Some things that have passed through my earphones recently:
- In a recent lean blog podcast episode, Norman Bodek talked about how great mistakes are, because making a mistake is the best way to learn something.
- In an episode of The Cranky Middle Manager that I just listened to, Patrick Lencioni talked about how one of the signs of a bad job is that you can’t tell whether or not you’re doing a good job at it.
Everybody wants to do things right. But if you make a mistake, don’t freak out about it: notice that you made a mistake, figure out how to do things right the next time.
This has two hard parts: you have to notice that you made a mistake, and you have to not freak out about it. Which points at a problem with our educational system (among other aspects of our culture): it’s designed to get you to freak out about making mistakes, without giving you nearly enough tools to help you notice that you’ve done it. As math teachers all know, telling students to check their work isn’t sufficient support; helping students develop the skills to notice when they’ve made a mistake is hard, and I suspect that attacking them when they screw up probably isn’t the best way to go about it.
Of course, while making mistakes is all well and good from a learning perspective, we don’t want to go too far with that. Which is why, as Bodek continues, we should distinguish between mistakes and defects. Making mistakes is all well and good, but we don’t want other people to suffer from them. This is where poka yoke devices come in: they help improve quality by making it as easy as possible for people to notice when something is going wrong.
The big news around here for the last week has been the oil spill in San Francisco Bay. The news coverage has been all about whether or not it was the fault of the pilot or of a machinery malfunction: train wreck management, or at least train wreck news coverage, at its best. I have no idea what really happened there, but I hope the actual investigation is focusing more on learning about what went wrong and preventing this in the future than on figuring out whom to point fingers at.
(I can’t remember where I read this – Gerald Weinberg somewhere, maybe? – but if you really feel a need for a rule on how to point fingers, here’s one: if you aren’t authorized to sign off on a purchase for X dollars, then you’re not ultimately responsible for a mistake that costs your company X dollars. Again, I don’t want to excuse defects, but people higher up in the company should be growing an environment that minimizes the chance of defects happening at an unacceptable frequency.)
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Yes, I did write that, somewhere in one of my books. Probably one of the Quality Software Management volumes. (Too many books to remember where everything is, but it’s a standard heuristic of my consulting.)
As you correctly say, it’s not to excuse defects, but to identify the level at which preventive action should start. Theoretically, that’s why managers get paid more–because they must take responsibility for more. Doesn’t always work that way in practice, but it should.
11/20/2007 @ 10:03 pm
Unfortunately, most investigations, be it plane crashes, medical mistakes, or this tanker spill do focus on “who” is responsible. The media is as guilty of this, but I think they play into people’s desires for neat, tidy answers. Saying “that guy messed up, so we fired him” seems like resolution, while saying “we blame the system, so we are implementing preventative measures for the future” somehow seems ineffective, ironically.
Thanks for the link!
11/21/2007 @ 6:04 am