Zero defects

Fermilab Director
Pier Oddone

On Tuesday, I took part in a meeting that included DOE Office of Science leaders and laboratory directors. Discussion topics ranged from the remarkable programs that the Office of Science supports, including scientific research and facilities, to non-scientific subjects such as safety. Certain lab directors shared particular concerns because some close calls have happened across the laboratory complex. Office of Science Director Brinkman suggested that, rather than emphasizing the concept of “zero accidents,” we should instead emphasize “zero defects.”

I like this emphasis for our laboratory because it can be embedded in a larger framework. “Zero defects” can become the single motto that sustains a culture that supports the construction of an apparatus that works the first time it is turned on, performs analyses without mistakes and detects flaws in safety procedures before accidents occur. A goal of zero accidents speaks only to outcomes and does not necessarily provide the focus on how to get there. A zero-defect goal, on the other hand, focuses attention on all our activities to prevent all manner of defects, including those that could compromise safety.

With a zero-defect focus we can also leverage the laboratory’s growing body of knowledge and tools related to human performance. The fundamentals of human performance improvement (HPI) demonstrate that people are fallible and errors do occur, but that in the vast majority of cases, error-likely situations are predictable, manageable and preventable.

One of the participants at the meeting provided an example of an accident that could have been prevented with a zero-defect mindset. An employee at a laboratory had recently fallen from 15 feet up a ladder. The individual was in the hospital for a week and could have sustained even more serious injuries. On analysis it was discovered that workers using the ladder had been afraid of climbing it for some time, but had never brought the issue forward. A zero-accident mindset may have kept the employee from using the ladder and avoided injury, but a zero-defect mindset could have led them to address what made the ladder dangerous to begin with. As we build our new projects and continue the excellent progress on shutdown work, let’s focus on zero defects to keep our colleagues safe and our accelerators and detectors starting up and performing perfectly.