Earlier this evening I was on a regional jet flight from Houston to Nashville. Once we reached cruising altitude the flight attendant told us that catering had forgotten to stock the cups so she’d only be able to serve soft drinks in cans without ice and there would be no coffee or water available. It’s really no big deal compared to arriving at our destination safely.
It’s true that catering forgot the cups, but the problem could have also been prevented if the flight attendant would have checked for the cups while we were boarding. Explaining to others what we specifically could have done to prevent the problem is irritating, because it places responsibility on us. It’s lot easier to just blame catering. In a root cause analysis, a blamer can cherry pick the cause, placing the responsibility on another person or group. The language sounds like this, “If they would have just put the cups in the galley like they were supposed to, this problem never would have happened.” The statement is true, but it excuses the flight attendant from preventing the problem.
At work, if someone decides to eliminate blame from their language, their individual accountability actually increases. This approach requires people to think about what they could have done, within their work process, to prevent the issue. Ideally, problems should be less about who made the error and more about what are we going to improve our work processes to prevent it. Work processes must be based on the premise that people make errors. No one is perfect. A core element of the ThinkReliability root cause analysis training is “to err is human, to prevent is process.”
Ironically five feet from the galley, where the cups should be, is one of the best examples of highly reliable work processes in any industry. On the flight deck, the pilot and the co-pilot step through checklists, just like they do on every flight. They’re trained, not only on the checklists, but how to communicate when using the checklists. And, they have recurring training at least annually. The commercial airline industry in the United States has made 12,000 safe flights per day something we expect. Work processes are put in place to take something that is seemingly high risk and make it routine.
Some people might ask “Do you really want flight attendants and catering using checklists too?…ONLY if you want to have cups on each flight.
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