If this chart would be useful for you or it looks like your group has mastered it already you may be caught in the Blame Game. You need to help your organization to push on past what we know as the human roots and on to the systemic and latent causes. Deming said it best when he said "blame the system not the people." In order to get past this issue you also may want to use the Root Cause of Success process to focus on the positive things and get past the blame. There is a blog post Root Cause of Success that describes it more fully.
Yep, a good example is sometimes the automation is not operator error proof. so the root cause is not the operator, it is the design. :>)
ReplyDeleteThat example gets into human factors engineering and how we design interfaces between humans and machines which does fall out in the systemic roots
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