tag:blogger.com,1999:blog-5167539222502940808.post6857908146047346366..comments2024-03-28T03:16:54.235-04:00Comments on A Lean Journey: Don’t Blame the Operator, Ask One More WhyTim McMahonhttp://www.blogger.com/profile/07780727768370988177noreply@blogger.comBlogger1125tag:blogger.com,1999:blog-5167539222502940808.post-21981636812619685932013-01-18T03:30:45.251-05:002013-01-18T03:30:45.251-05:00If you answer is that a person was at fault, I wou...If you answer is that a person was at fault, I would even ask why several more times. Another question to ask is why were they allowed to do so? Why was it so easy for them to do so (if it was)? Can't we design the process to make the error much more difficult or impossible? Sometimes the process needs to leave the operator with the potential to easily mess up.<br /><br />Operating on the wrong leg or arm, is inexcusable (processes can make this essentially impossible). Having the sharp scalpel with freedom of movement that lets a surgen cut something that causes a problem might well be a situation that has to exist in order to allow them to do what is needed. They probably need to be able to have dangerous sharp items to do what is needed, we can do things to make the environment safer but the process can't eliminate all risk (as far as I can imagine) in some cases.John Hunterhttp://management.curiouscatblog.net/noreply@blogger.com