Transcrição completa de Error is Normal - So What?

If we accept that error is normal, then we have to build resilient systems that let people make mistakes without really bad stuff happening. Another way that we need to think about error is normal. Is if it's perfectly normal for people to make mistakes, it's also true that as humans, we tend to respond in a similar manner to similar stimuli. I'm quoting Rob Fisher there. so the conditions that make it more likely for us to make errors are pretty consistent. And if we can recognize those conditions, Then we can take some steps to reduce the number of errors we make. So we can use some tools, some, some, some of those human performance tools to reduce the number of errors we make. So there's a there's a whole lot wrapped up into this idea that error is normal. But one of the things that really didn't dawn on me until I was I was thinking about it very recently is I I spend a lot of time speaking with leaders about. human and organizational performance, leaders at at all different levels. And when I talk about your behaviors being demonstrating the principles, the thing that occurred to me is if you're in in a position of leadership or or even someone who's looked to as an example of human and organizational performance, then one of the things we should try to do is normalize the way we talk about errors. Now Let me let me back up a second. have you have I I'll bet all of you can think of someone, maybe at work, maybe it was a boss, a coworker, a peer, somebody you work with, you know, you run across in in your life outside of work, but you can all probably think of someone who never ever ref or never ever would admit to making a mistake or being wrong. And when they were When they did make an error or a mistake or were incorrect, they made excuses or they blamed others. They tried to push off the responsibility to someone else. if that person is in a position of leadership, think about what that does to an entire organization. So if your boss, just imagine the CEO of a company is a person like that who never will admit to making a mistake. will always make excuses, will blame others around him. What does that tell the rest of the organization? Well I think it sends a real clear signal that error is really, really, really bad. And it's it makes me look like less of a person or not as intelligent or not as conscientious. And therefore we should avoid at all cost Ever having to acknowledge that we made an error. And when that behavior cascades through an organization, think of all the other issues it causes. If we don't talk about our errors, if we won't even acknowledge that we made errors, then we're probably never going to use those errors as opportunities to learn and improve. And we're constantly going to be blaming others when things don't go well because we won't acknowledge our own errors and mistakes. And if we never want to talk about or acknowledge those errors that we make, we're not going to try to understand the context around it. We're

not going to understand the conditions that I was in encountered that led me to make that mistake or let that that mistake or error. result in a bad outcome. And finally, our response when other people make errors is probably going to not be good. So we've we've just really set the whole organization up for everything that is exactly the opposite of those five hop principles. Just because we can't accept that we made errors. So I think one of the things that we need to do as leaders, and we, you know, we need to set the example for the organization. And I think one of the really powerful things we can do is acknowledge our errors, normalize talking about human error. You know, we we wouldn't apologize or we wouldn't we wouldn't try to make excuses or blame someone else if we do something like sneezing. Or coughing or hiccupping. Those are all normal human functions, right? So is error. So let's keep coaching people and trying to set the example ourselves of normalizing human error. Now, if I'm if I'm okay talking about where I made errors and mistakes, then a whole bunch of other stuff happens. Just, you know, it's just think about what we just talked about, a a leader that won't do that. Now let's not imagine a leader that does do that. So I you know, I walk into the morning stand up and I say, Hey, that that thing I did yesterday, I made a mistake. And here's what happened. And I I understand now that the conditions that I was faced with that I was looking at that kind of contributed to that. And I also understand why our sis where our system was was pretty fragile and it allowed that error to to have a negative outcome. So, what I'd really like to do is talk about how we can improve, how we can use that as an opportunity to learn and improve and build more resilience into that system so that the next time somebody makes an error, they don't go through what I went through. Just imagine what conversations like that at your morning stand-up meeting or your weekly staff meeting, what message that sends to the organization. That's where you start building a culture. Where it's okay to talk about errors. It's not only okay, but we see those errors and mistakes as opportunities for us to learn and improve and build more resilient systems and make other put other defenses in place that allow other people to make errors without having bad outcomes. That's the kind of culture we want to create with human and organizational performance. And I think it all starts. With this idea of normalizing human error. So let me go back to my story about the other day. I was, I, if you know me, or if you've watched some of my videos, you might remember that one of my hobbies is woodworking. And I came upon, I came into a couple really big, beautiful slabs of walnut. I got a good deal on them. My my son, who's my oldest son, who's also into woodworking, found them and asked me if I wanted a couple, and I I jumped at it. So I got these two big slabs of walnut and I'm wondering what am I going to do with it. And I decided I'm going to build a TV cabinet, a big TV