A few thoughts come to mind reading about this. First off, if a single employee error can cause such wide blackouts, is that more of a systemic issue than the fault of those particular workers? Would Deming have thought this was traced back to a management root cause?
How well are these workers trained? If such an error could occur, why was there not some sort of error proofing in place? Is this management’s responsibility?
I know sometimes that people, or a person, screws up. But, thinking of your factory or your site, what are those potential points of failure that a single person could screw up, causing catastrophic damage to the plant or the customer? Is it time to use the FMEA mindset to proactively identify those issues, institute better training and error proofing?
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