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  • Writer's picturethinklikeapilot

The Firework Factory

We had a really good session with a customer last week - we went through our communication module and had some really interesting discussion about the various ways communications flow within their business. We introduced how airlines adopt a Just Culture - No-one should be afraid of speaking up, errors should be reported, and so long as they were not with malicious intent, not penalised.

This sparked an interesting discussion.

"We give staff a bonus at the end of the month if they've made no errors. Errors cost us money".

This is true. Errors cost money. And time. And reputations. Errors are bad, right?

We are all human, and all humans make errors. So does incentivising a lack of errors help your business to grow and learn? I've had a think about this and come up with a scenario, The Fireworks Factory.

Jonny has worked in the fireworks factory for many years. His boss says that as they are dealing with gunpowder and explosives there must be no errors, and every month he will give Jonny £100 if he makes no errors. Jonny makes no errors, is £100 richer every month and his boss is happy. Great.

Jonnys job is to pick the casing up, fill it with gunpowder, add a safety fuse, and put a cap on the end of the firework. He comes in one day and his station has been cleaned, and the box of safety fuses isn't there. But Jonny doesn't notice, and spends all day making dangerous fireworks with no safety fuse. By 4.30pm he has hundreds of them.

30 minutes before going home, Jonny realises his dangerous error. His heart sinks. But if he owns up to the error, he loses his £100. So Jonny rushes off, gets a box of safety fuses, and spends the last 30 minutes of his day making all the fireworks safe.

Jonny has his £100 and his boss has his 100% safety record. Everyone is happy. But should they be?

The next day is Jonny's day off. Susan is working at the same station. Again the cleaner has moved the box of safety fuses, and Susan doesn't notice either. She spends 8 hours making unsafe fireworks with no safety fuses, then goes home at 5.00pm.

BOOM! The factory explodes. How is that 100% record now and did that zero error incentive help or hinder the factory owner?

Consider that if Jonny was encouraged to report errors honestly and openly, as we do in aviation, then at the point he realised his error, he could have made his fireworks safe, then in turn reported the error he had made.

With an open, honest, non-punitive culture a subsequent investigation would see that Jonny indeed did not correctly assemble his fireworks, but a strong contributory factor in this was that the cleaner moved the box of fuses out of his eyeline. A checklist of items required at the operators station at the start the day would have caught the error. Cross checking from a colleague would have caught the error.

These and more are all techniques we use in the flight deck coupled with a healthy error reporting culture, to enhance safety, efficiency, and performance. All of these methods would have kept that 100% safety record. Much more effectively than £100.

Speak to us at today to learn more about Threat and Error Management and how it is relevant to all operations.

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