Change Management / Workforce Development

A realistic (and more effective) approach to error management

In this Big Picture Interview, Jake Mazulewicz, Ph.D., says focus on the root of the problem rather than on assigning blame.

By Thomas Wilk and Christine LaFave Grace

Jake Mazulewicz, Ph.D., learned classic error prevention skills as a firefighter, EMT, and military paratrooper. He then served as a Human Performance Improvement (HPI) lead for a 3,600-person business unit at Dominion Energy. In 2015, he founded JMA to help leaders in high-risk industries reduce, mitigate, and learn from workplace errors. After delivering a keynote presentation at the Fluke Xcelerate conference in Fort Myers, FL, he spoke with Plant Services’ Thomas Wilk and Christine LaFave Grace about how successful organizations can seize on errors to improve processes.

PS: You mention that unforced errors in the workplace cost manufacturers $38 billion a year. Where does that number come from? How can companies begin to chip away at it?

JM: That’s a number that is opening eyes kind of all around the industry. The number came from a global analyst firm, IDC, in a white paper they put out in 2008. They looked at employee misunderstanding – in other words, human error. They looked at 400 leading companies in the U.S. and the U.K. as well and totaled up how much they all spent recovering from errors. The total is about $37 billion per year. And that’s not just in a bad year—that’s every year, year in and year out.

When I first got into error management at Dominion Energy, I learned about 20 or so classic individual and team defenses. They are what I now call Strategy No. 1. These are defenses or tools that individuals or teams can use very simply, very quickly and get some very quick return on investment. Examples include three-step communication, checklists, peer checking, confirming terminology, phonetic alphabet—Alpha, Bravo, Charlie—these are tools that are very simple to use; almost all of them come from aviation, the military, fire and rescue, and other high-reliability organizations.

They remained popular up through maybe 2010, but then people really started seeing the limitations of them, and then they started exploring more-advanced strategies.

PS: What are the biggest limitations of Strategy No. 1?

JM: Imagine a leadership team learning about these tools and going, “Wow, these can really prevent a lot of errors.” Sooner or later they’re going to make these tools required. They’re going to say, “Hey, if a little three-way communication is good, then a lot of three-way communication is better. We’re going to require our people to use it.” Sooner or later, they’re almost inevitably going to wind up framing almost every error as a failure to use human performance tools, and they’re not going to go any deeper.

PS: They’re not doing root-cause analysis on those errors.

JM: Correct. For very shortsighted leaders who are very discipline-oriented—the folks who say, “The punishment will continue until morale improves”—HPI is a perfect way to misuse that, or (those are the people) who will misuse HPI and make it a very punitive tool. Once that happens, the workers go, “I want no part of HPI. It’s just a discipline tool; it’s just a way to make me wrong.” Then they basically go from very positive to very negative on it, and the leaders wind up going, “Hey this just didn’t work. Maybe it works for the military or healthcare, but it doesn’t work for us.”

PS: We hear a lot about the need to develop resilience strategies, whether with respect to cybersecurity breaches or other plant incidents. How do you frame resilience as a strategy?

JM: Resilience is what I call Strategy No. 3—it’s the most advanced strategy, because it really requires a different way of thinking. It requires understanding a lot more about human nature in organizations and individually: People are going to make errors; there’s no such thing as an error-proof system.

PS: What are the characteristics of organizations that get this approach to error management and implement it successfully, and then on the other side, what can organizations that aren't so great do to change that?

JM: Two items jump to mind: One is timing. I speak with many organizations to which I might think, "Boy, you really need this," but they are not ready for it. And their leaders are in a very punitive mode, they say things like, “Nope, we can simply control errors; all we need to do is have better procedures, more compliance, more accountability.” And if they're in that mindset, there's not much you can do to convince them otherwise. Sooner or later though, enough incidents will happen where they will probably question some of their fundamental values and assumptions, and then, maybe only for a few days, or hours, they'll open up to other ways of thinking. The goal is to become someone who they trust enough that when they’re genuinely open to new approaches, they call you.

I was in a safety meeting with about 15 senior directors and an executive in charge of about half a billion dollars worth of assets. They were discussing three incidents –  minor car or truck crashes in substations. None of them caused serious problems. But any one of them could have caused an injury or broken one of the many delicate and expensive devices inside the substation fence. The executive and all of the directors got furious. They said, "We will not stand for this; we're going to make an example of it." They were getting extremely punitive. I sensed that I was only going to get one chance to put my two cents in. So I wanted, and listened for just the right moment. At a pause, I said something like, "Gentlemen, it feels like we're judging people based on the severity of the consequences of the incidents they were involved in, when what we should be doing is judging people based on the quality of the decisions they made based on the real-world imperfect situations in which they had to make them." The next ten or so seconds of silence seemed to last about an hour. Then I saw the vice president drop his shoulders and sit back in his chair and sigh. He said: "That's exactly what we're doing. We need to go back and rethink this; instead of just punishing people; let's find out why they really did what they did and see if we can learn anything from it." That one comment changed the course of the entire conversation. But if I had said it five minutes earlier or five minutes later, it would have just bounced off and had no effect. Timing is everything.

The second one is, one of the big differences in companies or teams that are successful in managing errors is they don't demonize or criminalize or punish errors. Nobody wants consequences; nobody wants to lose life or limb or property or damage, of course. But the good teams, when something bad happens, they don't give into their worst impulses and simply try to find someone to hold accountable. Instead they ask, “Why did this really happen the way it did?” They ask, “How did we set this person up to make this error?” Was the mistake essentially an honest one? And if it was truly a mistake, an error, a misunderstanding, they take discipline off the table, and that person who made that error just becomes your new best friend. They become the world expert in that company on improving that process. Many companies fire the person who erred, and that person then takes all of their experience and ideas on how to improve that process right out the door to different company, usually a competitor. The best companies actively, deliberately learn from their mistakes without criminalizing them.