An employee makes many decisions or choices during the course of their work. Some of those actions have undesirable outcomes, such as discrepancy, error, or failures that may impact organizational results, operational production, quality of the output (product or service) or result in an employee sustaining an injury.
There are often multiple contributing factors that may also influence the employee's decision-making. Most incident investigations and/or analyses fail to get at the reason for the decision made and instead focus on the employee's actions or behavior and its outcome. This determines the corrective interventions deployed, which relates to three broad categories: performance, quality, or safety. Due to the nature of safety management, official requirements, governmental data, overall research, and industry factors, this paper will focus on safety in general and construction in particular.
A review of typical safety interventions produces a list that includes program, procedure, process, or practice revisions, training or retraining, group discussions, postings, focused inspections, incentives, discipline, etc. Some of these have been in use since the industrial revolution, expanded by the enactment of the workers compensation laws (some going back about 100 plus years). To this we can add the Occupational Safety and Health Act (OSHA), which has been around more than 50 years, as well as various forms of behavioral interventions, which have been around for about 35 years. While all of these laws and interventions certainly have contributed to the reduction of construction incidents and accidents, they have not effectively eliminated them.
Identifying the Source
Most performance defects or incidents are caused by some form of human activity. Often, those involved in the process may not be aware that they contribute to the problem, or they may be aware but fail to respond properly or effectively. Some may lack the information, capability, or knowledge. Others may fail to adequately understand or evaluate the level of exposure or consequences of their actions.
Construction error can reduce productivity, result in poor construction quality, or cause injuries to the workforce. It is estimated that anywhere from 2 to 10 percent of the gross cost of a project is wasted due to such errors. Errors may contribute to the incidents or accidents that cost the industry $50 billion or more annually, and the traditional tools and techniques used to reduce accidents are not effectively and positively affecting this enormous cost. The resulting numbers of accidents or losses may be viewed as the "defect rate" of the operating process.
What most of the folks implementing safety interventions fail to address is why the workers chose to do what they did. The construction industry can greatly benefit by taking a page from manufacturing, where error-proofing has had a great impact on reducing the rate of defects. To reduce work errors, the contractor must incorporate error-proofing into the way business is carried out, the organization is structured, and the operational processes are performed, such as in partner selection, operational planning, task risk assessment, and effective execution. Following are six potential outcome improvement or error-proofing techniques.
Elimination seeks to eradicate the error-prone process step(s). This may involve a constructability review during the design of the building elements to make them easier to build and/or maintain. It will require the identification and elimination of the work practices that possibly create the risk of making a mistake.
Substitution identifies more reliable processes to improve error-free execution. This involves exploring the uses of alternate processes to diminish exposure and the potential for mistakes.
Prevention modifies the operational process or work procedures to reduce potential error-causing action. Anticipate the risks associated with the progressive changes as the work goes in place and the potential for lapses, slips, or mistakes. Reduce stress where possible to enhance error-free operation.
Risk reduction seeks to simplify the process, minimize exposure, or ease its execution. Prefabrication, preassembly, or standardization helps reduce exposure and the potential for making mistakes.
Detection is aimed at early identification of possible mistake-causing situations or conditions through preoperational planning so as to enable error-free performance. This requires an analysis of the operational processes, task procedures, or work practices for error causation, as well as peer reviews and performance/execution observations.
Mitigation tries to minimize the adverse effects of the error. Since humans are prone to make mistakes, and systems can degrade, errors are inevitable. So, this step tries to immunize the adverse effects of such an outcome. This may involve preoperational planning, pretask activity review, self-checking, the pairing of people, coaching, etc. Another effective tool is proper task design and matching the worker's capability to the task demand.
After a number of high-profile accidents in the 1970s, the airline industry searched for ways to improve operations. Those people recognized that human errors were a causal factor in many of the accidents and developed the crew resource management (CRM) process that teaches teams to make optimum use of all available resources—equipment, procedures, and people—to promote safety and enhance the efficiency of flight operations.
If we boil the organization's operational process down to its most elemental state, an output (building) is created by the use of the construction company's systems (processes, practices, and procedures), and these are activated and managed by the people (workers, supervisors, managers, and executives). Looking at this model, there are only two major sources of potential error or loss, and these are either in the systems or in the people. Unfortunately, in construction, the focus is primarily on the worker part of the people segment, resulting in trying to eliminate the problem by addressing only a small fraction of the whole. This is the underlying reason for the lack of greater success in a more substantive reduction of the negative safety outcomes.
