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Why do mistakes happen?

Updated: May 29, 2022

Why do mistakes happen?

"I happened to be busy and sent it next without checking."

"I didn't know there was a rule. My boss told the rule later."

"I didn't have any doubts because I thought this was fine."

They can say that it is a mistake to have a specific right world and deviate from it.

You can Kaizen if you know why you couldn't do the right thing.

At this time, people often blame people "because their ability is low", "because they are new employees", "because that person has a careless personality", etc., but this is a real solution.

  • Do you want "low-capacity people" to quit the company?

  • Did you hire a low-capacity "new employee"?

  • How do you get rid of your "careless personality"?

What is low ability in the first place?

Isn't it the ability needed to get the job done?

Did you evaluate your ability before leaving the job to him or a new employee?

In the first place, who is responsible for thinking about "resource allocation = which works is to be entrusted to whom"?

"From the beginning, I wanted to give him a slightly challenging job and have him study."

If that is the case, do you have a temporary job that will not affect your main business even if you make a mistake?

If you cannot afford such person-hours, it is essential to follow up to avoid making mistakes.

I don't know if there is a "careless personality" personality, but "people make mistakes". It is what brain science knows.

People make mistakes because they are not machines like computers.

The human brain has a RAS (Reticular Activating System).

People can only receive information that they think is relevant to them because the RAS filter in the brainstem blocks what they think is not relevant to them.

When the brain (= unconscious) thinks it has something to do with you; you pay attention to it.

In Tomabechi coaching, we often use the expression "RAS opens by setting a goal outside the current situation."

"My close friend bought a new car, so I want a new one too." It is also close to one goal setting.

After you hear the news, when you look at a car running in the city, information such as colour and shape jumps into your head.

On the other hand, you don't think your unconsciousness is very important in a job where you don't understand the purpose well, and you do it daily, so even if you make sure that there are no mistakes, you often overlook it.

If you start explaining RAS here, it will be extended. Please refer to the past articles as they are explained in the previous blogs.

Even in the Toyota production system, we think that "people make mistakes" and seriously think about ways to prevent those mistakes from leaking out of our organization.

The typical mechanism of that policy is the idea of ​​"standard work".

The world of "standard work" has been established at the production site so that it will serve as a model.

"Standard work" is a common and effective idea from a physical space such as a manufacturing site to an information space such as a development design. Still, the form of standard work also differs because the target is different.

The work order is stipulated in detail at the manufacturing site, up to the "work standard", which is precisely every move.

The knowledge cultivated from the past to the present is organized by "technical standards" in the design workplace.

If there is a case of a mistake that fails to comply with "technical standards" in the design workplace,

"Why did the technical standards not be adhered to?"

-Because the designer did not know the applicable items of the technical standard

"Why didn't you have that knowledge?"

-Because the designer did not know the items of the technical standard

"Why didn't you know such an important item?"

-Because I gave this job before I took the design new employee education

It is how "why-why analysis" proceeds.

The design of new employee training was supposed to take about half a day to educate the rule's background.

However, in this case, factor analysis such as "I entrusted the work to a person who should not be entrusted with this work (= designer who has not taken education)" can not be given such a job again. Therefore, I added it to the collection of design managers and shared it with everyone involved.

As the world of "standard work" matures, mistakes will decrease dramatically.

When you reach this level,

"Did you make a mistake? It is the first time. We have found the first challenge."

And if you can resolve this issue, one new finding will add to this organization.

This mistake level should be considered fortunate, not a disaster for the organization.
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