Stopping the same mistake

Greymill AcademyProcess, time and tools2 min read

The short answer

The third time it happens, it is a system problem.

The takeaway. Do not fix the mistake. Fix the moment where it becomes possible.

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AvoidReminding everyone to be more careful.
Do this insteadAdding one check at the point the mistake happens, so being careless is no longer enough to cause it.

Being told to concentrate harder has never fixed a recurring error.

Example conversation with Daily Operations
You
Third time this year we have turned up to a job without the right part. Everyone says they will be more careful.
Daily Operations
Being careful has now failed three times, so the answer is not more care.

The mistake happens the night before, not on the day. That is where the check goes.

One rule: nobody leaves the yard until the job sheet has been read aloud against what is in the van. Thirty seconds, out loud, by the person driving.

Out loud matters. Reading silently is how you see what you expect to see.

No software, no new system. If it happens a fourth time you will know the check was skipped rather than the care being insufficient, and that is a different conversation you can actually have.

It moved the fix to where the mistake becomes possible.

Play this demo in the Academy

Paste this to ELLA

This keeps happening: [describe the mistake]. It has happened [how many] times. Design me one check that prevents it, without adding software.

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