PROBES AND VIOLATIONS: A COMPARISON
Ok. I’m not going where you think I’m going with this. But nor am I above shameless click-bait. So, let’s talk about probes!
Of course, I’m talking about Ph probes used for recording scientific data. Are there even any other kinds of probes?
To be clear, we’re discussing one of the probes pictured on the right. Get your mind out of the gutter.
Now that we’ve cleared that up, let’s set the stage. You work at a manufacturing facility. For years, technicians have been using probes to test Ph. Recently there was a change to the process. A simple change, mind you, but one with big implications.
Since Monday (hypothetically speaking of course), technicians have been required to attach the Ph probes and their leads to a probe stand like the one in the picture above. The change is being made to prevent contamination and/or potential breakage of the probe. In the past, the probes were not captive and had frequently broken. In support of this initiative, each sample station is being given a sanitary container in which the buffer liquid cup can be stored without spilling.
Today, you have the task of auditing this new practice for compliance. You go to the first station and it’s perfect. Second, perfect. Then you come upon the third station. The technician there is hurriedly scurrying about and doesn’t have time for your intrusion. You start to walk by and then notice that his probe is not attached to the stand. In fact, he has reverted to the old practice of placing the buffer cup and probe in the permanent holder at the top of the station. You cite the violation, inform him, and leave.
I’m well aware that nothing like that ever occurs in a work environment but just go with me on this journey for a moment. If something like that had occurred at your facility, wouldn’t you want to know why? Many of you reading this “get it” on a fundamental level so I won’t insult you. But if even one person out there is content to just cite without understanding, then this needs to be said.
I mentioned the technician being in a hurry for a reason. If this example were real (totally fabricated, trust me), one might have noticed that he had placed the cup and probe in the old location because his new holder was gone. An inquisitive observer might then have asked him why he wasn’t using the new stand. Although that is an inherently dumb question (yes, they exist), it would prompt the technician to explain that he didn’t want the buffer cup to spill and the stand would not reach to the old holder. He would also explain that his new holder had been taken before his shift. Easy.
So now let’s draw that comparison. If all of this had been some sort of safety issue, how many Safety “Professionals” would have probed (see what I did there…) deeper and figured out why the violation had occurred? What if the buffer was a highly volatile acid that had a flash-point of -2 and could melt through your hand while at the same time spontaneously combusting it? Would the conversation have been civil, or emotion-driven due to the extreme risk that technician had placed everyone in?
Here’s a simple truth: People are task-based. We’re driven to complete tasks, not assess the risks associated with them. I would even argue that we don’t consciously assess risks as we encounter them. We either plan for them up front (build risk mitigation into the task) or react to them as they happen.
When the operator “violated” the new policy, he did it in the interest of completing the task. To some degree, he even did it to mitigate risk (the buffer cup spilling). In his case, however, the system failed him and he was faced with a choice: a) do it “correctly” and risk spilling his cup or b) do it the old way and finish the task.
How much better could we be at accounting for error and avoiding problems if we looked at the world through the lens of the worker rather than trying to spot what they are doing wrong? If you don’t practice this already, give it a shot. It may surprise you. In the meantime, if you haven’t already, check out SAFETY IS TIRED, LET’S MAKE IT RELENTLESS.