Six Key Questions Problem Solvers Fail to Ask
By Kevin McManus, Chief Excellence Officer, Great Systems
Whenever I talk to groups about incident investigations in the TapRooT® root cause analysis courses I facilitate, I kick off the dialogue by telling the group that I did 25 years of relatively weak investigations before the light bulb came on. That statement usually garners me some strange looks. When I go on to state that most of them are practicing equally weak problem solving efforts, the looks get even stranger. By the end of each course however, they usually understand my perspective all too well. They realize that they aren’t asking great problem solving questions.
Why Too Many Problem Solving Efforts Fail
Because we are socially conditioned to blame people, at least in Western cultures, we tend to focus our investigative questions on what happened, what went wrong, and who did what. Collecting responses to those three areas of focus usually gives us the information we need to assign blame. Once we determine who should be blamed for the problem, that person can be appropriately punished, reprimanded, reminded, or nagged. I don’t advocate this approach to problem solving myself, but it does seem to be the prevailing approach used in too many companies.
For example, one of the key reasons I did weak investigations for so many years related to the design of the investigation form itself. The form was not designed to help me ask better questions. Similarly, the training I received relative to form completion – here’s the form, fill it out – did nothing to help me ask better problem solving questions either. As time went on, I learned to use more and more problem solving tools, but rarely were these tools designed to help me understand why a person failed to perform a task correctly. How great are your problem solving questions?
Better Problem Solving Needs Better Questions
When I ask people the question “Why do people make mistakes?”, I am often disheartened by one of the more common responses I receive. All too often, people reply with a one word answer – complacency. I have been a disciple of W. Edwards Deming’s work for many years. I am convinced that essentially all people want to do a good job. When I hear the complacency response as an explanation for why people goof, it tells me that we don’t yet really understand how system design affects human performance on the job.
With this in mind, let’s look at the real reason people fail to understand human error – we don’t ask the right questions. I will share six key problem solving questions with you here. If you want to explore this topic in more detail, please find a way to attend one of the TapRooT® root cause analysis courses that I facilitate. If you do, I am convinced that the course will help you become a better problem solver.
To What Degree Was the Person Fit for Duty?
It is difficult to see what people are going through away from the job, and it is even tougher to explore what is going on inside their head. If we want to gain a better understanding of why they might have goofed on the job, we must ask questions to explore if they felt they were fit for duty or not at the time when the error occurred.
Stress, fatigue, low quality sleep, substance abuse, poor hydration, low carbohydrate levels, and distractions can all affect how we do our jobs. We are often not even aware of the effect these factors have on our own performance, let alone the performance of others. Simply asking the close ended “Do you think you were fit for duty?” question is not enough. We must explore, in a legal and ethical manner, the influence factors such as these might have had on correct task performance.
What Types of Paper or Digital Information Was Being Used to Guide Work?
Working from memory is a key cause of human error. If you think about it, most people work from memory most of the time. Work orders, job aids, screen prompts, and step-by-step instructions are often poorly designed or hard to understand when they are provided. To make matters worse, on-the-job document use is often seen as a sign of weakness. Only new people need instructions to do their jobs correctly – right?
Some of the smartest people in the world use in-hand instructions for a majority of their work. Astronauts, for example, do this because they know the weakness of memory as a correct task performance safeguard. They know that consistent, zero error work is only possible when one’s memory is supplemented by task-specific written or digital information.
How Did the Person Prepare for the Task Before Starting Work?
For too many years as a front-line leader, I missed out of the value of truly effective daily job preparation. I assumed that people came to work knowing what they needed to do. I assumed that they would remember the special instructions for today’s work that I reminded them of during the weekly planning meeting. How well do your teams prepare for each day?
The less one prepares for work at the start of each new task, the more they must rely on memory to make sure the task is done correctly. This rule is applicable enough when we do the same thing each day. It becomes even more important when work requires more customization to meet shifting customer expectations. Do your problem solving questions explore how people prepare for work each day?
How was Task Competency Gained and Maintained?
We place way too much faith in our training systems when it comes to their effectiveness in preventing human error. To begin with, most people are trained in correct task performance on a very infrequent basis. When they are formally trained, the training content is often lacking. To make matters worse, the training delivery method is often not practice-based. Because our systems for gauging training effectiveness and tracking daily errors are both weak, we often fail to realize how ineffective the training itself really is.
Too many people learn by trial and error. Too many people are considered competent in a skill that they have not practiced doing the right way often enough. Exploring how task competency was gained, and maintained over time, helps us better identify training system gaps that need to be addressed.
How Did the Work Environment Affect Correct Task Performance?
We often neglect the impact that our work environments can have on human performance. Poor lighting, a disorganized work area, excessive noise, and regular distractions can all contribute to performance errors. Even something as simple as a manual form’s design not matching its data entry screen can lead to regular errors that we often blame people for.
The best way to gain perspective on this possible problem area is to go to that work area as part of the investigation. Too many investigators however often try to conduct the investigation from their workplace or a comfortable office. It’s no wonder that we struggle to understand how a variety of human factors can affect correct task performance. Do your problem solving questions look closely at how the work environment might have affected performance on the job?
How Often Has the Task Been Done Correctly in the Past?
Asking this question alone should help us rule out complacency when most problems are being investigated. Human errors occur regularly in the workplace, but they are usually caught by someone or something before they become big problems. By better understanding a problem’s error rate, we can gain a more accurate perspective of where the true system weaknesses exist.
Unfortunately, we often don’t have the right kind of error tracking and trending systems in place to let us know the magnitude of our performance problems. We tend to track the really bad things that happen, but smaller errors often go undetected and untracked. All too often, we discover that a problem was bigger than we thought once we start digging into it.
The Power of Great Problem Solving Questions
Obtaining answers to the above six questions won’t get you to the root causes of a problem. They will help you identify some key factors are contributing to the different errors that make up a given problem. Exploring each of these factors with additional, more focused questions will help you find the system gaps and deficiencies that essentially invite human error – the real root causes.
Check out one of the many TapRooT® root cause analysis courses that are offered each month. You are also welcome to message me with your questions at any time. Keep improving!
Kevin McManus, Chief Excellence Officer, Great Systems
You might also enjoy reading my new “Error Proof – How to Stop Daily Goofs for Good” book if you liked this post. It can be purchased from Amazon.com.