Bill Holmes is an engineer who spent an unusual amount of time working to connect other engineers and people in industry to share learning. His business SIRF Roundtables allowed him the opportunity to participate in shared learning, industry benchmarking and problem solving. This evolved into a deep interest in preventing mistakes and the harm caused by preventable mistakes. He is interested in supporting Root Cause Analysis.
His concern is that if failures requiring remedial work are allowed to fester and repeat within an organisation then valuable, finite resources are consumed leading to a shortage of labour leading to new errors and failures.
This negative feedback loop is seen in every type of enterprise from handling claims by an insurer, to treating patients in a hospital or maintaining equipment. Conversely, if faults are identified early, causes identified and eliminated then they do not reoccur. Labour otherwise wasted is freed up to find and eliminate more flaws, thereby freeing up more labour.
Elimination of repeating problems can only happen if the true causes of failure are treated. In his TEDxCasey Talk Bill explains how our brains trick us and give us rapid, intuitive answers that are sometimes wrong. He challenges you to take a moment longer and ask a simple question “Why?” rather than rely on assumptions. He shares ways to think about decisions and trying to understand the causes of problems which match size and risk of harm if an issue occurs when solving problems to provide the most efficient and productive result.