Symptoms of Operational Error

OPERATIONAL ERROR has occurred whenever unplanned and undesired results stem from the acts or decisions of supervisory management. With that definition, this article relates safety to organizational improvement and offers eight aphorisms to guide the safety director in performing his role as a manager in the organizational context.

The themes advanced in this article were developed as the opening topic in a course in safety management. They were meant to open the door for course content to follow, content dealing with the management of a function rather than the do's and don'ts of safety technology. Robbed of the opportunity for full exposition, the themes have an aphoristic brevity. It may serve, however, to outline the role of the safety director as a manager, to help orient less-experienced safety practitioners arid to be interesting to the safety professional.

All Themes Tied Together by One Principle

One principle ties all the themes together. "The function of safety is to locate and define operational error." This quote, taken from an article by Pope and Cresswell, becomes the logical base to discuss the supervisory/management aspects of safety management. If the function of safety is to locate and define operational error, how does the safety director operate within the managerial context to do so? What is operational error; how is it defined? What effect do operational errors have on an organization? What effect do they have in implementing safety controls? How does the newly appointed safety director implement fundamental change in an organization instead of merely preaching his newly acquired "do's and don'ts" of safety? In short, how does he operate as a manager?

It becomes necessary now to attempt a definition of operational error. Operational error has occurred whenever unplanned and undesired results stem from the acts or decisions of supervisory management, or the failure to act or decide. The term "supervisory management" encompasses the entire management structure from chief executive to the lowest level of frontline leadership.

What are "unplanned and undesired results"? Examples are endless, including occasional accidents and injuries. If the customer ordered green and we send him pink, operational error has occurred. If 300 gallons of product go down the drain, operational error has occurred. If the crew goes to one location, the power equipment...