I once worked at a plant that did not allow a manager to blame an employee's actions as the root cause in a safety or quality incident investigation-even if the employee blatantly violated a procedure or rule.

At first, this policy made no sense to me, but then I came to appreciate it. For example, if an employee was grinding metal without wearing safety glasses and got injured when a metal fragment got in his eye, the accident's root cause was not that the employee was ignoring the rules. Not following the safety rule is the cause of the accident, but not its root cause. The accident's root cause is that the employee was not motivated to follow the safety procedure. The accident investigation becomes much more meaningful when the investigator attempts to find the deeper root causes in the work environment that motivated this person to do something unsafe. Tackling this deeper and more difficult question will lead to more effective corrective action.

What could be some possible root causes in the situation described above? Maybe the employee never follows safety procedures and management was fine with that until he got hurt. Maybe he was in a hurry to get a production line up and running and the environment he works in motivated him to put grinding the metal quickly ahead of creating a safe work environment. Maybe management rewards him for doing complex tasks fast, but never rewards him for working safely.

People stray from following important safety and quality procedures because management has created an environment where people, in reality, are motivated by factors other than safety and quality. The reality is that in some organizations many factors are valued more highly than quality and safety.

How about your organization? Are you more likely to be rewarded for hitting a challenging ship date or satisfying a customer? Are you more likely to be rewarded for making heroic efforts to address customer complaints about quality rather than making heroic efforts to make sure the products the customer receives are defect-free? When releasing new products, do you celebrate the completion of exhaustive quality testing or gigantic efforts to ship the first product?

Maybe employees, despite what management says, violate safety and quality procedures because quality and safety are not the highest valued operating principles. That is wrong. It is wrong from an ethical perspective and from a business perspective.

Now, let us turn those questions around. Instead of being the quality manager or manufacturing manager, you are now the customer. Would you rather receive a high-quality product a few days late or a defective product on time? Would you rather have great customer service from a company, or never need to make a service call? Would you rather have a thoroughly tested new leading-edge product two months from now, or have a buggy leading-edge product now?

As a customer, I put quality above the other factors in the questions above. Because customers ultimately decide which companies will succeed, quality really should be the underlying core culture in businesses that want to prosper.

While I struggle to understand why other factors creep into some companies to displace quality and safety as true core values, I think there are two main reasons. The first is that many businesses have a short-term focus. They are often motivated by stockholders who want good revenues and profits right now. Their approach is to collect the money now and deal with quality problems later.

The second reason is that management is reluctant to blame themselves for the root causes to quality and safety issues. The employee who did not follow the procedure is a great scapegoat to hide behind when the fictional quality and safety culture that management is responsible for is put to the test.

I am proud of the quality system that I helped build, but at the same time, I'm constantly frustrated when I find that procedures are inaccurate or not being followed. What makes it really frustrating is I have to blame myself for the underlying cultural issues that cause this. I need to do more than just get upset at the people not following the procedure. I need to ask what factors have crept into the system that motivates them to put quality at a subordinate level and then address those environmental issues that I control as a manager. That is a tough task, but if I am successful, we will (and have) seen high-quality results that give our products an edge compared to our competitors.