Anatomy of a Plant Turnaround - Part 1: Safety and Quality

Safety and Quality - Your Organizational Health Indicator

Most plants approach safety and quality from a compliance perspective. They expect to achieve or fail in their results based on the level of accountability they can create around each fully independent compliance set, safety and quality.

That's a good conventional approach and I do not want to undersell the value of process compliance. It's critical. However, pure compliance won't fix these metrics.

I think there is another important way to look at this. Work Injuries, Quality issues, and production issues too, they're frequently actually just errors where someone who normally performs a task successfully deviated in a way that created a problem.

But why would a person who normally does it correctly deviate? 

Well, something causes those deviations. And it's our job to lead such that we remove those causes.

What are those causes?

The first four come from a program I audited some years ago (that I believe was called "Safe Start") that made the argument that in the vast majority of all injuries, someone is either: 

• Rushing - Working with a high rate of urgency

• Fatigued - Insufficiently rested

• Complacent - Failing to comply with one's processes and procedures

• Frustrated - Elevated emotional state

They argued that employees could spot those conditions in themselves, self-identify, and then take actions to prevent injuries. I thought this was a good assertion, but not the whole story.

I flipped that and said, "if I want to systemically prevent injuries (and other errors), I need to systemically prevent rushing, fatigue, complacency, and frustration." 

And I use that to choose how I lead and how I design systems.

I've since added the below four states to the original four as they also originate errors.

• Habit Disruption: Changes in routine force reliance on conscious thought, increasing errors as people toggle between autopilot and deliberate action.

• Cognitive Overload: Too much information or task complexity overwhelms, leading to mistakes.

• Environmental Stressors: Noise, poor lighting, or discomfort impair focus and performance.

• Uncertainty/Lack of Communication: Unclear instructions or doubt about tasks cause missteps.

So when we look at an organization that has elevated safety and quality problems, chances are it has elevated levels of one or more of these eight states.

In fact, these two metrics (Safety and Quality) taken together could be viewed as conclusive evidence (multiple agreeing indicators) that there is a persistent issue within the organization with elevated levels of one or more of these eight drivers of errors.

And, just to be clear, elevated error rates in safety and quality will also present themselves in the core productivity metrics as well. Elevated error rates are universal when they're there. They affect everything.

So how do you fix them?

Rushing - Fix systems such that people have the right information at the right time. Study why people rush and build processes to stop it. Note: Rushing is sometimes called a "sense of urgency." Many organizations are ok with people rushing as long as production doesn't stop, but if people are rushing that cost will still be there.

Fatigue - Limit work hours. Enforce breaks. Rotate people doing strenuous work. Try to limit the exhaustion your work inflicts on your people.

Complacency - Enforce processes and policy evenly and unrelentingly. The concept of "shared accountability" is critical to beat this one. If processes aren't being followed, hold the leaders accountable so they will hold the people accountable. For examples, if people aren't wearing PPE, hold the supervisor accountable because that supervisor is not upholding standards on that shift.

Frustration - Fix systems such that people have the right information at the right time. Frustrated people love to explain why they're frustrated. Listen to those people. Find frustrations and fix them.

Habit Disruption - Anything that disrupts normal processes disrupts habits. Repetitive stops, maintenance issues, data logging, new processes, etc. You want to eliminate interruptions for operators.

Cognitive Overload - If they're overwhelmed for any reason they will not make good product safely for very long. 

Environmental Stressors - Hot, loud, hungry, wet, uncomfortable. These generate errors.

Uncertainty/Lack of Communication - Communication is a system. Draw out the entire process. Make sure everyone is given the information they need before they need it. This prevents errors, rework, rushing, frustration, downtime, etc.

Takeaways: 

1) Poor performance of Safety and Quality metrics is an indicator of elevated rates of issues in one or more of these eight drivers of errors.

2) Elevated occurrence of Safety and Quality issues will always be accompanied by elevated occurrence of production issues. Allowing your workers to remain in these states is very expensive.

3) These eight states are at the forefront of how we lead, how we gauge our organizational health, and how we drive change. 

4) Fixing any of these states anywhere in the organization will affect all of our metrics. Remember, while "Safety, Quality, Production" has been the mantra of production teams for ages, individuals are all just following a process.

Build these states out of each process and you'll advance every metric.