Learning from Our Mistakes
In high performing companies, systems and processes are resources that make the job more consistent and easier. Developing these effective programs can be a significant challenge due to the culture of an organization. One of the best ways to influence the culture is to encourage involvement and establish a climate of continuous improvement. Quite frankly, one of the most successful and impacting programs I’ve had the opportunity to work on is the reporting of near misses or hits. Let me set the stage for you…
My spouse understands the value of acknowledging a near miss because we frequently discussed it as a cornerstone of the construction organization I worked with. A few years ago, the two of us did a complete remodel of a 1915 commercial building. On one particular weekend, I experienced not only one, but three near misses. The task was hanging conduit and attaching a light fixture. The scaffold had limited working space. On the scaffold platform were tools and materials I used for various electrical tasks.
Now, some of us are quick to react and assign blame when things go wrong or frustration is high. I’m no exception as my blame shifted toward my spouse in this story. You see, two times I nearly fell off the scaffold. Both times I was able to catch myself. On each occurrence, she would say, “Josh, that was a near miss. Be careful and slow down.” It was easy to acknowledge she was correct; it was a near miss, but to me, it wasn’t a big deal. After all, I was only four feet off the ground and had been using this scaffold for months without incident. My perception was that it was an isolated case and severity was low. Yet, out of frustration, I quickly looked for an excuse to the problem and found it in my spouse’s presence. She was taking up more room on the scaffold and, with the combination of materials on the scaffold, it forced me to reach around her, thus losing my balance and resulting in the near miss.
When the third near miss occurred, I significantly lost my balance and started to fall backwards. Fortunately, my wife was close to me and reached out, grabbed my arm, and pulled me back…preventing the fall. After a few seconds of reflection and conversation with her about the last three situations, I realized the problem was not her presence on the scaffold (resulting in less work space), but rather I failed to modify my operation to accommodate the extra person. My own perceptions didn’t allow me to recognize the near misses that occurred. Within a few seconds of problem solving, we realized I didn’t need every tool scattered throughout the scaffold. A better approach would be to organize the tools into buckets and bring them up to the scaffold as needed. Implementing this strategy would give me the room needed to maintain balance, work together, and install the product easily.
I share this example because it illustrates an important factor in near miss incidents — the problem usually lies within the system or procedure. As the building owner, construction manager, and laborer of this work, I had the ability and knowledge to plan the operation in a safe manner. With the addition of my spouse and the resulting change in conditions, I chose to ignore the mistakes (near misses) because I felt they weren’t significant. Two times I had the opportunity to correct the deficiency in the system, but I didn’t. It was only until something more serious occurred that I realized we needed a new solution. By the way, the new solution increased efficiency as I was no longer wasting time looking for buried tools on the scaffold. I could also concentrate more on the task at hand, rather than focusing on maintaining balance to avoid stepping on materials. The value in talking about and correcting near misses are tremendous because the action taken impacts efficiency, quality, and safety.
Acknowledging errors and talking about them as a team allows the system to be corrected and prevention methods realized. Near misses should be viewed as learning opportunities.
The process in reporting near misses must be easy and simple. My personal example shows, that within seconds, I had acknowledged the situation as a near miss, talked about it with my spouse, and developed a solution to prevent reoccurrence. Our employees do this every day out of necessity. Management just doesn’t see or hear about it and, thus, can’t track the data. By making the process simple, we’re now able to start tracking and analyzing trends in the task.
Teamwork and the idea that people should “look out for each other,” are good attributes of an organization’s culture. Even the safest employees can recognize a near miss and mistake, but not see the significance of the event. In my example above, my spouse recognized the event as serious while I did not. It wasn’t until the third near miss when she caught me and said, “You’re going to get injured, so I am getting off the scaffold and you can work alone,” that I knew something needed to change. That statement helped me realize it was too close of a call, and I had to do something different. By working as a team and looking out for each other, it minimizes the individual perception or bias toward the particular situation. As people report incidents, the vision becomes more realized — near misses aren’t about blame or disciplining people, rather they’re about preventing reoccurrence and continuously improving the operation and/or company.
People and teams do make mistakes. Mistakes, when reflected upon and analyzed, can be a good thing! They promote a continuously improving climate and improve our operations outlining the programs necessary to achieve zero errors and/or mistakes.
Published on: 01.23.17