Case Study: “What About Bob?”
By Josh Williams, Ph.D.
Consider this true-life story. “Bob” works for a soft drink bottling company and part of his job is making sure the production lines keep running. A very large, heavy labeler automatically cuts labels and affixes them to the bottles. However, the labeler gets glue caked up on it which makes cutting the labels impossible. One day, he attempts to remove the glue with a rag without first locking out the line. He mistimes it and loses a finger and a half.
Finish this sentence: Bob is _____________.
And now for the rest of the story…
There were a number of factors influencing Bob’s choices that day, including:
- Production pressure was extremely high due to ambitious production schedules.
- It took too long to de-energize the line because of the lock out location.
- His area was shorthanded since positions weren’t backfilled after recent retirements.
- Bob had been working an extremely high amount of overtime.
- His supervisor was 10 feet away when the incident occurred.
- During the incident analysis, Bob’s comment was, “All of us have been doing it this way for years.”
Now, consider these questions:
- Does this change your opinion of Bob’s actions?
- What system changes are needed for the future?
- What would blaming Bob accomplish?
The point of this real-life example is that serious injuries happen every day. Too often, leaders employ “blame and train” tactics to deal with these incidents. The more intelligent and compassionate choice is to re-evaluate system factors contributing to incidents. This doesn’t abdicate personal responsibility, but it does help address lingering system problems that may contribute to even more incidents down the road.
Don’t blame employees. Fix the system!
At Propulo, we work with leaders to find new ways to improve system factors to prevent SIFs.