cabinet, for down here in my basement where I where I hang out and and watch TV. So I I did a lot of work on that walnut slab to make it look really good, and I built a big cabinet to go underneath it. And I'm putting a face frame on this cabinet. So if you're not into woodworking, you build the cabinet out of plywood, but you don't want those ugly plywood edges showing. So you buy solid wood and you make a frame that just goes over the front of it to hide the edges of the plywood. And I'm using these things called pocket hole screws to put the the top to attach the top of the frame to the cabinet because the the walnut slab's going to cover it up, right? And the rest of it I'm gonna glue, and you know, there's a couple other places where I can get some screws in that won't show. So I've got this huge thing, and this cabinet is about six feet long and it's about 34 inches tall, and it's got a bunch of shelves and dividers in it. So I've got this huge thing, I've got glue all over it, and I'm putting the pocket hole screws in the top of it, and I'm trying to hold the face frame in alignment with the cabinet as I'm driving these screws in from underneath. So I've got a drill with a big screwdriver, bit square bit screwdriver in my right hand. And with my left hand, I'm holding on to the face frame, trying to hold it in alignment, and I'm pushing real hard to drive this screw. The bit slips out of the screw head and jams into the palm of my hand. And I end up with a big oui on the palm of my hand. And I said a couple really loud curse words. And I ran around and found something to stop the bleeding. I ran inside and and ran it under the sink, washed it off, put a bandage on it because I've still got all this wet glue out there on this cabinet that I've just spent a lot of time and money on. And I wrap it up and then I run back out and I finish attaching the the face frame to the cabinet. And when I finally get a chance to catch my breath. I go right back to that thing that most of us do if we made a mistake like that. Well, that was stupid. I feel like a dumbass. I don't want to tell anybody about this. But I'm not going to be able to hide it from my wife, right? Because I've got this big bandage on my hand. And she's gonna notice that. I'm I I'm surprised she didn't hear me scream when I when I when I did it. And so I go in and I I Get done and I'm I'm I'm catching my breath a little bit. And she sees it, she sees the bandage. I tell her what happened, and of course she wants to look at it. And I said, No, I got it all bandaged up. And and then she says, Are you gonna tell your son? Our oldest son, the one that's also into woodworking. And and also coincidentally, he's probably the one of the three kids that is most interested in the work I do because he works in manufacturing. And I look at her and I say, Yeah, I don't know. And a few minutes later, my

son calls me and I'm talking to him. And I went ahead and I said, Hey, guess what I did? And I told him about it. And, you know, his typical response is, Well, you dumbass. And, you know, and I I deserve that. And and but, you know, that's the way I'm thinking. This was me being stupid. That's why that happened. And I'm going back. If this happened in a plant when, you know, excuse me, twenty years ago when I was working in a plant, if it when I was a superintendent, if somebody had done that, my reaction probably would have been the all too common name, blame, shame, retrain. I'd have said, Well, you know, you shouldn't have done that. Yeah, let me I'm gonna have to retrain you on how to use that tool. And then we're gonna put out a a lesson, you know, a communication to everybody else. So that everybody else hears what a dumbass you were. And we're gonna, you know, everybody else knows not to do that dumb thing that you did. And that's how we're gonna that's how we're gonna deal with that. And I I I can't do that now, right? And so I'm I'm talking to my wife and and she actually asked me, she goes, So you gonna talk about this on your podcast? Cause you know, she knows I've been working on this for a while. And I say, Yeah, I I I I will. And she goes, How are you gonna spend that other than you were a dumbass? And I I really had to think about it for a little bit. And what I keep coming back to is I don't ever want to say human error was the cause of an event because I clearly made an error. I I I use the the an abridged version of the Rob Fisher definition of an error. It's an action or inaction that unintentionally results in an undesired outcome. And that's exactly what happened, right? But I don't want to view an error. As the cause of an event. Because I, you know, I get to the question, if if that's the way I view this event, then what am I going to fix? I'm not just going to tell myself, don't be stupid. you know, don't try, try, try harder next time, be more careful, because we know those things don't work. And it's also insulting to the worker. Because when I tell you, be more careful, don't do that again, what I'm really telling you is. You were stupid. Don't be stupid next time. When I really think that this is just a fundamentally flawed system, and it was predictable. So I start thinking about this with my, you know, with my hop hat on. And I go back to the conditions I was facing. the task I was doing trying to attach that face frame to the cabinet. That's not something I do every day. Most of my woodworking is little small. you know, things, not big cabinets. And so I don't think I've ever tried to assemble a cabinet that big with a face frame. So this was a first time task for me. I was under I put myself under quite a bit of time pressure because I had all this glue on everything. And I wanted to hurry up and get the face frame, you know, all lined up and fastened before the glue started to set up. Now In actuality, the glue that I use has a pretty long open time. I wasn't in near as big a nearly as big a hurry as what I put myself in, but I felt like there was a lot of time pressure to hurry up and get it done. And you know, one of the things we know about time