Blaming human error is made by old-fashioned leaders

Violation of an instruction is not necessarily a human error

We often hear in the media about human error. It is usually an event to be explained, or explained away, and whether it is senior managers or heads of communications, they often land on the fact that the cause was human error. They can document that it is in their quality system how a situation should be handled, but the person who performed the job did not follow the instructions and therefore the incident occurred.

An instruction is seen as a watertight description of a process. If this is followed to the point, everything will be correct, but is it so in practice? Is the described instruction the best and the most effective way to perform the task? Are those who will perform the task trained in the process? Is there a responsible team that continuously develops the instruction? Has a culture been established that creates good attitudes in the organization? Does management have ongoing coaching and training of their team leaders? If we ask why an incident occurs, it will often be concluded that the system is not waterproof, even if there is an instruction.

Employees are responsible for acting responsibly

In society in general, we have a personal responsibility to live a responsible life. In the old days we had something we called morality, but this seems to have become a taboo word in our modern society. Nevertheless, most people try to do the right things in a decent way. We have government-imposed rules, but even if we had not had a law stating that it is forbidden to commit theft, the vast majority would probably not have been stealing from others. If an undesirable incident occurs in society, this is often solved by changing a rule or issuing a new one. In this way, a leader can avoid responsibility for the situation reoccurring. If so, it will be a human error, and in some contexts, this can be perceived reasonably. There are situations in society where individuals behave in a way that harms the community in order to gain their own benefits, although the reason for their behavior very often reflects a social problem. If a politician is not ready to issue a new rule on the kick, he is happy to say that precisely because this could happen, we have initiated a work or committee a long time ago that will soon come to a conclusion.

In a Lean organization, there is an overarching system and culture that aims to ensure respect for people and continuous improvement. If there is an undesirable incident, this is a system failure, then we analyze what caused the incident and come up with measures to prevent it from occurring again. Of course, this is not a contradiction to expect responsible employees of a Lean organization as well, but if everyone is shown respect and trust and can develop their own (job) situation, and the organization has good processes and systems for training, follow-up and facilitation, responsible employees are developed at all levels.

The CEO is responsible for both the successes and the failures

There is only one person in an organization who can commit actions that can be defined as human error, and that is the top leader. If a senior executive makes decisions to gain benefits for himself, disclaims his responsibility for events that have occurred, or otherwise corrupts the organization, then this is a human error. Similar errors elsewhere in the organization are in principle the responsibility of the senior executive as responsible for the development of the organization's culture and ways of working, with the necessary training and motivation of employees at all levels. All undesirable incidents can be explained by the failure of the system of a lean organization with modern management. Senior management who goes out with explanations that the cause was human error, without simultaneously emphasizing their own responsibility and what they themselves must do, apart from introducing new rules, show that they do not relate to modern management and do not understand their role as responsible for a system that should work and that should be improved every day. An incident that has occurred or a mistake that has been committed is the best starting point any organization has for real learning. Why did this happen, what do we have to do to make sure it does not happen again.

In a lean organization, employees have the trust and support of management

The OKTAV process emphasizes the development of culture in an organization based on strategic management, and practical ways of working in this development, a culture that highlights respect for people and continuous improvement. This is a way of working that allows the senior manager to involve each individual employee in the organization and develop a system over time in which human error is not a term. This is modern leadership based on lean principles in practice.

An effective organization is based on trust, an employee should never risk being blamed for an incident that the employer has been guilty of. Employees should know that their management stands up for them, when they perform their job to the best of their ability, and not use them as a scapegoat to disclaim their responsibilities. This means that no employee should be blamed for mistakes that has been committed in a lean organization.

Do you want to read more about this? The book OKTAV is a practical book about how you as an organization become Lean and what steps you must go through in the first phase to build a Lean culture, and mobilize the organization to start its own Lean journey with all employees involved.