Amathiphu asheshayo
- Bonga noma ubani okulethele izindaba ezimbi.
- Buza ukuthi kwenzekeni, hhayi ukuthi ubani okwenzile.
- Lungisa isimo, hhayi umuntu.
Cabanga isikhathi sokugcina lapho okuthile konakala ngaphansi kokubuka kwakho. Umthwalo waphuma ungalungile, iklayenti lathola inguqulo embi yefayela, inombolo esethulweni sebhodi kwavela ukuthi ayilungile. Manje cabanga isikhathi lapho othile kwadingeka anqume ukuthi akutshele yini.
Lokho kuma ngumdlalo wonke.
Ngesikhathi umuntu asithathayo ukukhetha phakathi kokuza kuwe nokuthemba ngokuthula ukuthi inkinga izozilungisa, isiko lakho likhombisa isimo sako sangempela. Uma beza kuwe kusesekuseni, uyakwazi ukwenza inkinga isesincane. Uma belinda, uyathola kamuva, uma isinkulu futhi inzima futhi isivele ithinte abantu abaningi. Abakunqumayo kulokho kuma kuncike cishe ngokuphelele entweni eyodwa: abalindele ukuthi kuzokwenzekani kubo lapho bekhuluma.
Yilokho isiko elingasoli okuphathelene ngempela nako. Hhayi ukwehlisa amazinga. Hhayi ukukhulula othile ecaleni. Ukwenza kuphephe ukusho "lokhu konakele, futhi nginesandla kukho" kusesekuseni ngokwanele ukuthi iqiniso lisawusizo.
Intengo efihlekile yokusola
Ukusola kuzwakala njengokuziphendulela. Ngokuvamile akunjalo.
Lapho okuthile konakala futhi umzwangedwa wokuqala egumbini uwukuthola umuntu onecala, abantu bafunda isifundo esisheshayo, esihlala isikhathi eside: amaphutha ayingozi ukuba eduze nawo. Ngakho bayeka ukubika amancane. Bakhuphula izilinganiso zabo ukuze babukeke bephephe kakhulu. Bathula ngemininingwane ebingakusiza ukuqonda okwenzeke ngempela. Unjiniyela uJohn Allspaw, ebhala ngendlela amaqembu abhekana ngayo nokuma kokusebenza, ukubeka ngokusobala: lapho abantu besaba ukuqanjwa amagama, ukusolwa, nokuhlazwa, baqala ukufihla ulwazi, inhlangano iyeka ukufunda, futhi akukho okwenziwayo ukugcina ukwehluleka okufanayo kungenzeki futhi.
Qaphela ukuthi ukusola kukuthengelani. Umuzwa wokuxazululeka, nethimba elisanda kuthula. Iphutha eliqalise ukusola akuvamile ukuba yilona elibizayo. Elibizayo yiphutha elilandelayo, lelo okungekho okuxwayisile ngalo ngoba babuka okwenzeka kumuntu wokugcina owenza njalo.
Kunento eyingqinamba enyantisayo ngaphansi kwalokhu. Abantu abasesikhundleni esihle kunazo zonke sokubamba izinkinga kusesekuseni yilabo abasondelene kakhulu nomsebenzi, labo abanezandla kuwo. Yilabo kanye abantu isiko lokusola elibafundisa ukuthula. Ugcina uyimpumputhe kanye lapho udinga kakhulu khona ukubona.
Ukungasoli akusho ukungabikho miphumela
Yilapho abaholi bethuka khona, futhi ukwethuka kufanele. Uma kungekho obekwa icala, ngabe amazinga awawi yini?
Angawa, okuyisona sizathu sokuthi isiko lokungasoli alizange lisho lokho. Igama elicace kakhulu, elibolekwe emkhakheni wezindiza nezokwelapha, yisiko elinobulungiswa: umugqa owabelwene, ovunyelwene phakathi kwephutha eliqotho nokunganaki kwangempela. Iphutha eliqotho, elenziwe umuntu ocophelelayo owenza umsebenzi onengqondo, lihlangatshezwana nelukuluku. Kwenzekeni? Yini esilungiselelweni eyenze lokhu kwaba lula ukuthi kwenziwe kabi? Ukusika ikhona lokuphepha ngamabomu, ukufihla ukwehluleka, noma ukuphinda isenzo esifanayo esinganaki emva kokukhonjiswa ingozi kuyinto ehlukile, futhi kuphathwa ngokwehlukile.
Umehluko ubalulekile ngoba uvikela ukuziphatha okufanele. Awusho ukuthi akukho lutho olubalulekile. Usho ukuthi ukusho iqiniso ngephutha ngeke kube yiyona nto ekujezisayo. Ubuqotho buphephile. Ukunganaki akuphephile. Abantu abaningi bangaphila ngaphakathi kwalowo mugqa kalula uma sebekwethemba ukuthi ungokwangempela.
Amaphutha ngokuvamile ayisistimu egqoke igama lomuntu
Nalu ukubukwa kabusha okwenza ukungasoli kusebenze esikhundleni sokuba nomusa nje.
