Punishment culture assumes people naturally do bad, lazy things unless they are deterred by punishment and fear. Therefore we must punish mistakes.
That perspective has long been debunked. You don't see competent, skilled leaders using it. It turns out that generally people want to do well (just like you do), and they don't when they are scared / activated (in fight/flight/freeze mode), poorly trained, poorly supported, or poorly led. They excel when they feel safe and supported.
If you are the manager and the technician makes the same mistake the 2nd or 3rd time, you will find the problem the next morning in your bathroom mirror. :) At best, you have put them in a position to fail without the proper training or support. Leadership might also be an issue.
I would say that every skilled leader must use punishments and consequences to some degree.
If your tech gets drunk every day and doesnt do their job, you need to cut them loose. This isn't a management problem.
Sometimes people end up in positions where they are not suited and will continue to fail. If you hired a plumber and you need a doctor, that isnt an on the job training, support, or leadership issue.
It isnt always managements job to make the person workout in the role. Sometime it is managements job to fire that person to find someone better.
Some people are bad fits for positions. They might look good on paper, they might be trying something new, they might lie to get hired, they might change after starting, they might have been a risky hire, or any number of reasons.
I think you're envisioning people all being absolutists who follow an exacting rule book and can't consider context. (that's covered by the *flexibility* tentpole)
As N approaches infinity, there's definitely a value of N at which we discover the root cause is the airman and have to move on from him. I don't think it's particularly interesting to try to identify a constant value for N because it's highly situational, and we know we have to do *just* and *reporting* as well, the reporting falls out when the just does.
You hit the nail on the head. I do perceive a lot of people being "no bad employee" absolutists.
All I am looking for is recognition that the content of N matters.
It is part of what I see as a broader phenomenon where people emphasize systems and ignore agents. In reality, agents shape systems and systems shape agents in continuous feedback.
If you implemented some changes so the mistake is caught before disastrous consequences, you're already doing better. Well enough to let the 2nd one slide. Even the 3rd. After that, action seems reasonable. It's no longer a mistake, it's a pattern of faulty behavior.
I expect there's precisely 1 safety culture that can tolerate a culture of apathy and indifference -- one in which no work is ever completed (without infinite headcount).
You apply risk mitigation and work verification to resolve safety issues.
Then you recursively repeat that to account for ineffective performance of the previous level of verification.
Ergo, end productivity per employee is directly proportional to integrity, as it allows you to relax that inefficient infinite (re-)verification.
Exactly! All this talk about man vs system misses the point that man is the system designer, operator, and component.
This is why Boeing cant just solve their situation with more process checks. From the reporting, they are already drowning in redundant quality systems and complexity. What failed was the human elements.
Someone was gaming the system saying that the doors weren't "technically" removed because there was a shoelace (or whatever) holding them in place, Quality assurance was asleep at the wheel, and management was rewarding those behaviors.
Redesign the system again if it's unintentional. It is almost impossible to control humans to the degree that they never make mistakes. It's far better to design a system in which mistakes are categorically impossible.
I'm trying to push back on the knee jerk sentiment that there are no bad employees, only bad systems.
There are no systems that are human proof, and what kind of human behavior is tolerated is a characteristic of the system.
In fact, there are humans that lie, cheat, are apathetic, and incompetent. Part of a good system is to not only mitigate, but actively weed these people out.
For example, if someone falsifies the inspection checklist for your plane, you dont just give them a PIP.
Because Im an engineer in a quality controlled field (Medicine), and my personal experience is that firms place too much faith in quality systems and not enough emphasis on quality employees.
I see lots of engineers and QA following a elaborate procedures with hundreds of checks, but not bothering to even read what they sign off on, so they can go golf all day.
People seem to think that you can engineer some process flow to prevent every error, but every process is garbage if the humans dont care or know what they are doing.
Every process is garbage is you dont hire workers with the right skills demanded by that process. In an effort to drive down costs, lots of companies try to make up for talent with process, with poor results, for both the companies and patients. you cant replace a brain surgeon with 2 plumbers and twice the instructions.
