance people have gotten distracted and let a car go out with loose wheel nuts. By the same token no surgeon would knowingly leave a sponge, clamp or anything else in a patient, yet to read the papers it happens all the time.  

To err is human; to admit it, superhuman. (Doug Larson)

Everyone makes mistakes. In my classes I frequently ask if anyone (who has carried tools in their life) has ever caused a worse repair problem doing a repair. I say the only answers are either you have or you are lying (or perhaps you never did anything with the tools you carried.) Sorry for being harsh. To make the matter worse the “right” mistakes at the “right” time make us grow and develop in our field. In fact, without mistakes, growth might very well be impossible.

In fact, when anyone touches a machine for any reason there is a small chance they will mess something up. What causes this? Another way to ask this question is what are the causes for error? Failures of this type, ones caused by the repair person, are called iatrogenic failures. The word comes from the medical field, and originally from Greek, meaning an illness caused by a doctor or other health professional.

We battle the causes of mistakes while accepting their inevitability. We know some causes of mistakes because they are common experiences, like fatigue, being preoccupied or not having enough light.

I remember one job like it was yesterday. I used to have a company that designed, built, installed and serviced motor fuel management systems. I was called in from Philadelphia to service a system I had installed on Long Island, New York. It was Friday afternoon and I knew if I left the job soon I’d be home in three to four hours but if I delayed it might be five or more hours before I got home. Typical for this equipment I diagnosed the problem and made the repair in about 45 minutes. So far so good.

I was installing the metal cover (remember, I was moving quickly) and I didn’t notice that a couple of wires got caught by the lip of the cover. I felt a little tingle in my hands, the circuit breaker popped and I smelled the characteristic acrid smell of burned plastic. I took the cover back off and saw smoke coming from the circuit boards. In my haste I fried all the circuit boards when 220V mains power was routed through the 5V supply and ruined the entire unit. I felt completely stupid and said some things that I might not repeat in polite company. Well, that night I did make it home in a short time but I had to return on Monday with a full set of boards and did the subsequent repair much more carefully!

There are many common causes for mistakes we see in the workplace:

• Preoccupation (comes in many forms – could be bad news, good news, no news)
• Pressure to complete
• Fatigue (lack of sleep, sickness)
• Drugs (both legal – like Benadryl – and illegal)
• Hangover or drunkenness
• Lack of competence on that equipment or that job
• Lack of strength, flexibility, endurance, visual acuity
• Lack of mental horsepower
• Injury (not healed yet)
• Bad attitude (rare by itself, usually accompanies another cause)
• Anger at company (sabotage)
• Working at heights with fear of heights
• Bad lighting, too cold or hot, other environmental factor
• Wrong parts
• Lack of specialized tool
• Lack of equipment (like lifting gear)
• Lack of diagrams, drawings, wiring schematics

Now the important question: how can we manage or eliminate as many of these causes as possible? Presumably once a cause is eliminated then the chance of a mistake is lowered. Clearly the supervisor is in the catbird seat (advantageous perch) to many of the potential problem areas. One problem is that we are blanketing our supervisors with computer work, which used to be called paperwork. A best practice is to insure supervisors are on the floor at least 65% of their time. Only if they are on the floor and spending time around the maintenance workers can they notice some of these issues.

Different people are accountable for different causes of mistakes. We are held accountable for specific causes of mistakes by our positions in our companies. For example, workers should report when they are not fit to work. A boss should be accountable to improve a workplace issue like lighting or environmental concerns.

Who has primary accountability?

Workers - Workers are primarily responsible for their own work. Pride in a job well done is a strong motivator of people in the maintenance crafts. That pride often forces a second look that catches and fixes many mistakes. If a worker cannot do quality work due to a problem listed above they should be complaining to their supervisor.

Supervisors - While the workers might be responsible, supervisors are held accountable. They are the ones that should have detected (lack of) fitness to work, bad conditions, excessive hours and sickness.

Bosses – Bosses should notice and help manage the conditions, keeping the pressure off the workers. Another significant role is to provide unwavering support for good job planning and effective scheduling. Good job planning accounts for the elements of the job being present and accounted for. That includes parts, PPE, drawings, tools, equipment and (to some extent) conditions. 

How can we avoid mistakes?

Creating a new kind of work environment can help prevent mistakes. Here are a few ideas:

Create an environment where it’s safe to be honest and start a conversation about mistakes
Create an environment where people can express their own shortcomings without ridicule. This might be a tall order but it is an essential ground from which everything else grows. Provide clear guidelines about the mistakes identified above. Can you imagine an environment where people feel OK about sharing their mistakes? A starting point is ongoing discussions (perhaps as part of toolbox meetings) of past mistakes by the bosses, following this format: “what I did was” and “what I learned was.” Can you see how useful it might be for the young’uns to hear the seniors recount what they did wrong and why that made them better trades people?

Take a close look and then dig a little deeper
To learn the causes, study mistakes after they occur, without giving in to blame. Then fix the causes. If you manage the investigation of a mistake, don’t stop at “employee did not follow SOP.” There is always something underneath that cause. A root cause analysis program can help train people to look deeper. For a program to be successful it must be driven from the top, with senior leaders making everyone aware why it’s important to create a culture that identifies waste and eliminates failure, taking avoiding mistakes to a whole new level. It’s easy to find educational resources on root cause analysis and developing a RCA program. If your organization isn’t already solving problems to root cause, you have a huge opportunity for improvement.

Look into and support planning efforts
No one system will reduce mistakes more than effective planning (identification of resources to do a job) and scheduling (making sure the resources get to the job when it starts). The role of maintenance planners is to improve work force productivity and work quality by anticipating and eliminating potential delays through planning and coordination of labor, parts and material, and equipment access. It takes professionally trained maintenance planners carefully planning and scheduling work to maintain the designed reliability of equipment. Job plans created by planners are intended to ensure or extend the life expectancy of equipment therefore reducing maintenance cost and increasing output. Is your organization using planning and scheduling best practices? If you’re not sure, it is well worth your investment to send your maintenance planners to training that will help them understand what best-practice planning and scheduling looks like. And once they are trained, make sure they are supported in trying to bring about changes within your organization.

Measure mistakes and report on progress
Figure out how to measure mistakes and report on progress. You might review rework statistics (shows a mistake was made requiring an additional service call) or call backs (when a maintenance person has to revisit a job that was supposed to be complete) as a starting point. In addition, consider the importance of the messages that are part of your organization’s culture. If people who fix mistakes after they happen are celebrated as heroes, consider celebrating people who find ways to change situations or processes so that mistakes don’t happen in the first place.

Make no mistake about it, this stuff is important! Good luck.

© Life Cycle Engineering, Inc.

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