Who’s to Blame?

A story on the radio yesterday described the three families of 9/11 victims who continue to wage a legal battle with the airlines. Most of the bereaved accepted payment from the victims’ fund. Some 90 others settled out of court with the airlines. These three have dedicated themselves to the “truth,” subpoenaing hundreds of thousands of documents related to the incidents.

The documents include calibration and service of the x-rays and metal detectors, training schedules for the personnel, time records for those on duty at each step of the process, etc. According to one father of a woman who died, “We know someone is to blame for this, and the world has a right to know who it is.”

Why? I’m not denigrating their grief, but it seems to me that their quest, if it ever completed, won’t serve any purpose. Of course, in any system with thousands of moving parts, many of them human, there are going to be a few, perhaps dozens , of failure points. Somebody looked away at the wrong moment, scratched his nose, snuck off to the bathroom, forgot to log the calibration, or didn’t plug something in.

So if we find, say, that an X-Ray tech misread the unit when servicing it a week before, what then? Do you sue the service company? Do you sink some business under a sea of claims because some employee didn’t execute his routine job, error free, at 100% of his ability and training, eight years ago? That employee has likely moved on. Do you follow him, or does the liability rest with his employer? Do all the people who work there now deserve to lose their livelihood because of his mistake?

It struck me that many small business owners do the same thing. When they find an error, they spend too much time trying to fix the blame. They believe that, if they can identify the person responsible, he or she can be retrained, reminded or reprimanded into not making that mistake again.

It is impossible to train human beings to be error free. Detroit tried to fix that in the 60’s by putting inspectors at the end of the assembly line. They missed things too. So they added more inspectors, same problem. Lots more inspectors only provided very incremental improvement.

Eventually they learned that the system had to be constructed to avoid errors, and quality shot up dramatically. The process of doing things the same way, documenting them, and being accountable for the results, is what prevents us from the need to be blame hunters.

In some businesses it started as TQM. Now it is codified in systems like Six Sigma and ISO 9000. For a small business, it’s as simple as a checklist. (But it has to be a checklist that someone reviews, and audits from time to time.)

Start with a simple checklist for a step-by-step process in the area where you spend the most time fixing mistakes. You’ll be surprised at the impact.