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Shobhendu Prabhakar


Five Reasons Quality Failures and Safety Incidents Still Happen

Even in well documented systems, people are the weakest link

Published: Wednesday, May 15, 2019 - 12:03

Someone recently asked me why quality failures and safety incidents continue to occur despite organizations communicating their quality and safety visions to the workforce, developing and implementing quality and safety management systems, and campaigning day in and day out about quality and safety.

This is an important question, and the broad answer is that even the best systems rely on people to design them and to carry them out. Let’s call them the scriptwriters or authors, and the actors who follow those scripts. Let’s take a look at what I think are five key issues.

Rules are not followed 100-percent of the time. Here are some everyday nonwork examples: Speed limit signs are everywhere, yet many of us break the speed limit at times; we are reminded not to text and drive, but still some people do; the same is true with buckling seatbelts. Who is to blame in these instances? The people who wrote the rules, or we the transgressors? When we don’t follow the rules, we are inviting something bad to happen, including accidents. In a similar vein, when defined work processes are not followed 100 percent of the time, the transgressors are inviting quality failures and safety incidents to happen. Performing tasks as per established processes 90- to 95-percent of the time is not always enough because we are leaving a 5- to 10-percent chance of something bad happening. The day when we follow the rules 100 percent of the time will perhaps be the day of no quality failures and safety incidents.

Feeling that processes are boring and routine. Though processes at times may seem routine and boring, they must be followed regardless because they are there for a reason. No matter how experienced an employee is, or how many times she has performed a routine task—and at times the task may be boring—it will be our tolerance for boredom that will reliably prevent quality failures and safety incidents. The less this tolerance, the more the quality failures and safety incidents. The less we allow complacency to sink into our day-to-day tasks, the more we prepare ourselves for better quality and safer operations.

People are less likely to follow the rules they can beat. In the business and technology world, the armor that protects rules from being broken is called engineering controls. Lack of, or inadequate, engineering controls allow people either to bypass the rules or to be punished for honest mistakes. When engineering controls are such that they effectively overcome human error (intentional or unintentional), only then can we be certain of a decline in quality failures and safety incidents. Simply stated: Foolproof = Robust engineering controls = Close to zero quality failures and safety incidents.

Details paralysis. I am sure at least one time in your professional life you have come across procedures that are too lengthy, with page after page of details. As a result, the important stuff is lost in the details and footnotes. I am by no means suggesting that we should not have detailed procedures, but are the details in the procedures clear, concise, and absolutely necessary?

Can a 30-page procedure be condensed into 20 without compromising the quality?

Can the life of the user be made simpler, i.e., is there a possibility of transferring critical and absolutely essential information from a 20-page procedure into a two-page version without compromising the document’s intent and quality?

Shakespeare once said, “Brevity is the soul of wit.” So true. Achieving the balance between details and conciseness in written procedures (or for that matter, in any writing) is a must for effectively delivering the message. This requires a lot of work and thought on the writer’s part but helps users immensely to understand, execute, and avoid mistakes.

Good script + bad actors = box office flop. We all can agree for the most part that the actors (doers) of the script (procedure) are really co-authors. Knowing what is in the procedure is a minimum requirement but not sufficient to avoid quality failures and safety incidents. Perhaps the sufficient condition is understanding why certain steps are in the procedure, what their significance is, and what the risks and consequences are of ignoring or bypassing those steps. Unless we as actors understand a script’s soul—its intent and essence—as well as its details, the execution will be flawed, and the end result will be a flop, leading to defective products, quality failures, and safety incidents.

I hope these ideas will help all of us better understand that despite organizations’ efforts to instill quality and safety, we may not be able to completely eliminate quality failures and safety incidents. But this isn’t a lost cause. Both those who write procedures and those tasked with following them can contribute to making our operations safer and of superior quality.


About The Author

Shobhendu Prabhakar’s picture

Shobhendu Prabhakar

Shobhendu Prabhakar is working with TechnipFMC in a project quality manager role. He holds a bachelor’s degree in mechanical engineering, a master’s degree in mechanical design engineering, and a master’s degree in business administration. He is a Jones Scholar (Rice University in Houston) and a certified ISO 9001 lead auditor with 14+ years of professional experience in quality assurance in oil and gas industries. This article does not represent any TechnipFMC position, and it is in no way related to TechnipFMC.


Quality & Safety Failures

I agree with the previous comment and would like to add one thing - if a process or task is "boring" to the point that workers are likely to become inattentive this is also a serious system failure.  The process should either be automated or eliminated because it is clearly a threat to the system in its present form.  One cannot simply mandate increased attentiveness to a process that by its very nature is repetetive, uninspiring, routine or all three together.   

Not Bad Actors

There is only one reason that quality and safety problems still happen...Because They Can.

Deming and Juran both attributed <15% of probems to the workers and >85% to the system.

Procedures should be written such that they are the best, fastest and cheapest shortcut to do the task.

Most workers want to do a good job and few will go out of their way to do it wrong.

When writing SOPs and developing processes we should remember the 3 rules of error proofing...

1 - Make it easier to do right than wrong.

2 - Make it obvious when it is wrong.

3 - Make it easy to correct if it's wrong.

A classic example is MS Word

1 - Auto-correct will fix most minor mispelled words as you type

2 - Unrecognized spellings and bad grammar are underlined

3 - Just backspace and retype to correct the error.

This should prevent all errors except those where the worker must rush and omit a step entirely.   (Like not proof-reading your document before printing.)

But again, this is a system issue as well.