This article explains how often the four states are involved in all aspects of human error, apart from when people are learning or doing something new. This is another huge paradigm shift for most people. However, once they realize just how many mistakes they make, every day or every week due to the four states, it’s relatively easy to get them to use the same critical error reduction techniques along with other concepts or techniques like fail-safe, double-check, Anticipating Error™ and Rate Your State™ to minimize or prevent making big mistakes that could affect quality, production efficiency or that could cause significant problems with sales or customer relations.
Welcome back. In the last article we looked at two aspects of deliberate risk and error. The first was that most people do not realize that risk that depends on error or not making any mistakes will grow over time and as a result, may easily exceed—in a large way—their tolerance for risk they can’t influence, or what they would consider to be their own risk tolerance.
The second paradigm shift or different way of looking at something—like distracted driving—was the problem of the “extra second” that was totally unexpected. In other words, I knew I was going to look away from the road to do whatever (phone, coffee, stereo, sandwich), but I didn’t expect to actually be distracted for that “extra second”. However, if you make people aware of the problem or the “trap”, then they can think about this extra second before they look away and—because they’re thinking about it—it doesn’t happen.
Unfortunately, there are more aspects or problems with decision making and risk than just the two that were previously mentioned. The four states can also affect decisions on checking critical components that hardly ever fail, like hydraulic hoses, wire ropes, seals, tires, etc. Part of the problem is that wire ropes don’t snap very often, seals don’t fail very often and tires don’t blow very often. Another part of the problem is the amount of complacency which is bound to start creeping in and adding up if nothing bad has happened in a long time. But if you now add some rushing or time pressure to that heightened level of complacency then checking and double-checking can easily be seen as wasted time or time, we don’t have today… in other words, as per the first article on deliberate risk and error, they are making an exception.
Then there’s becoming overly complacent with other people so you don’t anticipate potential problems—like what can easily happen if you’ve been driving for a while: you may have started passing transport trucks on “auto-pilot”, even though you’ve seen transport trucks move suddenly and erratically. And even more ironically, over 50% of most groups have indicated that they have actually had to swerve to get out of the line-of-fire when the big truck did move unexpectedly—and yet, they freely admit they can’t count (hundreds or thousands) the number of transport trucks they’ve passed on auto-pilot.
So, since we know this will happen—and we know that telling ourselves we have to pay more attention next time won’t work—we will have to change our habits. In this case, a good suggestion would be to try to find something on or about the truck that you have to “call out”. Meaning that you say (out loud or to yourself ) flatbed, box, tank truck, or Mack, Volvo, Kenworth, etc. Developing this habit will almost automatically bring your attention back to the truck, which will give you the full benefit of your reflexes—if you need them.
QUALITY, PRODUCTION AND CUSTOMER RELATIONS
The idea that you can anticipate potential problems caused by one or more of the four states can be applied to more than just injury-causing errors. As briefly discussed in a previous article (#8), we can think about all worst-case scenarios, not just injuries. And we can apply the concepts and critical error reduction techniques to prevent serious mistakes—even when there isn’t any potential for injury—because nothing is moving around you or you’re not moving. We can also look at how many of these “static” performance errors like not remembering where you put the car keys, can lead to “dynamic” performance errors—when you start driving in a rush—because of the delay caused by the lost keys (the first “static” performance error).
However, before we get into all that, let’s look at another (or what at least was for me) another big paradigm shift or change in perspective. And again, I’d love to tell you that I came up with this all by myself. But just like with the video guys helping me to figure out the deliberate risk decision tree (normal vs. making an exception), I got some help for this one too. And although we were making a video, a promotional video, it didn’t come from them. It came from a lady in customer service and inside sales that had seen us park our SUV. She opened the side door to help us get our equipment into the office. I was asking her if she had noticed any improvements in performance, error reduction, quality or efficiency since implementing the critical error reduction techniques with her co-workers in the plant and office. I figured there wasn’t much sense in asking her about safety, injuries or close calls since she worked on the phone, sitting at a desk with a computer. What she said was, “Oh yeah, I mean—not when you’re learning—you make lots of mistakes then… but after that, it’s always one of those. Meaning: rushing, frustration, fatigue and complacency. And although this isn’t very flattering, the significance of what she said still didn’t hit me until later in the editing suite: “Not when you’re learning…” I was looking for a take where she also said rushing, frustration, fatigue and complacency when it hit me: “Yeah, but—how much time do we get to spend learning or doing something new these days?”
In my case, I knew the answer, and I immediately began to ask people how much of their day or week did they spend doing something new or learning something new.
Not too surprisingly, their take on this was the same as mine: 90-95% of what I did and what they did every day or every week is not new: get up, make coffee, eat breakfast, shower, go to work… It’s not like we need to ask for directions. So, only about 5-10% of what we do is learning something new, which means that the rest of the time when we made mistakes, we were making the mistakes when we knew what we were doing. But why would anyone make a mistake if they knew what they were doing? Well, you might know what you need to pack for a trip. However, if you were in a rush when you were packing, if you were tired or if you hadn’t forgotten anything important in a while (complacency), you could easily forget something.
So, once again, it’s easy enough to see how the four states or a combination of them can cause performance errors. But now, take it one step or one question further: can you think of a time—even one time in your life—when you made a mistake that was not caused by rushing, frustration, fatigue and complacency or a combination of these four states? If you exclude the times when you were learning something new, chances are that you don’t have an example. And if you do, it’s likely due to extreme joy or sorrow. These states also cause problems but—fortunately and unfortunately—they are not something we have to contend with on a daily basis. Whereas rushing, frustration, fatigue and complacency certainly are. And as we’ve discussed before, it’s difficult to eliminate these states from life or “engineer them out” as if they were a physical hazard. So, if you give this a lot or at least a fair bit of thought, can you think of a mistake or performance error, out of the hundreds (or more likely—thousands) of performance errors you’ve made that was not caused by rushing, frustration, fatigue and complacency or—more likely—a combination of those states?
Can you think of a quality or reliability error? Can you think of a production or efficiency error? How about a customer relations error? If you’re like most people, you can’t think of even one example, let alone ten or twenty. But even if you could think of ten or twenty, that’s still less than .1% (most people make around 500-1000 mistakes a year or 15-30 per day—if you count all the little ones). And every one of them—other than when we were learning—was caused by rushing, frustration, fatigue and complacency; which means that we can use the same four critical error reduction techniques to prevent almost all of the quality errors, production errors and customer service errors, in addition to the injury-causing errors. But in order to make this work, or in order to make this all work with any kind of real efficiency (more than 40% improvement), we will need to engage the workforce, which is what we will discuss in the next article, along with exploring another (and final) paradigm shift.
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