When Things Go Bad, Don’t Ask Who, Ask ...


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In my experience, when things go bad, the first questions asked are usually, “Who did this? Who is responsible?” These are the wrong questions to ask and will actually create obstacles to conducting the root cause analysis needed to make a permanent corrective action. Before we look at the questions to be asked, let’s take a look at the Human Performance System to see where the performer fits in.

The Human Performance System

The Human Performance System had its origins in the behavioral psychology work of Thomas Gilbert, Geary Rummler and Karen Brethower. Mr. Gilbert’s original model noted that performance is a result of the interaction between a person’s behavior and their environment. As the model gained an acceptance, it was further amplified to reflect behavioral psychology, looking at stimulus, response and consequences.

Just as a single tool alone is not the sole contributor to a machining failure, the performer alone is only one aspect of the company’s system of parts production. The failure of the company’s production system should look at the entire system, and not only the performer.

Why it Probably isn’t the Performer at Fault

The human performer has the physical, mental and emotional capacity to do the work. They do until they fail. Why would we think they suddenly did not have what it takes to succeed? The human performer has the knowledge and skill through the training, education and practice or experience they have brought to the job. Why would their knowledge or training suddenly fail them?

The last place to look for a system failure, in my experience, is the “Who,” or the human performer.

We need to look at the system.

Three Questions to Ask

There have been many times when as a shift supervisor, plant manager or division director bad news developed and needed to be reported to me. The questions I asked were not led by “who.” They were led with, “Was anyone hurt and is the area safe?” After assuring that no one was hurt, I asked these three questions in this order.

Is There a Process?

Not a practice, a process. A defined, written and detailed description of the scope of responsibilities, authorities, tools and steps to complete the work to the defined standard. If there is not a process, there is no reason to blame the performer. They did their best to achieve a result despite the absence of a process. It’s not the performer.

Was it Followed?

If there is a well-defined, written process, the next logical question becomes, “Was it followed?” If the process was not followed, then we need to ask not “who,” but “why?” Was it not followed because of an exception or workaround dictated by conditions or circumstances? Was it not followed because the process was over-ridden by a supervisor’s new instructions? Did materials, tools or methods change beyond the normal scope of the process instructions? Is the performer being pushed to exceed capabilities of the tools on hand? It is difficult to hold the performer to account for failing to follow a process where the inputs are not as spelled out and may not be relevant to the work being attempted.

Was it Effective?

Just because there is a written process (and work instruction), doesn’t mean that it is effective. What circumstances have changed since the process was first laid out. What has changed? In addition to changing inputs and tools, could it be that the outputs desired were not appropriate to the process as defined? Trying to hold too fine a tolerance, or take too heavy a cut? Changing expected outputs without reviewing the entire process including inputs such as job specifications, work instructions, time allotted, tools or other resources is not likely to work out well.

Is There a Process? Was it Followed? Was it Effective?

These are the questions to ask when an unexpected event occurs in your shop. The question “who?” is not appropriate until after asking and answering these three queries. In my experience, after considering these three questions, it is generally not necessary to ask “who?” The “who” is the performer, the one that brought their capacity and knowledge and skill to do their best with the inputs that we gave them. They created the outputs that reflected the real state of our system. The performer is only one aspect of our system of providing products to our customers.

Is there a process? Is it effective? Is it being followed? These are the three questions you can use to audit your shop right now to see if you have a significant emotional event in the making.