Umcwaningi wezokuphepha uJames Reason wachitha umsebenzi wakhe efunda ukuthi izinto zonakala kanjani ezibhedlela, ezindaweni zabashayeli bezindiza, nasezitshalweni zamandla, futhi wadweba umugqa obukhali phakathi kwezindlela ezimbili zokubuka iphutha. Indlela yomuntu isola umuntu ngamunye ophethe, umhlengikazi onikeze umuthi ongafanele, umsebenzisi omshini ocindezele iswitshi engafanele, futhi isabela ngokuqondiswa nezikhumbuzo zokucophelela kakhulu. Indlela yesistimu icabanga ukuthi abantu abanamakhono ngezinye izikhathi bayophapha ngoba yilokho abantu abakwenzayo, futhi ibuza ukuthi yiziphi izimo ezenza iphutha lithi lenzeke futhi zalivumela lidlule.
Umusho wakhe ngowodwa ofanele ukugcinwa: asikwazi ukushintsha isimo somuntu, kodwa singashintsha izimo abantu abasebenza ngaphansi kwazo.
Kumodeli kaReason, iphutha elilodwa cishe alilokothi libangele ukwehluleka okukhulu likodwa. Umphumela omubi wenzeka lapho izindawo ezimbalwa ezibuthaka esistimuni zihlanganisa ngasikhathi sinye, umyalelo ongacacile, ukuhlola okushodayo, umuntu okhathele, ithuluzi elenza isenzo esingafanele sibe lula. Iphutha lomuntu ngamunye yimbobo yokugcina inkinga ewele kuyo, hhayi isizathu sokuthi zonke izimbobo zazikhona.
Kumholi, lokhu kushintsha umbuzo ngokuphelele. Othi "Ubani owenze lokhu?" ukunika umuntu wokukhomba nesistimu esaphukile. Othi "Yini eyenze lokhu kwenzeke, futhi yini eyenze kwaba nzima ukukubamba?" ukunika isixazululo esivikela umuntu olandelayo futhi. Umbuzo wokuqala uzwakala njengenqubekela phambili. Owesibili empeleni uyiyo.
Umjikelezo okugcina ubambekile
Kunephethini eyenzeka emasikweni okusola ngokuthembeka kangangokuba icishe ibe yiskripthi. Kukhona okonakalayo. Igama liyanamathekwa kukho. Umuntu uyakhuzwa, mhlawumbe uthunyelwa ukuqeqeshwa kabusha, futhi wonke umuntu uvumelana ngokucophelela kakhulu. Icala liyavalwa.
Bese, emasontweni noma ezinyangeni kamuva, kwenzeka futhi. Umuntu ohlukile, ukwehluleka okufanayo. Futhi impendulo iyafana: thola igama, khuza, qeqesha kabusha, vala. Ithimba liqala ukukholelwa ukuthi alinanhlanhla ngabantu, ukuthi liqhubeka nje liqasha abanganaki. Okwenzeka ngempela ukuthi isimo esingemuva kwephutha asizange sithintwe. Ifomu elididayo, isinyathelo sokuqinisekisa esishodayo, umnqamulajuqu ophoqa abantu ukweqa ukuhlola, konke kusahlezi lapho, kulinde umuntu olandelayo onengqondo ukuthi angene kuko.
Ukusola kuqeda uphenyo kusesekuseni, kanye ngesikhathi luba wusizo. Elithi "iphutha lomuntu" lizwakala njengempendulo, kodwa empeleni yilapho umbuzo wangempela uqala khona. Uma ithimba lakho liqhubeka lenza uhlobo olufanayo lwephutha ngabantu abahlukene, leyo akuyona inkinga yokuqasha. Yisistimu ekutshelayo, ngokucacile, ukuthi yaphukephi. Isiko elingasoli yilokho okukuvumela ukuze ukuzwe, ngoba akekho okufanele avikele igama lakhe kuqala.
Lapho iqiniso liphephile, livela ngokushesha
Umcwaningi wase-Harvard u-Amy Edmondson, ofunda ukuthi amaqembu afunda kanjani, wathola into engalindelekile ecwaninga amayunithi asezibhedlela. Amaqembu abika amaphutha amaningi kunawo wonke ayengewona amaqembu amabi kunawo wonke. Ezimweni eziningana ayengcono. Ayengenzi amaphutha amaningi. Ayekhipha obala lawo ayevele enzeka, ngoba abaholi bawo babekwenze kwaphepha ukukwenza.
Leyo yinzuzo yesiko elingasoli okutholakele okukodwa. Amaphutha akhona noma kunjani. Okukodwa okuguqukayo okulawulayo ukuthi uzwa ngawo ngesikhathi ukuze wenze okuthile yini.
U-Edmondson unakekele futhi ugibe, futhi kufanele kubambelelwe. Ukuphatha konke ukwehluleka njengokulungile ngokulinganayo akuyona impendulo nayo. Okunye ukwehluleka kunobudedengu futhi kuvimbeleka. Okunye kungukungqubuzana okungenakuvinjelwa komsebenzi oyinkimbinkimbi. Futhi okunye kuhlakaniphile, umphumela wokubheja okuhlakaniphile okungahlangananga, uhlobo lokwehluleka ofuna ngempela okwengeziwe kwalo uma ithimba lakho lihloselwe ukuzama izinto ezintsha. Umsebenzi womholi akukhona ukugubha konke ukwehluleka noma ukukujezisa konke. Kuwukuwehlukanisa lezi zinhlobo, ngokuzwakalayo, ukuze abantu bafunde ukuthi iziphi izingozi ezamukelekayo neziphi ukunganaki okungamukeleki.