Instituting Error-Proofing in Construction Projects
Mistake (error) proofing is a powerful tool adopted by the manufacturing industry to increase the quality of its products, improve efficiency, and reduce cost. Construction is also a production process, and many of the error-proofing tools and techniques used in manufacturing are applicable. The following steps can be useful in the effective implementation of an error-proofing process into construction.
Create a cross-functional team to evaluate the existing systems and identify error-proofing opportunities. The team should include representatives from all levels of management, departments, and producers (workers) as well as key subcontractors' personnel, as necessary.
Devise standard procedures for error-proofing the organizational, business, and operational systems so that they are easy to use, generate positive results, foster involvement, and are sustainable.
Utilize a structured problem-solving methodology to isolate problem areas and determine the most effective way to improve performance.
Value stream mapping can be used to identify areas where improvement is necessary and to ease implementation.
Select the most effective and appropriate solution after a thorough review and analysis of the issues and constraints involved. Utilize the six progressive steps listed above.
Error-proofing all of the company's systems is an important step in increasing efficiency, improving quality, enhancing productivity, and facilitating safe execution, increasing job satisfaction, and improving profitability.
Another thing to consider is that, in the traditional (worker) intervention practice, the underlying assumption is that the worker has total control and, therefore, can resolve the problem. This cannot be further from the truth; the worker has to function within the overall operational system. Yes, the worker can control their action to some degree and perhaps exert some influence over the immediate area, but a vast number of extenuating conditions and circumstances influence the outcome. Management controls the "big picture" (strategy, goals, objectives, schedule, costs, etc.). At the operational level, management selects the worker, assigns the task, provides the tools and equipment, makes assignments, supervises the work, etc.
So, if management places the worker in a predicament where the production goals conflict with safe procedures, the worker may choose production to stay employed. This speaks to both internal alignment and system integration, which are controlled by management. Therefore, management can greatly influence the error-proofing of operations and improve the worker's success rate.
Defective Performance Analysis
Workers have to successfully utilize organizational systems to accomplish their work. The resulting discrepancy, errors, or accidents may emanate from the employee's action, the operational systems, or the interaction of the worker with the systems. Below are some general classifications that may lead to "defective" performance. This list is by no means complete and may differ for different situations.
Capability. Physical strength, dexterity, experience, competence, skill, talent, etc.
Knowledge. Lack of information, understanding, intelligence, or miscommunication, incomplete information, misinterpretation, etc.
Judgment. Prejudice, expectation, perceptiveness, acumen, awareness, insight, assessment, misjudgment, etc.
Attention. Lack of focus, breaks in concentration, interruptions, disruptions in flow, multitasking, focus, etc.
Mistakes. Slips, lapse, oversight, deviation, perception, etc.
Personality. Habit, disposition, temperament, drive, disposition, ignore rules or standards, arrogance, over-confidence, risk-taking, disruptiveness, stubbornness, etc. Motivation. Desire, impetus, impulse, actuation, cause, induce, influence, etc.
Intention. Deliberate action, personal agenda, sabotage, etc.
The above categories provide a different approach to risk reduction and error-proofing the operation. These affect the worker's performance, but most of the solutions have a management or system component. Generally, management designs systems, devises processes, or implements procedures that can be error-proofed. An example of error-proofing where the systems make it impossible to make a mistake is the USB plug: you can only install it one way. Likewise, management can devise systems that either eliminate or significantly reduce the error-making possibility.
Traditionally, employees making errors were told to be careful, pay attention, or they were retrained. Training is only useful in cases of knowledge deficiency and don't address many other underlying causes. Some research findings indicate that humans make five or more mistakes per hour, and since we cannot change human nature, error-proofing is a proactive approach to minimizing the potential negative results.
Motivation, feedback, and/or training work best if and when the physical environment as well as the systems and expectations are well designed and do not provoke errors. There really is no way the organization can expect to achieve excellence unless the systems facilitate ease of execution, minimize required effort, and enhance flawless achievement while promoting safety. It is difficult, if not impossible, to achieve excellence in operations if the operational, as well as organizational systems, are error provocative.
Error provocative systems may create situations that increase the potential for workers to make mistakes. Management must study their construction processes or procedure, their operational means and methods, as well as their organizational systems to identify elements, functions, or areas that are error provocative and redesign or modify them to correct such predicaments. Sometimes, design defects come to light during the construction phase. Astute contractors should alert the owner that an error-proofing assessment should be conducted before construction commences, or better yet, during design development to identify such problems and resolve them preconstruction.
