Complacency Revisited
We are used to looking at human factor problems with a focus on the employee, so let’s turn this around and look at human factors problem focused on management. I’ll only look at one issue: complacency. In this respect, complacency is failure to act appropriately and resting too much on our laurels. Complacency, at first blush, is not a problem. Don’t we have a moment of complacency when we have completed a big project and reflect on what was accomplished? It becomes a problem when it hinders other activities or blinds us to other problems. Excess complacency is the problem.
There was an accident on the “L” train blue line going to Chicago’s O’Hare Airport. The operator failed to stop and ran through the boarding area, went through the barriers and proceeded partially up the escalator toward the airport terminal. It was all caught on a security camera and was a devastating accident. Surprisingly, no one was seriously injured.
The investigation revealed that several safety devices were designed to stop the train automatically. The barrier at the end of the track had failed in its task. The train operator admitted that she had dozed off just as the train entered the terminal — aha, a victim was found and terminated. The train was not speeding but the train had produced enough kinetic energy even at slow speed to climb the escalator to the airport terminal. The train operator was a fill in, so she works different shifts at different times to fill in for manpower gaps. The operator was trained properly; however, she had a previous incident with dozing off and missing a stop. What would you do?
The transit authority has had a “zero accident” policy in place for some time. Its instant decision was to fire the train operator and also find out why the safety devices, although activated, failed to stop the train. I see this all too often — “let’s have a fair trial right after the hanging.” All in all, this sounds like a reasonable approach, a perfect example to tag some “Dirty Dozen” labels on it and put it to rest. Fatigue comes up immediately; we can also add a cup of lack of awareness and complacency and throw in a dash of pressure and a pinch of stress. The recipe all points to a person, the operator, being the cause — but does it solve the problem? Aren’t they missing something?
I’ll admit that all those Dirty Dozen labels fit but they should lead us to a root cause. The Dirty Dozen is not a list of root causes or any kind of cause. The Dirty Dozen is a list of symptoms and the finger is always pointed toward the employee. We are good at addressing symptoms and shooting the last person to touch the object because it is staring us in the face. Get rid of the symptom and you don’t have anything staring at you. Remove the obvious and we can pretend that the cause has also disappeared and we can be content with being oblivious. Unfortunately, the Dirty Dozen is seen as the great list of causal human factors. We place too much emphasis on its usage. It has become a crutch to lean on to identify causes but problems persist. I wonder why.
setting people up for failure
It’s quick and simple solution — get rid of the person. If it weren’t for people mucking up the works, everything would work perfectly. Really? Think again. Machines break, wear, and need maintenance and upkeep. If your car gets a flat tire, do you get rid of it and get another car, thinking that solved the flat tire problem? That sounds ridiculous, doesn’t it? In the previous scenario, the train crashed due to the operator falling asleep because the system had her working relief shifts and she crashed the train. Will firing the train operator fix the problem?
If you have ever worked a relief shift, you know the problems that can arise. You get off work at 4 p.m. and go home expecting to have a nice quiet evening, planning to retire to bed around 10 p.m. At 8 p.m. you are called into work the late shift, midnight to 10 a.m. This will put you in a sleep-deprived mode from going more than 24 hours without sleep. Add to the fact this is a midnight shift that strains a human’s circadian rhythms, even when it is your normal shift. This is a recipe for disaster.
We continually set people up for failure. Managers are surprised when the failure occurs and they blame the individual. I never could understand that. I am always reminded of the scene in Casablanca when Captain Renault, Claude Rains, shuts down Ric’s Café, stating, “I’m shocked, shocked to find gambling is going on in here,” as the croupier hands him his winnings from the table. Management becomes complacent with settling for the status quo. We seek quick answers and short-term results.
zero tolerance
While employed at a major airline, I went through a root cause training session. It was a robust training course in sound root cause analysis, but the odd thing was that the root cause analysis was done after employee discipline has been administered. Yes, you read that correctly: ready, shoot, aim. This is zero-tolerance at work; complacency is illuminated because it simply won’t be tolerated. No brain matter is required, thinking is not required, merely shoot the person who touched it last.