Similarly, I read some head of a leading engineering organization (I think a NASA head or maybe Admiral Rickover) who said, essentially, 'you can't replace ability with process'. All the process in the world, they said, will not substitute for highly able personnel.
But perhaps safety, not usually dependent on ability, is a different matter. Possibly, the problems you describe are a matter of leadership and management - which doesn't undermine your point; those also are things that can't, past a certain irriducible point, be replaced with process.
>Possibly, the problems you describe are a matter of leadership and management
I wholeheartedly agree that leadership/management is a part of problem. My main objection is the "no bad employee" rhetoric. Sometime times the problem with management is that they aren't getting rid of bad employees. Rot can start anywhere in an organization, and the rest of the org really needs to push back, not just management.
It actually reminds me a lot of the culture/discipline problems with some Police departments in the US. It is hard to enforce and cultivate organizational culture top down. Most of it is maintained peer-peer.
I think that scales very much with the complexity of the task.
If you are talking about someone who cant server coffee, the balance is clearly in favor of poor management over inadequate skills and trainability.
If you are talking about very specialized skills like aerospace engineering, I think the balance can move further in the other direction.
There is also the combination of the two, where in the interests of growth or cost savings, an organization has cut corners on the quality of talent hired.
It's seemingly simple "oh the technician keeps messing up"
Did the technician mess up (sometimes true), or were they doing their job in good faith - was it the system/protocol/organization that made the task mistake prone? Did someone else actually mess up but the situation made it look like it's the technician's fault?
Does this technician do a task/service that is failure prone? Are there other technicians on other tasks that are far less failure prone? Here the former technician would seem poor, the latter, excellent, but it's a function of the task/role and not the person.
I've been "the technician" - I catch a lot of blame because people know I'm anti-blame culture, so I'd rather take the blame on myself that point my finger to the next guy in line. I'm also willing to take on high risk tasks for the greater good even if they suck and are blame prone / risky. I believe in team culture in this way. If the organization doesn't respect that belief and throws me under the bus, I leave - which is quite punishing for them since they remain completely unaware of a major internal problem. If an organization "sees me" and my philosophy, then together we get very very good at optimizing the system to minimize the likelihood of failure / mistakes.
Imo it's a function of time, company and team culture, severity, and role guidelines.
If an employee makes a mistake but followed process, and no process change occured, that's just acknowledging the cost of doing business imo and would be a unbounded number of times so long as it's good faith from the employee
Not severity; that sort of thinking is actually part of low-safety cultures. A highly safe culture requires the insight that people don't behave differently based on outcome. In fact, most people can't assess the severity of their work (this is by design; for example someone with access to the full picture makes the decisions so that technicians don't have to). So they couldn't behave differently even if they did somehow make better decisions when it matters.
But, and I'll reiterate the point for emphasis, people make all their decisions using the same brain. It is like bugs; any code can be buggy. Code doesn't get less buggy because it is important code. It gets less buggy because it is tested, formally verified, battle scarred, well specified and doesn't change often.
Would s/severity/impact/g also be counterproductive of safety culture? Genuinely trying to learn here, gotta be responsible/accountable and all.
Maybe impact relative to carelessness/aloof-ity?
I agree that an engineer/person will not behavior differently based on outcomes, but if they know in advance something can have a wide, destructive blast radius if some procedure is not followed, I feel there's a bit more culpability on the part of the engineer. Regardless I don't think I feel I have a sufficient grasp on this concept I'm trying to define so definitely agreed I shouldn't have included 'severity' in the function definition nor any alternative candidate
Punishment culture assumes people naturally do bad, lazy things unless they are deterred by punishment and fear. Therefore we must punish mistakes.
That perspective has long been debunked. You don't see competent, skilled leaders using it. It turns out that generally people want to do well (just like you do), and they don't when they are scared / activated (in fight/flight/freeze mode), poorly trained, poorly supported, or poorly led. They excel when they feel safe and supported.
If you are the manager and the technician makes the same mistake the 2nd or 3rd time, you will find the problem the next morning in your bathroom mirror. :) At best, you have put them in a position to fail without the proper training or support. Leadership might also be an issue.