Is it Really a Mistake?

by Mathew Bowen | 20, Dec, 2023 | Newsletter

I was recently on-site attending a pre-shift meeting, and as is customary in many such meetings, the group was asked if anyone had a Safety Share. One of the team put their hand up and spoke about an incident that had occurred in the surrounding area. They explained a young farm worker had stepped into a piece of machinery, sustaining serious and irreversible injuries to his foot. The intent was to remind people of how ‘easy’ it is for injuries to occur, but it was the response by other members of the team that was far more interesting to me.

One of the team immediately replied, “Bloody stupid”, only to be followed up by another team member saying, “They probably didn’t train him properly”. While these two comments seem worlds apart, they are in my mind, highly connected. Both comments suggested someone was to blame. It was either a stupid mistake by the worker, or a gap in what was provided by the employer. Black or white. The buck must stop with someone.

If everyone makes the same mistake, is it really a mistake?

If we assume that the worker made a mistake, does that mean that they were just stupid? That they should have known better? 

We can be very quick to judge when someone else makes a mistake, while at the same time forgetting the countless times we make mistakes and are fortunate nothing detrimental occurs. To highlight this further, research by the the Australian Transport Safety Bureau suggests that people, on average, make between three to six errors every hour of work. So, in this line of thinking, we must all be stupid!

I recently shared one of my many mistakes with a leadership group. Driving in an unfamiliar area, entering a side road from a T-junction, I turned into the wrong lane. Fortunately, it was quiet so there was no oncoming traffic, and all it took was a quick correction to get back on track. As I talked through the details of this incident with the leaders, one of them said, “That happens all the time at that spot”. 

I replied “Does it now? Well, if many people make the same mistake, at the same spot, maybe there’s something we could do about it. Maybe we could re-train everyone on the correct way to navigate T-junctions?” 

The only challenge with this is that it’s a tourist town, so we’d need to catch people on the way into town and make sure they’d completed the module. Another option could be to promote situational awareness with a series of road signs and campaigns that encourage people to pay more attention. But then, maybe the signs would create more distractions and actually inhibit driver attention.

Or, perhaps we can look at the situation and ask why so many drivers get it wrong. Is the layout of the road confusing? Is there a way we could remove that confusion and reduce the chances that others will make the same mistake? Ultimately, if it’s easy to get it wrong, then how do we make it easier to get it right?

Does the organisation need to do more?

Many in the Health and Safety space are dogmatic in their ideals around not blaming the worker, highlighting that the leadership or systems of the organisation are to blame when things go wrong. Yet merely shifting blame from one group to another is unlikely to achieve any lasting improvement in the performance of the organisation. As the saying goes, you can blame or you can learn, but you can’t do both. 

If we consider a young worker operating in a complex environment, there is certainly a responsibility for organisations to adequately prepare that worker to be safe, well and productive. But there is also no perfect technical training program that equips a person with the skills, knowledge, and abilities to manage every conceivable scenario they will face. Nor is it likely that an individual will retain everything they have learned and be able to bring it to mind when it is needed. Instead, we need to look more broadly at how such a worker can be enabled to navigate the complexity of their work and feel comfortable in seeking support when the need arises.

This is ultimately where the culture that exists within a team and an organisation becomes a critical part of the picture. Does the culture encourage people to put their hand up when there is confusion or challenges, or does it promote the quiet, silent type who pushes on and resolves it on their own? 

Toyota faced this challenge many years back, where workers would notice a fault and engage in what they referred to as a Quiet Fix. That is, resolve the issue and keep the production line going. No one wanted to be the person who held the process up. Recognising that a Quiet Fix did little to resolve the real issue, they began driving a focus on responding to faults or problems with a Noisy Fix. The Noisy Fix process that was implemented involved the workers pulling an ‘ondon’ or ‘ondon cord’. This was a visible and audible signal that a worker had noticed a problem. It enabled people to come together and work out the best solution and then implement immediate actions that solved not just the immediate problem, but the likelihood of the same problem occurring again.

However, the implementation of a Noisy Fix goes beyond the installation of a cord. It required a culture shift where people valued others who were willing to stop production and make a noise over remaining unseen, unheard, and just getting on with it.

What’s The Takeaway?

The reality is that we all make mistakes, and there is no perfect system that will ever prevent these from happening. Equally true is the fact that every error, mistake or fault represents an opportunity for learning and improvement. 

If we want to increase our learning opportunities, it can be helpful to consider how we respond when these situations arise:

• Remember that no person or system is perfect, so we are never going to completely eradicate the chances of mistakes being made.
• Talking about errors (not just incidents) increases our opportunities for learning to occur.
• If a lot of people are making the same mistake, maybe there is an opportunity to ask ourselves why. Is the task confusing, and if it is, is there a way to remove that confusion?
• Celebrate the behaviours that enable us to learn, and focus on developing a culture that normalises open discussion about our mistakes.

We hope you have a great and safe rest of your 2023. From all of us at Cognicent, thank you for joining us throughout 2023. We wish you very Happy Holidays.

– The Cognicent Team