Zero is an absolute. Zero-tolerance policies are upper management’s message to everyone that we don’t trust you to do any thinking so we will do it for you. Crash a train and you’re fired, get a paper cut and you’re fired. Wait a minute, that’s ridiculous. Hey, zero is zero, remember? If we allow paper cuts, what else will be on the allowed list? If zero isn’t zero anymore, then what is it? Now everyone is confused.
Complacency occurs when we step back and relish our accomplishments, but we shouldn’t lose focus of what got us there and rest on our laurels too long. BP was celebrating six months of achieving its goal of zero quality escapes when it incurred the largest oil disaster in American history. Surprisingly, the celebration was on the platform that exploded. No executives were injured in the blast although several employees were killed. Aiming for zero quality escapes and zero accidents is a noble goal but it also has a tendency to promote what you are trying to prevent. Zero is also a fleeting accomplishment and not sustainable. When touched upon, it is time for celebration but with the reality that it is temporary. Trying to sustain that level is distressing; however, letting up is not an option. I’ll age myself with this analogy but you have to wind a clock every day to maintain the time; if you don’t wind it enough, it loses momentum during the day and doesn’t keep accurate time. Wind it too tight and it breaks. Seeking zero as a goal is winding things too tight.
What’s wrong with chasing zero?
Zero sounds like a logical target. There was even a bestselling business book call “Zero Defects” some years ago. Unfortunately, zero accidents and zero quality escapes set up what is referred to as binary thinking. You are either perfect or a failure. Upper management message of “zero accidents” or “zero defects” or “zero tolerance” sends a mixed message because they are just words without substance and actually exacerbate what they purport to denounce. The pursuit of zero sets an admirable but unachievable goal. Management 101 teaches that setting unachievable goals frustrates the workforce and reduces productivity. With a zero mentality, anything less than zero is a failure, so why put forth extra or any effort when failure is inevitable?
The argument will no doubt come up that if I am not pro “zero accidents,” “zero defects” and “zero tolerance,” then my goal is to plan for accidents and defects to occur and I’m tolerant of all aberrant behavior. This is thought-limiting mentality and binary thinking in action again; life is not black and white and just comprised of zeros and ones. The fact that I see the fallacy in perfection doesn’t mean that I pursue imperfection. On the contrary — I recognize imperfection for what it is and don’t hide behind the perfection poster. I also recognize that the phrase “all incidents are preventable” is hindsight thinking that cannot predict future events, as many may think. It should more correctly be stated, “All incidents were preventable.” We need that hindsight as a learning tool but it is not predictive. It is our nature to learn from our mistakes and the mistakes made by others, the idea is not to repeat them.
more on predictive actions
That seems to go right in the face of proactive activities that are designed to prevent things from occurring before they happen. It is true that this is a predictive action but it is based on probability and severity. There is a probability of anything occurring with varying degrees of severity. Aliens from another planet could attack us tomorrow — but if they can travel between planets and galaxies, they are obviously more advanced then us. If they wanted to destroy us, we would be helpless. Should we gain international support and promote huge capital expenditures to develop a defense against an interplanetary attack? That’s not going to happen. Even though the severity of the attack means the annihilation of the human race on this planet, the probability is too low to take action. It is better to spend money on defenses that are more be necessary even though the severity is less than total extinction. We refocus but it doesn’t mean that we completely ignore this issue. We might revisit it occasionally to see if the probability has changed. Never be complacent, even if it is absurd.
Zero is an absolute number. A void is a void. Perfection is also an absolute. Zero is not sustainable and if it is reached, we should not be complacent. We should be attentive enough not be lured into a sense of permanence, knowing that zero is temporary.
Thomas Jefferson said, “Our new Constitution is now established, and has an appearance that promises permanency; but in this world, nothing can be said to be certain, except death and taxes.”
Patrick Kinane is an FAA-certificated A&P with IA and commercial pilot with instrument rating. He has 50 years of experience in aviation maintenance. He is an ASQ senior member with quality auditor and quality systems/organizational excellence manager certifications. He is an RABQSA-certified AS9100 and AS9110 aerospace industry experienced auditor and ISO9001 business improvement/quality management systems auditor. He earned a bachelor of science degree in aviation maintenance management, a master’s of science degree in education, and a Ph.D. in organizational psychology. Kinane is presently a senior quality management systems auditor for AAR CORP and a professor of organizational behavior at DeVry University.