Are You Relying Too Much On Process To Catch Errors?


An organization leader once remarked: "Our process is so good that there is no way we could make a mistake".  The following discussion on Design for Manufacturability and Assembly (DFM/A) illustrates how we can become so reliant on the process and process improvement that we neglect the role of the human in the process. ." A "Cadence Chance" magazine article, "Design for Manufacturability and Assembly"(DFM/A), by Joe Greco defined DFM/A as "…any tool or process that helps a designer or engineer think about, and therefore avoid, manufacturing and assembly problems down the road."We have been asked how Error Management differs from the process that is used in the DFM/A as Error Management begins in the design process.

While it is true that Error Management begins in the design process, it is not necessarily true that the process will preclude error.  Unfortunately, in every process, humans are involved, and therefore human errors will occur. We need to be constantly reminded what Cicero the Roman philosopher, statesman and orator said in 106 BC - 43 BC:  "To err is human, but to persevere in error is only the act of a fool."The basic belief that a thoroughly reviewed and understood process precludes errors is a commonly shared belief. During Error Management discussions we often hear many well-meaning stories about the effectiveness of processes from a variety of functional organizations. 

The title of the organization may vary; but the common statement goes something like: "Our organization is already using Error Management in the process we use for start of the day or change of shift meetings" It was at one of these discussions where we heard the statement:  "Our process is so good that there is no way we could make a mistake". Comments on our human tendency to rely on the effectiveness of processes can be found in even the highest levels of management.  When commenting on the loss of the Mars Orbiter spacecraft, Dr. Edward Weiler, NASA's Associate Administrator for Space Science said: "People sometimes make errors.  The problem here was not the error, it was the failure of NASA's systems engineering, and the checks and balances in our processes to detect the error".   To mitigate too much reliance on processes, we and our team members need to constantly reminded that processes by themselves don't care.  It is the people who make the process a success or contribute to failure.  An organization may believe they have the best process in the world; but it is the humans that make it work or screw it up. With humans in the process, they are subject to the limitations in our personalities and the Traps in human nature that are identified in Error Management training.  Error Management has a set of common sense, "nuts and bolts" approaches to detect, avoid, mitigate, and preclude reoccurrence of errors.  Pearl Buck, the Pulitzer prize winning author said:   "Every great mistake has a half-way moment, a split second when it can be recalled and perhaps remedied". Error Management provides Tools to help individuals and teams to raise their level of Situational Awareness so we can be aware of when we are about to make a mistake.

Some specific Error Management Traps (dependent on a number of factors including the specific process and individual members of the team) that can be associated with allowing error in the process to go unresolved include: 1. Excessive Professional Courtesy- The individual does not feel free to question the validity of a process because of reluctance to speak up to the team lead or out of deference to the technical expertise of the team lead or more experienced team members. 2. Spectator Syndrome - The individual does not raise questions he might have about the process as he assumes that the process is completely valid because it has been used many times before and has been thoroughly reviewed prior to use by a competent team of individuals.

The concern over individuals involved in a process was amplified by Joe Greco in his "Cadence Chance" magazine article on DFM/A when he said "The subject of DFM/A cannot be discussed for too long until words such as collaboration and team will come up to help describe a system where engineers talk to designers and manufacturers.  However, no matter how advanced the technology is allowing these professionals to collaborate, the question still remains whether or not they will, simply because many engineers are used to going off on their own to solve problems.  Joe Greco went on to say: "Miles Parker III, a DFM/A manager at the University of Rhode Island feels that changing the thinking of this "engineering culture" is a major factor in successfully implementing a DFM/A system"Are you relying too much on a process to catch errors?  Are you creating an environment where individuals and teams feel free to speak up when they have concerns or questions about a process?  Error Management can help create the right environment to meet your needs and improve the bottom line.

- Larry Tew

© The Center for Error Management 2004-2011