The Parable of the Compliant Company

Once upon a time, there was a company. It doesn’t really matter what company, because the company is representative of many organizations. This company had a secret strategy, one which it practiced but did not publicize.
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Posted August 21st, 2007 in Observations, Operational Excellence

The Accident Report said “The post hit the truck”

I just finished reading Mistakes Were Made(but not by me). The authors, Carol Tavris and Elliott Aronson, made me think about an accident report from a few years ago. I was responsible for reviewing and approving all incident analysis reports in the lessons learned system. I was also responsible for building a learning culture that accepted individual responsibility for errors and accidents. (more…)

Posted August 7th, 2007 in Human Factors, Operational Excellence

Operational Excellence is Like a Web

A spider web is a good way to think about operational excellence. When a spider spins a web, it finds a sturdy starting point to anchor the first strand. When that strand is connected to both points, it has high tensile strength. Once all the strands are connected, the tensile strength of the entire web are multiplied. If one of the individual strands get broken, the entire web is weakened. The spider has to pay attention to the entire web and every strand, not just the strands that are easiest to maintain.

In my experience, companies that want to achieve operational excellence understand that a systemic approach is necessary. They cannot look at operational excellence as a project to improve procedures, for example. An effective procedure program is an element of operational excellence, but not the only element. Other necessary elements include administrative policies, human factors, training, performance measures, and an integrated lessons learned program.

After a major organizational accident, one company decided the “silver bullet” was to develop procedures, train people on the procedures, and address noncompliance with the procedures. While those things were necessary, we had to add several other elements to address all aspects of the sociotechical system. Simply, we addressed people, process, and technology. Then we had an Operational Excellence program that worked. The Operational Excellence web had the tensile strength to hold up and perform well over time. All the strands were constantly maintained.

We did not focus on one, and neglect the others. That is a recipe for problems. One has to be careful not to focus on one’s favorite solution or the solution one always uses. Lots of companies believe training is the fix-all for everything. Put more tools in the toolbox. Remember the saying that if your only tool is a hammer, everything looks like a nail.

Posted January 7th, 2007 in Operational Excellence