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Human Factors: Challenging Traditional Assumptions and Methods That Focus on the Actions of Individuals

Posted by Jessica Peel on Thu, Nov 17, 2016 @ 04:11 AM

Author: David Wilbur, CEO - Vetergy Group

To begin we must draw the distinction between error and failure. Error describes something that is not correct or a mistake; operationally this would be a wrong decision or action. Failure is the lack of success; operationally this is a measureable output where objectives were not met. Failures audit our operational performance, unfortunately quite often with catastrophic consequences; irredeemable financial impact, loss of equipment, irreversible environmental impact or loss of life. Failure occurs when an unrecognized and uninterrupted error becomes an incident that disrupts operations.bigstock-Worker-in-factory-at-CNC-machi-82970306.jpg

Individual Centered Approach

The traditional approach to achieving reliable human performance centers on individuals and the elimination of error and waste. Human error is the basis of study with the belief that in order to prevent failures we must eliminate human error or the potential for it. Systems are designed to create predictability and reliability through skills training, equipment design, automation, supervision and process controls.

The fundamental assumptions are that people are erratic and unpredictable, that highly trained and experienced operators do not make mistakes and that tightly coupled complex systems with prescribed operations will keep performance within acceptable tolerances to eliminate error and create safety and viability.

This approach can only produce a limited return on investment. As a result, many organizations experience a plateau in performance and seek enhanced methods to improve and close gaps in performance.

An Alternative Philosophy

Error is embraced rather than evaded; sources of error are minimized and programs focus on recognition of error in order to disturb the pathway of error to becoming failure. 

Slight exception notwithstanding, we must understand people do not set out to cause failure, rather their desire is to succeed. People are a component of an integrated, multi-dimensional operating framework. In fact, human beings are the spring of resiliency in operations. Operators have an irreplaceable capacity to recognize and correct for error and adapt to changes in operating conditions, design variances and unanticipated circumstances.

In this approach, human error is accepted as ubiquitous and cannot be categorically eliminated through engineering, automation or process controls. Error is embraced as a system product rather than an obstacle; sources of error are minimized and programs focus on recognition of error in order to disturb its pathway to becoming failure. System complexity does not assure safety. While system safety components mitigate risk, as systems become more complex, error becomes obscure and difficult to recognize and manage.

Concentrating on individuals creates a culture of protectionism and blame, which worsens the obscurity of error. A better philosophy distributes accountability for variance and promotes a culture of transparency, problem solving and improvement. Leading this shift can only begin at the organizational level through leadership and example.

The Operational Juncture™

In contrast to the individual-centered view, a better approach to creating Operational Resilience is formed around the smallest unit of Human Factors Analysis called the Operational Juncture™. The Operational Juncture describes the concurrence of people given a task to operate tools and equipment guided by conflicting objectives within an operational setting including physical, technological, and regulatory pressures provided with information where choices are made that lead to outcomes, both desirable and undesirable.

It is within this multidimensional concurrence we can influence the reliability of human performance. Understanding this concurrence directs us away from blaming individuals and towards determining why the system responded the way it did in order to modify the structure. Starting at this juncture, we can preemptively design operational systems and reactively probe causes of failure. We view a holistic assignment of accountability fixing away from merely the actions of individuals towards all of the components that make up the Operational Juncture. This is not a wholesale change in the way safety systems function, but an enhanced viewpoint that captures deeper, more meaningful and more effective ways to generate profitable and safe operations.

A practical approach to analyzing human factors in designing and evaluating performance creates both reliability and resilience. Reliability is achieved by exposing system weaknesses and vulnerabilities that can be corrected to enhance reliability in future and adjacent operations. Resilience emerges when we expose and correct deep organizational philosophy and behaviors.

Resilience is born in the organizational culture where individuals feel supported and regarded. Teams operate with deep ownership of organizational values, recognize and respect the tension between productivity and protection, and seek to make right choices. Communication occurs with trust and transparency. Leadership respects and gives careful attention to insight and observation from all levels of the organization. In this culture, people will self-assess, teams will synergize and cooperate to develop new and creative solutions when unanticipated circumstances arise. Individuals will hold each other accountable.

Safety within Operational Resilience is something an organization does, not something that is created or attained. A successful program will deliver a top-down institutionalization of culture that produces a bottom-up emergence of resilience.