Indlela yokulakha, ezikhathini ezijwayelekile
Isiko elingasoli alimenyezelwa emhlanganweni. Lakhiwa ngendlela osabela ngayo emasekhondini ayishumi okuqala emva kwezindaba ezimbi, kaninginingi, kuze kube abantu bayakukholelwa.
- Qaphela ubuso bakho lapho othile ekulethela inkinga. Ukusabela kokuqala yikho abantu abakukhumbulayo bese belungisela kukho. Ukudlikizela, ukububula, ithoni ebukhali, noma yikuphi kwalokhu kufundisa igumbi ukuthi likulethele okuncane ngokuzayo. Ukuzinza lapha kwenza umsebenzi wangempela.
- Buza ukuthi kwenzekeni ngaphambi kokubuza ukuthi ubani. Yenza ukulandelana kwezehlakalo kube setafuleni ngokugcwele, okwakwaziwa, okwakucatshangwa, ukuthi isimo sasibukeka kanjani ngaphakathi, ngaphambi kokuba igama likamuntu libe yisihloko. Indaba cishe ngaso sonke isikhathi ivela inengqondo kunalokho eyayizwakala ngakho ekuqaleni.
- Bonga umuntu okutshelile. Ikakhulukazi lapho kubabize okuthile ukukwenza. Uvuza kanye ukuziphatha okudinga kakhulu, futhi wonke umuntu obukile uyaqaphela. Le yinto eshibhile kunazo zonke, enenzuzo ephakeme kunazo zonke ohlwini.
- Yenza inguqulo engasoli yokuhlaziywa kwemva kwesehlakalo. Emva kokuba okuthile konakele, qoqa abantu ababandakanyekile ubuze ukuthi yini esistimuni eyenze iphutha laba lula futhi laba nzima ukulibamba. Umphumela yisimo esilungisiwe, hhayi isoni esiqanjiwe. Bhala phansi lokho ozokushintsha, hhayi ozombheka.
- Yiba qotho ngamaphutha akho. Lapho uthi "Ngenze isinqumo esingalungile kulokho, nakhu engikufundile," unika wonke umuntu imvume yokuba umuntu owenza amaphutha bese elulama. Umholi ofihla amaphutha akhe akanandawo yokucela omunye ukuthi avume awakhe.
- Dweba umugqa ngokucacile bese ubambelela kuwo. Yenza umehluko phakathi kwephutha eliqotho neliyibudedengu ucace, bese ngempela uwuhloniphe. Ukuvikela kusebenza kuphela uma abantu bewubone ubambelela lapho wawuvivinywa.
Akukho kwalokhu okuyinkimbinkimbi. Konke kunzima, ngoba ukudonseleka ekusoleni kunamandla kanye lapho ucindezelekile, okuyilapho kanye kubaluleke khona kakhulu.
Lokho okwakhayo ngempela
Ithimba elikwethemba ngezindaba ezimbi ithimba ongalihola kucishe kube yinoma yini. Uzozazi izinkinga zisesencane. Uzothola idatha engancomeki esikhundleni senguqulo encomayo. Abantu bazothatha izingozi ezihlakaniphile ezishukumisa umsebenzi phambili, ngoba bayazi ukuthi ukwehluleka okuqotho ngeke kubekwe ngokumelene nabo.
Enye indlela ibukeka izolile ngaphezulu. Izinkinga ezimbalwa ezibikwayo, izingxoxo ezinzima ezimbalwa. Kuwukuzola kwethimba elinqume ukuthi awuphephile ukukutshela iqiniso, futhi kuhlala kuze kube yilanga lapho into abangakutshelanga yona ifika ngasikhathi sinye.
Uma lokhu kuzwakala njengokungaphezu kwenkinga yesiko, ngezinye izikhathi kunjalo. Ukwesaba okuqhubekayo, ukwesaba ngaphambi komsebenzi, noma ithimba elibukeka lilungele ukujeziswa kungakhomba ekucindezelekeni okujulile, kubo noma kuwe, umhlangano ongcono ongeke uwulungise. Alikho ihlazo ekungeniseni usizo, noma ngabe kungumhlanganisi wangaphandle wethimba noma udokotela wezengqondo wakho uqobo uma isisindo sokubamba konke siqale ukukubiza. Ubuholi obuzinzile bakhelwe emuntwini ozinzile, futhi lowo muntu uvunyelwe ukudinga usizo naye.
Sources
- Harvard Business Review, Strategies for Learning from Failure (Amy C. Edmondson)
- The BMJ / PubMed Central, Human error: models and management (James Reason)
- Etsy Code as Craft, Blameless PostMortems and a Just Culture (John Allspaw)