Unfortunately, leaders are called upon to perform incident investigations involving safety occurrences, quality mistakes, and reliability failures on a routine basis. In each of these cases, the leader is trying to identify the root cause and get to a corrective action. From my experience over years in performing these investigations regarding the various situations noted above, I have noted that a significant number of these failures are the result of human behavior to at least some extent. More specifically, many of these cases involve a decision or choice someone either made or didn’t make that resulted in the injury, quality mistake, or reliability failure. These type incidents can be the toughest for the leader to address. Far too often, I have seen supervisors and managers just go directly to disciplinary measures as the answer to these issues.
Now, before I provide another consideration for leaders in this situation, let me say that I am not saying that facilities and/or organizations should neglect individual accountability, diminish the importance of following policy/procedures, or abstain from disciplinary measures when appropriate. I am merely suggesting another consideration in the midst of this process. This suggestion is simple. Ask Why! By simply probing into the “why” of the behavior, we may learn a great deal about our facility or organization. If we would just take the time in the midst of the investigation to ask why and be patient for an honest response, we could learn a great deal. By asking this question and calmly probing with follow up questions, we can learn a lot about the effectiveness of our systems, our training, and maybe our leadership.
Over the years, I have had incidents where employees made a choice to use the wrong tool or use equipment improperly that resulted in an injury or near miss. Many times I discovered that we had not designed the environment for success. We did not ensure the employee had easy access to the right tools. We did not maintain the equipment properly and placed the employee in situation to make a bad decision. We simply did not provide a work environment to make it easy for the employee to make the right choice. I didn’t realize our shortfall until I asked why.
There were many occasions where I asked this question and discovered that our people just didn’t understand the safe process to follow, the hazard of not following the process, or the proper steps to follow in completing the quality procedure. I would often hear from others in the organization that I shouldn’t listen to those excuses because we had trained on the respective subject at some point in the past. Maybe that point has merit, but just maybe our training is not as effective as we would want it to be. Just telling people what to do is not training. Effective training is conveying necessary information in a manner that people understand, validating that understanding on the production floor, highlighting those key processes through postings in key areas, and reviewing those key requirements regularly in engaging discussions with our people. Asking why just may reveal the effectiveness of your equipping system.
I have also heard many times that the employee was just in a hurry. Sometimes this “rushed” behavior was the result of reliability issues causing the crew to be behind in production. Sometimes this rushed behavior was the result of pressure placed on the crew from a manager to expedite the process. I have even witnessed examples of “rushed” behavior driven by incentives to increase throughput. In each of these cases, there was some degree of supervisory or management influence that had some level of impact on the employee’s decision. I would have never realized the mixed messages that were being conveyed on the production floor if I had not asked why. I learned a great deal about our engagement level and messages that were being sent by our team leaders.
I am not justifying poor choices or decisions by any means. I am simply suggesting that all leaders take the time to ask “why”. You will learn a great deal and have a more thorough incident investigation and corrective action. Don’t rush to discipline before you truly understand the entire “why” behind the behavior. The few extra minutes in that investigation may prevent your next injury, your next quality issue, or your next reliability failure. It will also help expand your leadership influence with your people. Take the time and ask “Why”!