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Topics: root cause analysis, corrective actions, incident investigation, accident investigation, human factors

How to Avoid the RCA Corrective Action Graveyard

Posted by Jessica Peel on Wed, Jun 22, 2016 @ 03:06 AM


Many of us have them. The invisible “graveyard” where good intentions (AKA – corrective actions from your root cause analysis investigation) went to die.

How do they end up there? bigstock-Spooky-old-graveyard-at-night-71555167.jpg

We all know that all the time and money spent on a root cause analysis investigation and identifying solutions is worthless if the solutions are not implemented. An investigation can usually be done within a week but solutions can take much longer to implement. They sometimes require the involvement of multiple teams or departments, regulatory agencies, engineering, planning, budgeting, and the list goes on and on. For these reasons, it can be challenging to stay on top of all the corrective actions you identified in your investigation, who’s responsible, and the status of an action item at any given time.

We can offer a few basic tips that will give you a head start in tracking action items effectively:

  • Be clear about who is responsible for each corrective action. You don’t want to create the opportunity for people to be able to pass the buck with “I thought Bob was going to do it”.
  • Have a mechanism in place by which the implementation of corrective actions can be tracked.
  • Give ownership of a solution to an individual, not a group or department.
  • Assign a due-date for each corrective action.
  • Support people in their efforts to implement corrective actions.
  • Make sure you follow up on each corrective action – check back with the individual responsible to make sure that progress is being made.

But even these “basics” are easier said than done.

In reality, most likely you come out of your root cause analysis investigation with a list of action items for which various people are responsible. Then everyone goes about their regular workdays and may or may not remember to follow through on any additional tasks they were assigned. Even if you have an appointed person to follow up with the action items and make sure they’re on track, it can be difficult to keep up with who has done what. Many managers rely on an Excel spreadsheet to manually track what has and hasn’t been done, due dates, and so forth. But this puts a lot of pressure on one person to keep up with everything – to manually send reminders to folks who haven’t completed their tasks and to enter the information properly when it has been done.

Even when the Excel file has been carefully kept up-to-date, it often lives locally on the manager’s hard drive, and other members of the team don’t have any visibility as to what has and hasn’t been done.

Sound familiar?

If your RCA program is starting to mature it may be time to consider an enterprise solution to help you better manage all your investigations.

Corrective action tracking inside of an enterprise RCA tool can help you maintain visibility and accountability by tracking the status of action items and assigned solutions. Team members get sent automatic reminders of incomplete or overdue action items and they can easily update the status of their assigned tasks, instantly informing everyone when a task has been completed. You can also create personalized dashboards with reports showing open, completed, or overdue corrective actions.

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In addition to effective action tracking, an enterprise RCA solution can more broadly help your company implement and manage an effective overall root cause analysis program.

Here are some of the main features to look for:

Enterprise-wide visibility of your RCA program
Expand the RCA knowledge base and accessibility across an organization.
 
Search across the database for past RCAs, solutions, causes, equipment items, etc
Leverage information from previous investigations in your current investigation.
 
Classify problem-types by company or industry standards or by a pre-set list
Classify and tag files for easy search-ability. Create custom tags incorporating company or industry standards.

Create and share interactive KPI reports
Build reports on your chosen metrics and visually display key performance indicators in tables, charts and graphics.
 
Create personalized dashboards
Specify which reports are most important to you for immediate dashboard display on your home page.
 
Save and embed reference files such as photos equipment failure data, interviews, etc
Preserve integrity by securely collecting and storing evidence and important reference files.
 
House internal company resource documents and tools
Store company corporate standards or reference files such as frequently referenced industry documents in a central location for immediate access when facilitating an RCA.
 
Progress updates
Communicate with all users through on-page messaging that lets you quickly share information, receive feedback and record comments.
 
Keeping your RCA investigation corrective actions out of the graveyard is a very common challenge in maturing RCA programs, but it’s just one of many. To see what you may be up against in the future, check out our free eBook, “7 Challenges to Implementing Root Cause Analysis Enterprise-Wide and How to Overcome Them”.

Remember, in order to resurrect your RCA investigation corrective actions, start with the basics that we listed at the beginning of this article. But also keep in mind – the more mature your RCA program becomes, or the larger and more complex your organization, the larger and more complex your problems become. So when you’re ready to alleviate this pain point altogether, consider whether an enterprise RCA solution might be the next step in your program’s development.

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Topics: root cause analysis, rca skills, rca facilitation, corrective actions