“Moka – a gift you avoid to get”
What a delight it is to acknowledge that others fail too – massive or small, but us, as humankind, tend to screw up occasionally. Screwing up might mean restless nights, wasting money or other unpleasant circumstances. As a scholar, we should have an intellectual interest in the failure – knowing why we screw up is eventually a fascinating question. As there are several types of scholars, there are several causes for screwing up. Sometimes screwing up means the love of the lifetime or great innovation; ordinarily, it’s either of these but suffering critical assets, such as money or precious time.
Often, we base our decision making to the calculated risks in the very same way as the aviation industry has done since the first flight. Since then, risks have been reduced and rarely planes descent accidentally and crash. When such a rare occasion happens, the strict procedure will take place to understand in detail what caused unwanted failure. Industry professor Stephen Wright explained the philosophy of error management and models to understand why things go wrong in aviation – some of these are applicable in our daily lives. It is incredible to know how simple looking assembly such as a single bolt with eight nuts assembled in strict order has 40320 different combinations – where only one combination is correct. Failure in bolt assembly may cause the whole plane to crash. One aeroplane usually has over 6 million moving parts, which expand the chance to make error exponentially. This is a prime example of why it’s important to follow the rules when the critical assembly is required. In the same way, applied torque to attach nuts is vital. In theory, it all sounds easy, check the order of the nuts and assemble those in the correct order, with right torque. When one performs such a simple task several times, it becomes routine, which leads to a human error.
The aviation industry leads the way how to use errors to gain insight into the reliability and safety by implementing a particular set of rules and procedures, which has to needs to be followed. However, the human factor is part of the equation, and it’s often difficult to predict where, when and why humans make mistakes. It might be that industry professional is changing the routine because of the environmental reasons such as hot weather or interruption in the work process. Changing task, for example, might cause small slip into the process, which is leading to a significant impact over the chain of occasions. It is not very easy to predict how humans behave and operate in a changing environment. People make mistakes all the time; defensive layers will be needed; however, each of these layers has gaps, and in a worst-case scenario, these gaps align in a such a way that mistakes can penetrate the whole systems and error will happen.
When an error occurs, it is crucial to foster the culture, where one can admit a mistake for further analysis. People should be able to report mistakes without blaming or punishment. Fostering such a culture is building ground for continuous improvement and additional safety. Screwing up will happen each of us from time to time. Let’s take advantage of it – analyze the reasons and foster the learning experience to avoid it happen again. “Moka” is a gift; let’s use it for good purposes and continuous learning.
- Jari Ovaskainen