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Topic Title: Dealing with Human Error
Topic Summary: Countermeasures and human error.
Created On: 04/13/2017 10:51 AM
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04/14/2017 03:06 PM
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rbossingham
Rick Bossingham



We had a salesperson who failed to forward a signed contract from a client to our accounting group to be turned into a project. Ultimately it resulted in a non-serious violation of a permit, because the project didn't get completed. This goes against every incentive that the sales person has, and this has only happened once before as far as anyone can remember.

Any thoughts on countermeasures for this type of error?
04/17/2017 09:43 PM
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TRB
TIM BELL



Hi Rick,
Often the most effective solution is also the easiest. Checklists can easily address any lapses in memory or follow-through. The checklist can be completed much like a "To Do" list. The checklist can be associated with tasks or can be an end of the week style to remember to close tasks out at the end of each week.
Hope this helps.
Tim
04/17/2017 09:44 PM
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JohnWitherspoon
John Witherspoon



I would ask the question, is it in his/her standard work and, if the reply is yes, it's a non-conformance and should red binned (or whatever process you use to identify non-standard production) and identify how it happened (5 why's, fishbone,...) and what activities should be integrated into the standard work to ensure it won't happen again, the goal is to have the process thoroughly Poka yoke (error proof).

Now, if it's not in his/her standard work, then I guess it needs to be added, standardize and measure against the standard, hard to measure if there is no standard.
04/24/2017 06:36 AM
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ChristianS
Christian Sampedro



Agreed with everyone, the solution for this specific kind of error would be a checklist.

But I really want to dig deeper... Rick said that this has only happened once before. Even though I am a strong believer on creating standards for all processes, is it a wise use of resources to create a standard to prevent an error that may never happen again? Isn't that Over-processing?

Because of the custom nature of the work I do I find this "single occurrence" kind of errors all the time. My plan of attack is always to go for the most frequent errors and processes and make them easier, liberating time and resources so people can pay more attention to the nuances. Maybe the salesperson was too busy doing other activities that she forgot to send the contract? Maybe all those other activities are the ones that need attention and not the defect itself. Don't forget to look at the negative space...
04/24/2017 06:36 AM
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bmackeyvt
Brian Mackey



Hi Rick,

If I were in your situation, I would dig a little deeper with a root cause analysis (using 5 Why's or fishbone or other methodology) and let the root cause dictate my countermeasure(s).

It's important to ask, "Why wasn't the signed contract turned in?" Keep asking why to find out if this is an issue with: a single employee's competence, standard work, education / awareness, overburden, prioritization, etc.

Bottom line, the root cause of this error will help you determine the correct countermeasure and reduce the likelihood that it will occur again.
04/28/2017 09:42 AM
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leanwannabe
Brian Koenig



Sorry, while checklists are nice to define activities that need to be completed, I'm not always a fan of managing through completed checklists.

If the Salesman forgot to submit the contract, do you think he would have updated the checklist to find out it wasn't turned in?

Another possibility would be an "Open Unsigned Contract Log" that would let him know daily / weekly / monthly all the contracts that haven't been received. (just a thought)

Not to say that the a checklist might not eliminate recurrence. What works at one place, doesn't necessarily work at another which is why I thought I'd throw in another potential countermeasure.

Good luck.

Brian
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