Human Error in Maintenance

(Video Transcript)

Is it really Human Error?…or are our Processes and Systems setting us up for failure?

I took my cat, Marko, to the veterinarian for his annual examination and the vet diagnosed him with asthma.  And to manage those consequences of failure, he prescribed Marko, Albuterol.  And he prescribed that Marko get 0.2 milliliters twice per day.  You can see this is in liquid form.

When I picked up the medication…it was called in to a pharmacy that’s used to prescribing medications for human beings.  They gave me this syringe to draw the Albuterol out of the bottle.

If you notice, this syringe is in increments of one milliliter.  So you can see that one syringe is a total of ten milliliters.  So, if I’m going to use this syringe for Marko, I would only draw up enough fluid to the very first increment which is just like this much.  That’s within the margin of error for this syringe.

Really, what I should have been given is an insulin syringe.  See this syringe is in increments of…one entire syringe is one milliliter.  So, each increment here is in tenths of a milliliter.  So, for Marko, that would be about this much.  So, you can see that this one [green syringe]…it doesn’t make any sense.

Now just imagine that, if I weren’t technically minded…or if I was distracted…or overtired…or just not paying attention because I’m a human being and NOT a robot…  If I gave Marko 10 times the amount of albuterol that he really needed, worst case that could stop his breathing and he could have died.

So, the question is, if that had happened, would it have been my fault?  Or would it have been a problem with the system or the process that was in place?  Because really, I should have been given a syringe like this.  Now this reminds me about Maintenance and Reliability.

Because in our environment, oftentimes technicians or people get blamed for mistakes when really, we have not set them up for success.  Because oftentimes we maybe have technical manuals that are not as detailed as they should be, or maybe there are mistakes.  Or maybe Operating Procedures are vague.

Or maybe the training that we have set up is less than adequate.  So at the end of the day, people get blamed for stuff when really, we as responsible custodians need to take a look at really what’s going on.

Things like this are called Latent Failures.  These are things that exist…issues that exist…and they’re just waiting…it’s like you’re just waiting for disaster to happen.  And obviously if Marko had died, that would have been a disaster for us.

So, how can we combat that?  Well, one way is with a process called Reliability Centered Maintenance.  If I could hop in my time machine and go back 40+ years, I might whisper into the ears of the architects of Reliability Centered Maintenance, Stanley Nowlan and Howard Heap.  I might have said, I’ve looked into the future and this process, it yields way more than just a Proactive Maintenance plan.  You can get so much more out of Reliability Centered Maintenance – especially if you do it the right way – with the right people.  So it needs to be named something different.

Because when you use a Facilitated Working Group approach to the process…when you get all of the equipment experts around the table…and when the process is facilitated by someone who really understands the process, this person can lead this group of equipment experts to identifying specifically what causes failure of our machines.  In other words, what would specifically cause us not to get the kind of Reliability that we want?

Now when you get all of these people around the table, issues like this come up because the people who are in the field…the people who understand the equipment and understand the operating environment, they know where these latent conditions exist.

And when they’re asked the right questions and they’re all around the table at the same time, giving all of their different perspectives about a piece of equipment, these kinds of issues come to light.

So not only do you create a Proactive Maintenance Plan, but you can come up with a whole host of other solutions that can help you to realize the Inherent Reliability of your equipment.

So, there you have it.  If you want to achieve the kind of Reliability that you want, and you want to cut down on what is perceived as Human Error, then it is up to us as Responsible Custodians to identify those issues that exist with our Processes and our Systems, that could maybe confuse people or not set people up for success that, worst case, can end up in disaster.  I’m Nancy Regan.  Thank you for watching.