Prior to the preliminary project startup steps, the preconstruction group and the potential project team should review their operational, tactical, and logistical plans and the project schedule, budget, procurement plan, subcontractor selection, staffing, and other controls for error-provocative potentials. This early investment of resources will ultimately have a tremendous impact on the reduction of variability, uncertainty, inconsistencies, and constructability—leading to substantial efficiencies and elimination of waste and injuries.
An assessment of the project systems should first look at the project team and ensure they have all the necessary capability, knowledge, and motivation and that they can and will function as an effective team. All potential deficiencies should be addressed and mitigated prior to the start of work. The systems critique starts with a review of all the potential processes, procedures, expected practices, and performance expectations that will be in effect, utilizing the framework of steps listed above.
System error-proofing guidelines may include the following.
Assign project team members who are capable, knowledgeable, motivated, and who will work as an integrated team.
Devise robust systems that enhance error-free performance.
Utilize shop prefabrication over field installation where possible to reduce error.
Use preassembly to reduce exposure time and field error.
Incorporate modularization to foster ease of installation.
Implement standardization to help reduce task difficulty/variability and reduce error.
Utilize checklists and use them every time the activity or situation changes (similar to CRM).
Anticipate deviations, fluctuations, and changes in flow with "ready" preplanned possible interventions.
Minimize disruptions so as to reduce distractions and focus attention.
Have recovery plans ready for use for potential disruptions or failures.
Make "doing it right" the first time an organizational "living" core value.
Utilize a team environment that promotes open participation and leverages experience in the continuous improvement process.
Employ planning, risk assessment, and problem-solving methodologies to drive performance to perfection and defects to zero.
Implement a continuous improvement process supported by an organization-wide sustainable system.
Once the systems are optimized, the next step is to address the interaction of the people with the systems. This is the understanding or perception of the people who are operating and utilizing the operational systems, as well as their understanding of what is expected of them. They may misunderstand or draw the wrong conclusions and so act in ways that are not in the best interest of the organization. Some of these problems may result from communication or information that is not clear, insufficient, untimely, or confusing. Management must ensure that workers have a clear understanding of expectations.
Mistakes may occur because of the following.
Perception errors (misunderstanding, misreading, misidentifying, or misjudging)
Communication (ambiguous, incorrect, incomplete, or untimely)
Expectations (urgency, production goals, performance, compliance, task demand, rate of production, or achievement)
Influenced by others (failure to deliver as promised, lateness, shortage, defective part, improper tools, or defective plans)
Task assignment that ignores worker capability (strength, experience, skill, competence, or proficiency)
Poor planning or risk assessment (which increases variability, uncertainty, pressures and stress, or surprise)
Failure to assess worker knowledge (lacking experience, training, or skill)
Not controlling the environment (stress, noise, heat, cold, lighting, or risk)
Motivation (influence, desire, engagement, persuasion, or stimulation)
Dan Petersen, arguably the best-known safety professional in the United States, said that "incidents are caused by the combination of management system failure and human action or error" and "human action or error may also be caused by management created environments that reward risk taking."
Probably there are as many mistake-proofing strategies as there are mistakes. Generally, a holistic approach to mistake-proofing requires engagement, communication, and cooperation between the producers (workers) and supervision. The internal systems have to be fully integrated and aligned with business goals and objectives. Managers must become leaders to empower and motivate the workforce to become fully engaged and contributing to improving the processes and practices. The culture and climate must support and sustain the error-proofing procedures and the worker-system interface. Error-proofing must become an organizational value and the guiding "way of life."
The error-proofing approach can have a much broader impact on the construction process than just reducing or eliminating worker injuries. Studies have determined that anywhere from 40 to 65 percent of the cost of construction does not create value for the project owner. Whatever percent may be the true reflection of this waste, it is a waste, and every effort should be made to address this. The error-proofing process defined above looks at the three key areas where the risk of defects may occur in the organization's systems, business practices, and operational process, as well as the behavior of the people within it. If error-proofing is integrated into the organization's "means and methods," the potential benefits are going to give it an error-free work environment, significantly improve the bottom line, and improve the company's competitiveness and reputation.
Opinions expressed in Expert Commentary articles are those of the author and are not necessarily held by the author's employer or IRMI. Expert Commentary articles and other IRMI Online content do not purport to provide legal, accounting, or other professional advice or opinion. If such advice is needed, consult with your attorney, accountant, or other qualified adviser.