Our factory has clear, well-communicated operating standards. Our workers know them very well. Sometime ago, a worker committed a serious mistake resulting in losses worth millions. Our code of conduct prescribes a maximum one-month suspension without pay, as the owner, with a paternalistic management style, does not want to dismiss anyone. So, the company must absorb the damage and keep the employee on board. How do we prevent this same error from happening again? — Red Falcon.

Except for your paternalistic boss, this scenario sounds uncomfortably familiar. Many organizations fall into the trap of believing that written rules and clarity will prevent worker mistakes. It’s an appealing belief — after all, if the instructions are crystal clear and everyone has signed the acknowledgment form, what could go wrong?

However, policies and clarity are small parts of the productivity net equation. There are a lot more. Human nature, systems design, and company culture all play an equally critical role.

People get tired, distracted, or become overconfident. Systems have gaps that reveal themselves under pressure. And the paternalistic culture — the invisible hand guiding daily behavior  — can either encourage vigilance or breed complacency.

SOLUTIONS
With that in mind, here’s how to make sure those expensive mistakes become an important lesson and prevent the same situation from happening again through the following solutions:

One, do a root cause analysis. When a serious mistake happens, the first impulse is to focus on the what: the broken machine, the ruined batch, or the production delay, among others. But the real learning comes from the why.

Was the person rushing to meet a quota? Was he distracted by a personal issue? Was the tool faulty, the design flawed, or the procedure broken? Or was it willful negligence — knowing the rule but ignoring it?

Two, let the worker come up with a solution. Sure, you’ll want to guide them so they don’t just say, “I’ll be more careful next time.” They must go beyond that. After all, their job is still there waiting.

Therefore, they must be empowered to come up with specific and measurable preventive actions that make them co-owners of the new system.

Three, put the right system in place. Even seasoned operators can become absent-minded. They forget important steps, skip checks, and even make false assumptions — all because of their misplaced confidence.

To avoid that, apply some proven safeguards like having a new checklist, mistake-proofing (Poka-Yoke) the process, and doing peer verification with two people signing off.

Four, match the consequence to the impact. A one-month suspension for losing millions sends mixed signals. It says, “We’re disappointed, but it’s OK. See you next month.” A fair approach is graduated discipline, if not employment termination.

The first offense with minor impact might mean retraining, but a grave mistake with costly damage may require a demotion from a safety and quality-oriented role, or dismissal if willful neglect is proven. But you must convince your management about it.

Five, make the lesson public without shaming people. Every major error is tuition paid to the “school of experience.” The worst thing is to pay the tuition and not attend the class.

Hold a post-incident learning session where the concerned worker explains what happened without bring humiliated. This puts the lesson in everyone’s mind and turns a mistake into a shared responsibility.

Six, retraining is for everyone. Many factories assume that once training is done, knowledge remains perfect. In reality, familiarity breeds shortcuts. Annual or semi-annual, if not quarterly, refresher training on critical processes keeps the standards high in everyone’s mind.

Simulation is powerful. If a mistake happened in the packaging line, recreate the scenario in a controlled setting and walk everyone through the correct handling.

Seven, reward prevention, don’t just punish mistakes. A culture of vigilance doesn’t grow from punishment alone. Fear-based cultures often hide problems until they explode. Balance discipline with recognition for hazard prevention.

Make it easy for people to report an issue. Praise them for preventing a problem before it becomes an accident. Create a “Doing It Right” program where data is captured, recorded, analyzed, and the worker is recognized.

Eight, lead from the shop floor. If standards are important, leaders must be visible in enforcing them. That means walking through the process regularly. Without “snoopervising,” ask the workers to demonstrate a step. Then, point out positive compliance.

Address small deviations immediately, before they grow into big risks. A visible leader communicates that procedures aren’t just words on paper — they’re a living expectation.

REAL CHALLENGE
When rules are clear but violations still happen, the issue isn’t ignorance — it’s the presence of an unreasonable management policy that favors workers who make mistakes. In other words, the fence may be sturdy, but the gate is swinging wide open. The fix?

Close it with a lock made of firm consequences, regular follow-through, and visible leadership. This is the best time for your company, locked in a paternalistic mindset, to change its culture.

There could be legal challenges. But it’s worth challenging a deeply ingrained culture that protects employees at all costs, to the detriment of both performance and profitability.

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