pressure, it doesn't matter if it's somebody else doing it to us or me doing it to myself, it affects us the same way. And so I'm rushing, I'm under feel like I'm under time pressure. It's a first time task. This was predictable that I was ripe for making an error. The conditions were ripe for me to make an error. So I I kind of failed to acknowledge that, which people do all the time. And then I start thinking about well, if human error, if my error was not the root cause of this event, then what was? And I think one of the ways to get back to that is okay, what am I going to fix? I don't want to do this again. And I I will be sooner or later building more cabinets like this. So what do I want to fix? I don't want to just tell myself, be more careful. You know, remember how bad that hurt last time. So so be more careful next time. And I started thinking about it. And there are screws with different drive systems that I think hold grip better. So it's less likely for the screwdriver bit to slip. There are also clamps that are Purpose made for the task I was doing for holding a face frame in position while you use pocket holes and pocket hole screws to attach it. And I know they exist and I've avoided buying them because they're not cheap. So I I I you know there's two things that I can think of that I can do. I can get different screws, different screwdriver bits, and go buy a couple of those clamps because, you know. price of the clamp would be a whole lot better than the the the pain I went through you know, jamming a bit into my hand. So I can come up with corrective actions that try to improve the conditions around which the work happens rather than just tell myself, be more careful. And this whole thing kind of was a was a a big eye opener for me because it it It is changing the way that I explain human error to people, and that we have to normalize it, we have to talk about it normally so that we can as an organization learn from it, and so that we set the example for the rest of the organization that it's it's good to talk about our errors because then we can, you know, build that that comfort in acknowledging our errors and also. The idea that errors are are great opportunities to learn and improve. And no matter how much you want to stink after an event, well, that person was really stupid. I would have done that. So that person just needs to try harder. They need to be more careful. I just need to tell them to be safe. And maybe I'll make them reread the procedure, or maybe I'll put an extra step in the procedure that says, be safe when you're doing this. And then we'll then we'll make a a single point lesson and we'll send that to all the rest of the crews and tell them, hey, don't be a dumbass

like this guy was. That still is a very, very common response to an incident like this. And I gotta tell you, I didn't intend to do that. And I don't believe anyone in a plant intends to do that kind of thing to themselves either. So when we think about human error as a root cause. I like this really simple test that that somebody told me, I didn't think of this myself, but it's pretty intuitive. If I just replace that worker with any other similarly qualified worker, does that mean it'll never happen? And I apply that to my incident that I happened that happened to me the other day. And I I can't say, yeah, i i if I just get a better, a more conscientious, a more careful worker to do it, then there's no possibility that'll happen because that possibility exists. If somebody else is faced with the same conditions using the same equipment that I was, then there's every chance that they could have the same thing happen. So how do I change that? And I have to change the conditions that that go that, you know, that the work in which the work happens. And I've I I thought of ways to do that. So I really want to encourage you. When you think about this idea, principle number one, error is normal. Be the example of normalizing the way we talk about errors to others. Be the example to others. Talk about where we made errors, where we make mistakes. What are the conditions that we face that led to that or that allowed that error to have a bad outcome? Because if if I'd been using a clamp and the screwdriver slipped, no big deal. Nothing happens. Okay. But since I wasn't, then you know, I I had the bad outcome. So have those conversations be the example. Normalize the way we talk about human error. Don't ever allow yourself, don't ever allow others around you to say that an event was caused by human error. And when they want to go there, like I did, I was just I just did something dumb. When they want to go there, ask them the question. What are you going to fix? If you think this was purely a case of an event caused by a human error, what are you going to fix? And are you comfortable that just by name, blame, shame, retrain, just by doing that, are you comfortable that nobody else is going to find themselves in a similar situation and have a similar event? And the answer to that question is always, no, I'm not, I'm not comfortable that I've done anything. So Normalize the way we talk about error. Don't accept human error as causal to an event. Understand the conditions that allowed the error to occur and that allowed the error to have a bad outcome and change those conditions. That's how we build more resilient systems. That's how we set the example that error is normal. It happens to all of us. Let's talk about it. Let's use them as opportunities to learn and improve. Let's not blame events on human error. Sound good? All right. Hey, I hope this is helpful. if you if you like this podcast, subscribe to it. If you got an idea for a future podcast, drop me a line. also I'm I'm really interested in your feedback. If you hear something you like or you don't like, let me know. you can you can hit me up on LinkedIn or you can leave comments. if you watch this on YouTube, you can leave comments on the videos. But stay tuned. I'm gonna try to do this every week. And I hope I got something there for you. So until next week, I'm Steve Scott. I'm out.