"A very important concept often misunderstood by managers."

By Dean B. Wisecarver

I’ve noticed lately I’ve used this sentence – Fix the problem, not the blame. – more and more while doing my safety consultations at electric utilities we serve. I don’t know why I’m so aware of it lately. It’s certainly not a new concept for me – I’ve been trying to teach this to people I work with for well over 30 years. Perhaps it’s because, through all those years, this is the one very important concept that today I find to be as misunderstood by the managers I deal with as it was 30-plus years ago.

The concept is really simple. Competent, well-trained employees who really want to do a good job sometimes make mistakes. When the mistake occurs, management should ask these key questions: “Why would a competent, well-trained employee who really wants to do a good job make this mistake?” and “What can we do to help assure that neither this worker, nor any other competent, well-trained employee who really wants to do a good job will not make this same mistake again?”

Too often when we bring this idea up, we find that managers agree “in principle” but they think that in practice it’s just not practical to try to redesign work practices simply to prevent human errors, mistakes, and the occasional poor decision. I disagree. In fact, attending to and fine tuning the details of a task is the only way to prevent these errors, mistakes and poor decisions, by removing the opportunity for error from the process itself. To that end, it does little or no good to berate any competent, well-trained employee who really wants to do a good job, but failed. That’s not fixing the problem, it’s “fixing the blame.”

Imagine, if you will, that a commercial airliner runs off the end of a runway with 200 people on board. After an initial investigation by the National Transportation Safety Board, it begins to surface the accident was the result of “pilot error.” What happens? Does the airline management simply take the pilot aside and chew him out and leave it at that? If the airline fires the pilot and the FAA revokes his license, would that be a satisfactory resolution?

I certainly hope not, and I suspect you hope not, too. In truth, we fully expect the NTSB and the FAA to determine why any experienced, fully licensed pilot would make this error and then mandate changes that will better assure that no other pilot will make the same error!

Now imagine a different scenario with me. Visualize a journeyman lineman who hooks up a dual-voltage transformer incorrectly and sends the wrong voltage out to the consumers. This may well be seen as simply a case of “lineman error.” What should we do? We could take him aside and read him the riot act and tell him to be more attentive since a guy with his experience shouldn’t make this kind of mistake. We can threaten him with loss of his job if it happens again. We could just fire him on the spot. (Well, maybe we don’t want to fire him just yet. After all, it’s getting harder to find people that want to be linemen, so maybe we’ll just give him 2 days at home without pay.)

Unfortunately, some variation of these actions is exactly what happens in the typical distribution utility. When things go wrong, supervisors jump into action, fix the blame, try to “fix” the offender who is the target of the blame, and finally get back to work as if the problem has now been resolved. When I see this, I usually ask, “Wait! Aren’t you concerned that some other lineman in your company might make the same mistake?” The answer all too often is, “No, that’s not likely. Our other linemen are well enough trained and experienced not to make that same mistake.” But, of course, the day before it happened we all believed the same thing about the guy that actually made the error! So, whenever you are tempted to fix the blame and fix the offender, first you should take a deep breath, steady your nerves and ask yourself this question, “If we fired this person, would that stop this mistake from happening ever again?” I submit that the honest answer to this question will be no, at least 999 times out of 1,000!

If we really want to improve our company by resolving things that go wrong in ways that truly make errors less likely in the future, we must learn enough from what happened to devise and implement changes that make it less likely to ever happen to any employee that faces the same job or situation in the future. We must adopt an approach like that of the National Transportation Safety Board. The NTSB isn’t interested in exactly who the pilot was. Sure, they want to know about his training, his thought process at the moment, about the procedures and techniques that applied. In fact, they are careful interviewing the pilot to win his cooperation, not point fingers at him. Their approach is that it could have been any pilot. Their goal is to fix the problem, not the blame. Our goal should be the same.