JUST PLANE CULTURE
awareness and complacency and throw in a dash of pressure and a pinch of stress. The recipe all points to a person, the operator, being the cause — but does it solve the problem? Aren’t they missing something? I’ll admit that all those Dirty Dozen labels fit but they should lead us to a root cause. The Dirty Dozen is not a list of root causes or any kind of cause. The Dirty Dozen is a list of symptoms and the finger is always pointed toward the employee. We are good at addressing symptoms and shooting the last person to touch the object because it is staring us in the face. Get rid of the symptom and you don’t have anything staring at you. Remove the obvious and we can pretend that the cause has also disappeared and we can be content with being oblivious. Unfortunately, the Dirty Dozen is seen as the great list of causal human factors. We place too much emphasis on its usage. It has become a crutch to lean on to identify causes but problems persist. I wonder why.
SETTING PEOPLE UP FOR FAILURE It’s quick and simple solution — get rid of the person. If it weren’t for people mucking up the works, everything would work perfectly. Really? Think again. Machines break, wear, and need maintenance and upkeep. If your car gets a flat tire, do you get rid of it and get another car, thinking that solved the flat tire problem? That sounds ridiculous, doesn’t it? In the previous scenario, the train crashed due to the operator falling asleep because the system had her working relief shifts and she crashed the train. Will firing the train operator fix the problem? If you have ever worked a relief shift, you know the
problems that can arise. You get off work at 4 p.m. and go home expecting to have a nice quiet evening, planning to retire to bed around 10 p.m. At 8 p.m. you are called into work the late shift, midnight to 10 a.m. This will put you in a sleep-deprived mode from going more than 24 hours without sleep. Add to the fact this is a midnight shift that strains a human’s circadian rhythms, even when it is your normal shift. This is a recipe for disaster. We continually set people up for failure. Managers are
surprised when the failure occurs and they blame the individual. I never could understand that. I am always reminded of the scene in Casablanca when Captain Renault, Claude Rains, shuts down Ric’s Café, stating, “I’m shocked, shocked to find gambling is going on in here,” as the croupier hands him his winnings from the table. Management becomes complacent with settling for the status quo. We seek quick answers and short-term results.
ZERO TOLERANCE While employed at a major airline, I went through a root cause training session. It was a robust training course in sound root cause analysis, but the odd thing was that the root cause analysis was done after employee discipline has been administered. Yes, you read that correctly: ready, shoot,
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