One of the key tenets of Lean is the focus on the process, not the people. Six Sigma calls this “common cause” variation, but doesn’t talk much about respecting people as a general rule.
If something goes wrong at your work, the first step should be to scrutinize the process, and naturally assume that the people (workers) were trying to do a good job.
However, this mindset is too often ignored by many businesses, even today.
Let’s take a look back at the oil train derailment disaster that happened on July 6, 2013 in Lac Megantic, Quebec. If you don’t recall what happened, here is a quick summary.
An unattended 74-car freight train carrying Bakken formation crude oil rolled downhill and derailed, resulting in the fire and explosion of multiple tank cars. Forty-two people were confirmed dead, with five more missing and presumed dead. More than 30 buildings in the town’s centre, roughly half of the downtown area, were destroyed and all but three of the thirty-nine remaining downtown buildings are to be demolished due to petroleum contamination of the townsite. Initial newspaper reports described a 1-kilometre (0.62 mi) blast radius. The death toll of 47 due to the crash and resultant explosion makes it the fourth-deadliest rail accident in Canadian history.
Horrible. The textbook example of a disaster. If you wanted to review the details, check out the Wikipedia page.
Just like other disasters, the corporation involved (Rail World) completely avoided responsibility, and actually blamed the employee they felt caused the disaster.
The CEO was quoted as saying “I think he did something wrong. It’s hard to explain why someone didn’t do something.”
TIP: If you ever hear leadership in a company blame an employee for something going wrong, 99% of the time they have no clue what is actually going on, and they are probably the underlying cause of the problem in the first place. I’ll get to that shortly…
Looking back, here is what actually happened (from Wikipedia). There were 18 distinct causes and contributing factors, many of them influencing one another. Not just a single cause of operator error (as the CEO suggested). This is pretty common, if you go back and review other major disasters.
Here are a couple of the causes:
- An engineer reported trouble with the locomotive 5017’s engine on a separate trip two days before the crash in Lac-Mégantic. The locomotive remained in service despite that concern
- A quick and cheap repair using inappropriate materials allowed oil to accumulate in the turbocharger and exhaust manifold, resulting in a fire.
- In order to put out the fire, the Nantes fire department shut down the locomotive thus inadvertently disabling the air brakes.
- The “reset safety control” system was not wired to set the entire train’s brakes in the event of an engine failure
- The tank cars were prone to puncture and the Bakken oil was highly volatile.
Of the 18 findings, there were 2 that I could find that were related to the engineer:
- Improper handbrake test: The engineer erroneously did the brake test with the locomotive air brakes left on. This gave the false impression that the hand brakes alone would hold the train.
- Insufficient hand brakes: The engineer set 7 hand brakes. The TSB said that a minimum of 17 were technically required and perhaps as many as 26.
Without getting into the details to know the root cause of these issues, here is how I assess whether the worker is at fault.
- Is there a documented process for that task (completing a brake test, ot setting hand brakes)?
- If there is a process, was the employee trained and approved to perform the task?
- Did the employee have all the proper materials, tools and equipment to be able to complete the task using the process?
- Did management review and enforce the documented process? Was it being done the same way by everyone?
- Were all incentives to skip or not follow the documented process removed (pay/bonus incentives, time pressure, understaffed, etc)?
- Did the management solicit feedback, ideas and improvement suggestions and act on them, to make the process better?
If any of the answers to the questions are “No” then the company is at fault. That is why Dr. W. Edwards Deming provides the following quote from his book “Out of the Crisis”
I should estimate that in my experience most troubles and most possibilities for improvement add up to the proportions something like this: 94% belongs to the system (responsibility of management), 6% special.
He believes that 94% of the problems are assignable to the company, while only 6% are assignable to the employee (blatantly not following the rules or sabotaging the process).
Think about it this way: Only after all the other factors for why the worker might have done something incorrectly are removed can you consider assigning it to them.
Next time you hear a company leader or manager blame the worker, stop the conversation, remind them of Deming’s quote, and focus them on the process breakdown that occurred.
Photo: “Lac megantic burning” by Sûreté du Québec – Licensed under CC BY-SA 1.0 via Wikimedia Commons