A Human Error Conundrum
Professionals in a variety of industries speak of that moment they had to make an important decision and take the right actions to keep the facility and its personnel safe. Seldom do these moments present themselves at the opportune time without stress and all the time needed to collaborate to make the right call. Will we operate the right valve, press the right button, make the proper notification?
Even the industry's best and brightest falter at times in these scenarios. Ever participated in an incident investigation and heard someone on the team mention "they shoulda known that"?
“People generally do what they do because at that moment, they believe they are doing the right thing.”
Such watershed events as:
- Three Mile Island
- Chernobyl Nuclear Accident
- Deep Water Horizon Oil Spill
- Shanghai Metro Collision
- NASA Shuttle Challenger
are reminders that having a lot of experience, or being "good" at what you do may not be enough. These events and many like them have been the catalyst for sweeping updates to regulations and internal operating standards.
Compliance isn't enough
Most regulators of risk averse industries enforce laws that companies must implement procedures that document operational practice. Further, this regulation usually states that procedures must be correct, accessible, and reviewed periodically. Not surprisingly, most companies that pass regulatory audit and are deemed "compliant" continue to struggle with unacceptable and recurring incidents.
From common cause analyses, human error persists as 70% to 80% cause or contributing factor of incidents. Of these errors, at least 40% are precipitated by procedure inadequacy. In a compliant organization, how can this be?
Regulators are charged with defining and enforcing the minimum acceptable standards to protect the health and safety of the public. Operational excellence is reaching far beyond compliance, is internally motivated, and requires a continuous improvement mindset.
The Procedure Paradigm
Procedures should be:
- considered a value center
- relied upon for consistent human performance
- efficiently and proactively managed
- intuitive and easy to use
- available in any format needed by the worker, including mobile
- workers believe procedures are a useful tool
Procedures are traditionally:
- considered a cost center
- considered a necessary evil
- inefficiently managed
- not user friendly
- developed using inadequate tools like MS Word
- stuck on paper
- not valued by the workforce
The Procedure Paradigm is our forum for sharing important procedure implementation concepts in the areas of Quality, Efficiency, Compliance, Culture and Technology. We aim to enable organizations to shift from the traditional procedure mindset to the Next Generation of Procedures.
We believe in pushing the envelope to provide the absolute best procedure to employees at the time they need it. You'll hear our thoughts as industry leaders in this space as well as thoughts and experience of other notable pioneers. Ultimately, Next Generation procedures should enable every employee to go home with all of their body parts which requires a shift in the paradigm of procedures.
Meet the Author - Nate Rightmer
What's Important to You?
We want to hear what is challenging your procedure program the most. We'll weigh in on how to address them in upcoming posts.