Causes rather than blame.
WHAT PEOPLE ASSUME
That failures are caused by carelessness.
WHAT IS USUALLY TRUE
The process permitted it.
WHY THAT DISTINCTION MATTERS
Blaming individuals changes nothing; changing the process prevents recurrence.
WHAT COMMON CAUSES ARE
Unclear standards Insufficient training Missing information Tools inadequate for the job Time pressure Poor handovers between people No check before it reaches the customer
WHY HANDOVERS DESERVE ATTENTION
Most defects originate where work passes between people.
WHAT TO ASK WHEN SOMETHING GOES WRONG
What allowed this to happen What would have caught it What would prevent it
WHAT NOT TO ASK
Who did it.
WHY
It ends honest reporting immediately.
WHAT HONEST REPORTING PROVIDES
Knowledge of problems before customers find them.
WHAT TO ESTABLISH CULTURALLY
That reporting a mistake is safe and expected.
WHAT THAT REQUIRES
Never punishing the report.
WHAT TO DO ABOUT REPEATED IDENTICAL ERRORS
Treat them as process failures, always.
WHAT TO DO ABOUT DELIBERATE DISREGARD
Treat that as conduct, separately.
WHY DISTINGUISH
Conflating them destroys trust in the whole approach.
WHAT TO RECORD
Every failure, and what was changed.
