Workers Trigger Outage By Connecting Wrong Wires

By Mark Graban On Sep 12, 2005

NBC 4 – News – DWP: Workers Trigger Outage By Connecting Wrong Wires

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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Mark Graban

Mark Graban is an internationally-recognized consultant, author, and professional speaker who has worked in healthcare, manufacturing, and startups. His latest book is Measures of Success: React Less, Lead Better, Improve More. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. He also published the anthology Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also a Senior Advisor to the technology company KaiNexus.

Workers Trigger Outage By Connecting Wrong Wires

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