When Common Sense Rolls Away
NOTE: This post is from one of our frequent contributors to this blog, "Birdseye59604.
Imagine a
car incident where the vehicle ends up through a picket fence and into a yard.
The incident may have been caused due to another traffic swirling in the path,
or because the black cat crossed in front. Incidents are results of being
distracted by outside events, which causes a split-second of distraction from
task and with no time to invent a recovery process.
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It is common
sense to put out the fire, and common sense was applied.
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When the
events are heated, or literally on fire, unless there are established processes
in place it becomes easy to do mistakes, since the processes now has to be
invented at the time of reaction.
Assume for
a moment that this incident happened on top of a hill and the vehicle caught on
fire. Fire trucks arrive and firefighter are running towards the vehicle ready
to put out the fire. Then, in a split second, the car begins rolling away and
down the street. Still on fire, the fire fighters run behind trying to catch
up. But with no luck, and the car crashes into another fence.
After all
the excitement is calmed down and the fire is extinguished, the next step is to find out what happen,
what caused it, what link in the process was lacking, and what is the root
cause.
After an
incident the event must be made right again. Not just to prevent further
similar incidents, or not just as a "lesson learned", but to make it
right for what just happened. What makes it right is to find the root cause and
make the current event right again with accountability.
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| A process in control paints a marvelous picture |
Since there
was no process of action established between fire crew arrival and putting out
the fire, everything else became common sense.
BirdsEye59604
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