Tag Archives: process thinking

European Blackout: Human Error-Not

German utility E.On says major European blackout was caused by human error [the broken link was removed]

Germany utility E.On AG said Wednesday that a European-wide blackout earlier this month that left millions without power was the result of human error and not any technical glitches.

The Duesseldorf-based company said the power outage, which led to blackouts in parts of Germany, France, Belgium, Italy, Portugal and Spain on Nov. 4, was not caused by a lack of proper maintenance or enough investment in transmission grids and facilities.

The blackout was caused after a high-voltage transmission line over a German river was turned off in an aborted attempt to allow a newly built Norwegian cruise ship to pass safely under it.

That triggered a blackout that briefly left 10 million people without power, stopping trains in their tracks and trapping people in elevators.

Ok, the focus seems to be that we didn’t do anything wrong, just some “human” made an error, which seems to be implied is out of their control. Why would the organization not be responsible for the people and the system working together? Management needs to create systems that work. That system includes people and equipment and process management and suppliers…

E.ON says human error responsible for Nov 4 power outage [the broken link was removed]:

It said that its control centre shut down part of an ultra-high voltage transmission line without checking whether the outage of a second transmission line might overload the power grid.

About half an hour later there was an outage at a second transmission line, which ultimately created a domino effect that led to the temporary disconnection of the European interconnected power grid.

The German utility said that all systems reacted in accordance with standard procedures, effectively preventing a complete blackout across Europe.

It seems obvious the process was not well designed if they believe a mistake was made that led to the tens of millions of people being without power. Failing to admit that the process was designed poorly and needs to be improved is troubling. Blaming “human error” does not help or help improve in the future (and is not a way to develop a culture that respects people). And it reinforces the notion that this event is due to one special cause (or 2…). It seems to me, even with this very little evidence at hand, that this is a system problem.

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Find the Root Cause Instead of the Person to Blame

When encountering a problem or defect the inclination of many is to find a person to blame. W. Edwards Deming believed that the system was responsible for 93% of the problems and over time he increased that number to at least 97%. Why did he see it that way, while so many others first inclination is to blame someone?

As I see it the issue has to do with what is the effective way to improve. Often if you ask why do we have this problem or defect, people will point to some error by someone. So you can blame that person (there are reasons this is not a very accurate way to view the situation often but even without accepting that premise the blaming a person strategy is not wise). The reason the blaming a person is a bad idea is that your organization will improve much more effectively if you keep asking why.

Why did they make that error? Why did the process let them make that error? When you follow the why chain a couple more steps you can find root causes that will allow you to find a much more effective solution. You can then pilot (PDSA) an improvement strategy that doesn’t just amount to “Do a better job Joe” or “that is it Joe we are replacing you with Mary.” Neither of those strategies turns out to be very effective.

But investigating a bit more to find a root cause can result in finding solutions that improve the performance of all the workers. What kinds of things? You can apply poka yoke (mistake proofing) concepts. You can institute standard practices so that everyone is using the best methods – not whatever methods they have developed over time. You can rearrange the process to simplify the steps and eliminate chances for errors. These improvement, and many more, are sustainable and can be built upon over time.

In addition, the psychology effects of seeing people as the source of errors and defect instead of seeing people as the source of improvements to process weaknesses are powerful. If you find yourself thinking a problem or defect is the fault of a person try asking why a couple more times and see if you can find a system improvement that would eliminate or mitigate such problems in the future. That is a much more effective improvement strategy.

I always have had a bias toward finding system improvements but over time that bias has increased as I have applied management improvement concepts. As you gain experience working on improving systems you gain experience showing the wisdom of Deming’s 93-97% figures. My belief is that he increased the percentage of problems attributable to the system over time as he experienced the same thing.

Using Design of Experiments

How to Institute DOE in Your Company (link broken – removed) by Davis Balestracci:

DOE works, but I don’t need to sell that to the readers of this newsletter. But as certain as we all are, no one can deny that design of experiments faces resistance even in environments where it is a proven tool. Every research scientist or engineer who has had a major success from DOE can tell you story after story of how management still wanted problems solved one-factor-at-a-time.

Design of Experiments (DoE) was developed by R.A. Fisher in the 1920s (related terms: factorial design, multivariate expertness). Six Sigma was the first general management approach that specifically highlighted the use of Designed Experiments for improvement. Still the use of factorial designed experiments is much less than it could be.
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Managing Innovation

TQM, ISO 9000, Six Sigma: Do Process Management Programs Discourage Innovation?

“In the appropriate setting, process management activities can help companies improve efficiency, but the risk is that you misapply these programs, in particular in areas where people are supposed to be innovative,” notes Benner. “Brand new technologies to produce products that don’t exist are difficult to measure. This kind of innovation may be crowded out when you focus too much on processes you can measure.”

Well I don’t think the idea that innovation is needed was not understood decades ago. It seems to be one of the typical refrains when people want to change – oh that old stuff was only about x and now we need to focus on Y.
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