“An ounce of prevention is worth a pound of cure.” ~ Benjamin Franklin
At a customer site visit earlier this year, I read a white board that had the following conversation (paraphrased).
Question: Do we have to report all near misses?
Question: Even if no one is hurt?
Answer: Yes. Not only do we expect you to report the untied shoe lace, we also expect you to include your idea for what we do differently to prevent the shoe lace from being untied tomorrow.
The above customer conversation states very well my expectation for quality OPEN reporting, specifically to include a best practice or preventive action. A quality report of an event includes thoughtful consideration of not only what happened and how we correct, but also how we prevent. In the above example, correction is STOP and tie the shoe lace; prevention could be to use a different method like tying a double knot, using a different lace with more grip, using tape to keep the knot and laces in place, or even using a different shoe that has no laces to tie. I am sure you can come up with a dozen more. The point is we must be thoughtful about what we report so we can learn and continuously improve and move from reacting to proacting.
And if you think a concern with tying shoes is “elementary” or “mickey mouse” and not worth our attention … Consider this story regarding one of the greatest teachers of all time, the legendary basketball coach John Wooden.
YES, every detail matters.
- APM President, Jake Locklear