On Thursday 29th October 2014, a digger cut through a major gas pipe in the centre of Christchurch and a major evacuation ensued.
There was plenty of talk about this in the tea room at my work place the next day, about the major traffic jams and hassle it caused. The usual “I bet the digger driver gets it!” comment was made….and, possibly, he will. But, on reflection, do any of us think that the digger driver did it deliberately? I doubt it.
The Press article reporting the gas leak notes that the Fire Service representative said “a digger driver working in the area caused the widespread disruption”. Whilst maybe taken out of context, as the media delight in doing, it’s pretty emotive to single out the digger driver.
Much better, I would suggest, is that SCIRT (the infrastructure rebuild organisation) claimed responsibility, stated that they will be doing a full investigation and said “it is essential that we work out how this happened so it does not recur in future.” That’s a lot better, looking much wider than the person AND wanting to improve the process.
It is interesting to note that the reader’s comments section below the article is a mixture of blaming the digger driver, blaming SCIRT and conversely, trying to ‘cut them some slack’ by noting that the post-quake Christchurch environment is a somewhat tricky one to be operating within and it would be a miracle if no such defects occurred given the magnitude of the work being undertaken. I am often frustrated at how people jump to blame without being in possession of the facts.
Whilst this example of a defect causing pain for others is pretty major, we could (if we looked with our ‘blaming bad people’ radars turned on) find lots of examples at work in which you and I think badly of a person because of what we perceive they did, or did not do.
But, standing back, how many people turn up at work to deliberately do a poor job…conversely, how many people are doing their best given the environment they work within…and, perhaps most concerning, how many people have effectively turned their brains to their ‘low setting’ because of the system they have to work within?
So, whenever you find yourself blaming a person, try to stand back and think about the environment that they are working within. If you think about it, you are very likely to find many reasons as to why they acted as they did…and the harder you look, the more likely you are to consider the process could be improved.
Finally, if you think the process should be improved but believe it won’t be…I would ask you to reflect on why this is the case…perhaps the constraint is within the design of the ‘management system’ in which the workers have to operate.
As the Toyota saying goes “Be hard on the process, but soft on the operators.”
Squire to the Giants 
There are a few different emotions that hit me when things like this are brought up.
After trying to quickly summarise Seddon’s method I was asked by the process improvement guy at the local authority in the north island where I work how I would go about solving the issue of complaints from bus users being left at bus stops (drivers not stopping).
Responding on my feet, I thought about obscured bus stops like my own where there’s a big transformer box blocking the seated prospective passenger’s view of the oncoming bus and vice versa. A testable hypothesis if you like. In De Bono’s terms, not something you could discover through logical thinking but logical in hindsight.
Question for you Squire:
How would you get out and study a phenomenon that is statistically rare (so you as an observer/mystery shopper will not likely see it happen), where the ‘witnesses’ – operator and customer/resident – are unable to see the whole context even after the fact or feel threatened(driver – in his current command and control situation) or aggrieved?
It seems that the instinct (inculcated by the culture) is to blame the driver because we tend to discount the systemic pressures at play. (In the case of the bus driver my first question was to ask about pressure to stick to the time-table whether based on a target or not).
I guess I’m asking about the mechanism behind how people (aggrieved service users/managers/me) instinctively notice ‘trends’ where there are none, statistically, and miss trends where they are staring them in the face. And conversely how would “all others bringing data” overcome the cognitive dissonance without a plausible alternative hypothesis already front and centre in the mind?
Thanks for this and all your articles.
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Hi Alex. Thanks for commenting and very sorry it’s taken me so long to read/ reply. I’ve been away over the summer and am only just getting back into things. I haven’t got time to go into a detailed response (and, whilst I am pleased you commented, I never intended my blog to be any form of advice), but some thoughts though:
– I’m intrigued by your comment of “the process improvement guy”. This implies, to me (perhaps wrongly) that this is someone’s role, which would be common in a command-and-control environment wanting improved results (usually ‘efficiency gains’) from their processes. Deming, Ohno, Seddon et al didn’t/ don’t see such a distinction. Instead, the need is for management to provide an environment in which the supervisors/ team leaders and the process performers are the process improvers themselves….and they want to do this because they are intrinsically motivated to do so…which will only happen if extrinsic motivators and constraints have been taken away from them;
– This means a major change in the management system such that bus drivers understand the purpose of the system from the customers perspective and want to improve it…and this won’t be achieved by cascaded personal objectives, targets, incentives, performance reviews and judgement;
– Some questions that I would ask of the system: (how) does the system enable and encourage a customer to report a ‘drive by’ at the point it happens and provide useful information about the event? (how) does the system provide capacity to properly look into such reports and consider what counter measures to experiment with? (how) does the system encourage and enable a bus driver to report a known ‘drive by’ as it happens and collect important information as to why this occurred? (how) does the system see such a report from a bus driver as a good thing, rather something to cast blame on?
– Better that the environment is such that reporting and solving issues is desirable for customer and driver than sending out process improvement experts with brilliantly designed sampling, data collection and analysis tools and methods.
Hope that the above isn’t all gobbledygook/ is of some interest to consider
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Thanks very much for your comments. You’ve focused my attention on the structural aspect to how command and control organisations operate when things go wrong. And why the better way you describe, works.
I wonder how many Business Improvement teams there are out there?
Thanks again for all your articles. Loving your work.
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No worries.
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