Human Error

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Figure 1 Pumps
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Figure 2 Confine Space.
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Figure 3 Part Installation
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Figure 4 Wrong Gasket Selection
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Figure 5 Relief Valve
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Figure 6 Valves
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Figure 7 Inspection
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Figure 8 Instruction
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Figure 9 Right or Wrong
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Figure 10 Right or Wrong
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Figure 11 Determine the cause
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Figure 12 Incorrect Project

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This is my favourite picture depicting the chaos of a project implementation which could go wrong in every
single aspect. It was shared in many implementation workshops which I participated or hosted before. As the
team is laughing about how ridiculously different between the deliverable and what the customer really
needed in this tree swing project, ironically, it’s possible that you are facing the exact same reality in every
project and every day.
Just to analyze what went wrong on the surface, you can name a few general areas such as communication,
scope and stakeholder expectation/requirement management etc. Recently as I read this quote attributed to
Konrad Lorenz, a light-bulb went on in my mind. This could be such a simple, concise concept for every
project implementation to take into consideration.
1. What’s thought is not said

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It might be a very common assumption that the customer must know what they want before the project is
initiated. Is that true? Unfortunately, the reality will probably tell you something opposite. Even for those
customers who have official RFP, RFQ or SOW, with the increasing complexity in the global supply chain
environment, it is very difficult to specify all the granular functions and features. It’s the project manager’s
job to help the client articulate their requirements through various tool such as brain storming, check list or
questionnaire etc.
2. What’s said is not heard
Have you found yourself in the situation which you lost the points discussed through the conference
meetings, calls or messages? Maybe the customer specified what the deliverable should be in the mix of
difficult channels. Maybe the whole discussion is progressively elaborated through a period of time. It can
take a great deal of effort for the project manager to keep the discussion on track and restate the key points
loudly and clearly. Remember someone said before if it’s important, repeat 3 times
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3. What’s heard is not understood
It might be a tendency for the project manager to conclude the discussion after the points are outlined
clearly. However, you will find it’s super invaluable if you give the team a bit more time and room to digest
and acknowledge what they heard. A great project manager may even extend their effort to explain the
downstream and upstream impact to help them to understand the full picture.
4. What’s understood is not agreed
Understanding and acknowledgement doesn’t equal agreement. Do you agree? Often, you are so busy to
make our points crossed and understood. It’s easy to forget to ask the formal agreement. If you go ahead to
execute without it, it can fire back on you later. All the scope creep or variation will be a nightmare with a
proper documented agreement of service deliverable
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5. What’s agreed is not applied
Believe most project managers know this part very well. It’s their job to direct and monitor the execution.
The usual challenges nowadays are responsibility isn’t as clearly defined and performance isn’t as easily
measured in global organizations. Sadly, the project can be slowed down because of internal silos, cynics
and politics. Collaboration and coordination is becoming very difficult for project managers. Constant
checking, testing, inspecting and auditing is required to make sure what's produced is what's agreed on
schedule.
Does this make sense to you as a project manager? If the project manager of the swing project followed the
above steps, would it help align the deliverable with what the customer really needed? Next time, if you see
your project off track, please pick up a couple work streams such as IT or finance, give it a try to use the
above steps to exam where went wrong. I hope you find them useful to avoid a project result like the tree
swing project.
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Figure 1 Proper Handover

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Figure 14 Alignment
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Figure 12 Incorrect Project

1. What’s thought is not said

2. What’s said is not heard

4. What’s understood is not agreed

Figure 1 Proper Handover

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