Was it really Human Error…?

I love yogurt and eat it every day 🥄. My favorite is Oikos Lemon Meringue 🍋. I buy it every week.

But one day, I was unpacking my grocery bags and found that I had bought banana flavored (yuck! 🥺) instead of Lemon Meringue.

In the context of RCM, this “failure” has 𝗢𝗽𝗲𝗿𝗮𝘁𝗶𝗼𝗻𝗮𝗹 𝗖𝗼𝗻𝘀𝗲𝗾𝘂𝗲𝗻𝗰𝗲𝘀. Not only did I lose money when I gave the banana yogurt away, but I had to spend my time going back to the store to buy the right kind.

Was this all my fault?  Was it purely 𝙃𝙪𝙢𝙖𝙣 𝙀𝙧𝙧𝙤𝙧? Or does Oikos bear some responsibility?

There’s no denying that the packaging is very similar. It (obviously) was very easy to make this mistake.

Ok, you may be thinking, “this really isn’t a big deal.” And I agree. It isn’t.

But it could be a serious disaster if something like this happens with our equipment.

What if a valve is vaguely labeled?

What if a crucial step in an Operating Procedure is inadvertently left out?

What if a maintainer is not feeling well, is overtired, or distracted (like I was that day)?

Disasters happen every day in our world for causes that could have easily been avoided. Just turn on the news.

What can we do about it?

𝗧𝘂𝗿𝗻 𝘁𝗼 𝘁𝗵𝗲 𝗽𝗲𝗼𝗽𝗹𝗲 𝘄𝗵𝗼 𝗸𝗻𝗼𝘄 𝘄𝗵𝗲𝗿𝗲 𝘁𝗵𝗲 𝗶𝗺𝗽𝗿𝗼𝘃𝗲𝗺𝗲𝗻𝘁 𝗼𝗽𝗽𝗼𝗿𝘁𝘂𝗻𝗶𝘁𝗶𝗲𝘀 𝗮𝗿𝗲.

The untapped gold 🥇 in an organization is the people who operate and maintain the equipment every day. 𝗧𝗵𝗲𝘆 𝗸𝗻𝗼𝘄 𝘄𝗵𝗲𝗿𝗲 𝘃𝘂𝗹𝗻𝗲𝗿𝗮𝗯𝗶𝗹𝗶𝘁𝗶𝗲𝘀 𝗹𝘂𝗿𝗸. 𝗪𝗲 𝗻𝗲𝗲𝗱 𝗼𝗻𝗹𝘆 𝗮𝘀𝗸.

𝘉𝘶𝘵 𝘮𝘰𝘴𝘵 𝘰𝘧 𝘵𝘩𝘦 𝘵𝘪𝘮𝘦 𝘸𝘦 𝘥𝘰𝘯’𝘵.

And that’s just one of the reasons why 𝗥𝗲𝗹𝗶𝗮𝗯𝗶𝗹𝗶𝘁𝘆 𝗖𝗲𝗻𝘁𝗲𝗿𝗲𝗱 𝗠𝗮𝗶𝗻𝘁𝗲𝗻𝗮𝗻𝗰𝗲 (𝗥𝗖𝗠) is so strong.

When done correctly with the right people, failures that are just waiting to happen can proactively be identified – 𝘢𝘯𝘥 𝘦𝘭𝘪𝘮𝘪𝘯𝘢𝘵𝘦𝘥. (Or at the very least, the Consequences of failure can be minimized.)

𝗥𝗖𝗠 𝘁𝗮𝗸𝗲𝘀 𝘁𝗶𝗺𝗲 𝗮𝗻𝗱 𝘁𝗵𝗲 𝘄𝗶𝗹𝗹 𝘁𝗼 𝘀𝗲𝗲 𝗶𝘁 𝘁𝗵𝗿𝗼𝘂𝗴𝗵.  But when an organization commits to applying it correctly, the results can be overwhelmingly positive. 𝗢𝗿𝗴𝗮𝗻𝗶𝘇𝗮𝘁𝗶𝗼𝗻𝘀 𝗰𝗮𝗻 𝗯𝗲 𝘁𝗿𝗮𝗻𝘀𝗳𝗼𝗿𝗺𝗲𝗱. I’ve seen it first-hand.

What do 𝙮𝙤𝙪 think? 𝘗𝘭𝘦𝘢𝘴𝘦 𝘭𝘦𝘵 𝘮𝘦 𝘬𝘯𝘰𝘸 𝘪𝘯 𝘵𝘩𝘦 𝘤𝘰𝘮𝘮𝘦𝘯𝘵𝘴.

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