When organizations try to solve problems, there are two things that I see them struggle with that tend to drive them towards ineffective analysis, conclusions, or corrective actions.
Robservation # 19 – Extent of Condition
The first is an ineffective evaluation of how big their problem is before they try to solve it. And the second is not diving deep enough into significant incidents, “hits,” and “near hits” to keep the bad thing from happening in the future.
We have also noticed that organizations don’t perform an effective analysis of the extent of condition on the collection of near misses.
I want to focus on the first of these. Ineffective evaluation of how big the problem is – or what we call “extent of condition.” Extent of condition can be described as “how big is THIS problem we are trying to solve?”
Knowing the Extent of Condition is of primary importance because in my experience, if you don’t know how big the problem or condition really is, then you will tend to solve the LEAST of the problem as it presented itself, rather than also solve the otherwise hidden EXTENT of the problem, which could prevent further harm.
Too many organizations eventually discover the extent of condition long after the analysis is complete, usually and unfortunately, because of another similar incident or condition.
When organizations put a priority on identifying Extent of Condition in the early data-gathering phase of an incident or near-hit analysis, they stand a much better chance of solving the problem the first time and preventing future harm.
There are some simple ways to look at Extent of Condition that will help. The method is called SAME-SAME and SAME-SIMILAR…
Do we have the SAME condition in an identical entity? For example, is the same failure mechanism present in identical equipment? Do others use the same work practice in the same workgroup?
If so, we have identified an issue on ‘Same-Same’ and will expand our review to ‘Same-Similar.’
Do we have the Same Condition in similar equipment, workgroups, processes, product, etc.? If so, the extent of condition expands to that other similar elements.
Once you discover the true size of a problem or, the Extent of Condition, then you can go about the use of your analytical processes and methods to determine causes, contributors, and corrections.
You can be sure that if you identify the extent of condition BEFORE you determine actions and start to take them, you stand a much better chance of fixing things right the first time.
It could be the difference between life and death, prevention of a serious injury, or significant impact on equipment or product.
Here is an example –
A Near Hit occurred at one facility when scaffold poles, which were being lifted up to the platform on a scaffold, fell to the ground and nearly stuck some workers.
The ropes on each end of the bundle of poles were not tied-off but were instead looped around and woven through the poles. In effect, the weight of the poles kept tension on the ropes.
During the lift, one of the two workers hoisting up the poles noticed he’d lifted the bundle too high on his end and tried to lower it to the same level as the other end.
When doing so, that end of the bundle came to rest on a portion of the scaffold, which took up some of the weight of the poles. The resulting loss of tension allowed the rope to slide out and poles to fall.
The Cause Analysis team confirmed that others used the same method for lifting scaffold poles in the same contract organization and took steps to have the method discontinued.
While addressing the ‘Same-Same’ element of Extent of Condition, the team did not consider ‘Same-Similar’ ramifications… specifically, whether the method was used by other contract companies who were also erecting scaffolding at their facility.
Three days after the Near Hit, the same thing happened at the facility, this time involving workers from a different contractor.
In the second occurrence, one of the poles bounced after hitting the ground and struck a worker in the face, resulting in a serious injury. Had the team performed an effective “extent of condition” analysis, they would have discovered that other contractors were using the same flawed method and probably prevented this worker from being seriously injured.
If you want to learn how to effectively manage Extent of Condition, or other elements of cause analysis, sign up for our Advanced Cause Analysis for Team Leaders or our 2-Day Cause Analysis workshop in February 2020. You can click the link in the description for more info.
Please share your examples of identifying the correct extent of condition and the outcome, in the comments. Don’t forget to LIKE, Subscribe, and Share. And remember, Intentional Leadership starts with YOU.