🔍 Article co-created with Moisés de Jesús Hernández, General Manager at Proquinal Costa Rica (🇨🇷 Costa Rica), and Augusto Unzaga, host of Keru Podcast.
🎙️ This article was inspired by Episode 31 of Keru Podcast.
Keru Podcast, created by Globalita.io, is a series of conversations (in Spanish) with industrial leaders from Latin America about management, technology and decision-making in complex environments.
When the finger points at the operator, the problem lies elsewhere
In many industries, when something fails on the plant floor, the automatic reaction is to look for someone to blame. And, usually, the operator is the first one singled out. But blaming the operator is an easy answer that usually hides a deeper problem: the lack of a system.
“When the only solution we find is to fire the operator, it is because we understood nothing about the process,” says Moisés de Jesús Hernández Proquinal Costa Rica.
Most errors on the plant floor do not happen due to negligence, but due to structural deficiencies in processes, in work standardization and in organizational culture. That is why real improvement does not start at the desk or end with a sanction. It starts with rigorous analysis and with the will to build a culture where error becomes shared learning.
Structural improvement in industrial processes: a change of approach
Moving from reaction to prevention means adopting an approach of structural improvement in industrial processes, where errors stop being individual and are analyzed as part of a complex system.
This requires:
- Understanding the context in which the failure occurs.
- Recording repetitive variations.
- Analyzing how the physical environment, task design, training and production pressure have an influence.
- Asking questions that go beyond “who did it?”, such as “why did it happen?” and “what enabled it?”
This is where the disciplined use of methodologies for analyzing operational failures comes into play, which we will explore in depth in Part 2 of the article.
The culture of shared resolution: from blame to judgment
Many companies that are advanced in technical terms are still primitive in cultural terms. “Who did it?” still dominates conversations. In contrast, mature organizations promote a culture of shared resolution where the problem belongs to everyone, not to one person.
This does not mean permanent tolerance of error, but the development of:
- Clear protocols for reacting to failures.
- Spaces for collective analysis (not just by the boss).
- Feedback that teaches instead of punishing.
- Metrics that measure improvement, not just compliance.
At Proquinal Costa Rica, this cultural change is palpable. As Moisés de Jesús Hernández states:
“When an operator makes a mistake, the question is not whether to sanction them. The question is: who failed earlier in designing the process, in training, in communicating?”
That is the shift that makes it possible to move from blaming… to improving.
Methodologies for analyzing operational failures: from complaint to an improvement system
Structural improvement in industrial processes is not just a technical matter. It is a cultural and methodological transformation that demands analysis tools, operational discipline and consistent leadership.
As Moisés de Jesús Hernández Proquinal Costa Rica puts it:
“We cannot keep solving with intuition problems that were born from a lack of method.”
That is why, instead of sanctioning the operator, organizations should ask themselves:
- Do we have documented processes?
- Was the training sufficient?
- Was the instruction clear?
- Did production pressure cause the failure?
Answering these questions requires method. Here we explore the most effective ones.
1. The 5 Whys: getting to the bottom without shortcuts
The 5 Whys technique is one of the most powerful —and underused— in industry. It consists of repeating the question “Why did this happen?” until the root cause of the problem is found.
Classic example:
- Why did the machine stop? → An overheating alarm went off.
- Why did it overheat? → The cooling system failed.
- Why did it fail? → The filter was clogged.
- Why was it clogged? → It was not cleaned during maintenance.
- Why was it not cleaned? → It was not on the daily checklist.
This analysis reveals that the problem was not the operator, but a flaw in the design of the maintenance system.
Integrating this method into every failure analysis prevents superficial reactions and makes it possible to tackle the real problem.
2. Process FMEA: anticipating error before it happens
Failure Mode and Effects Analysis (FMEA) makes it possible to evaluate the critical points of a process before they fail. Its application in industrial plants makes it possible to:
- Identify possible failure modes.
- Assess their severity, occurrence and detectability.
- Assign an intervention priority (RPN index).
- Design preventive actions.
This turns continuous improvement into a structured and preventive practice, aligned with operational excellence models.
“We don’t wait for something to fail to act. FMEA forces us to think through scenarios before they happen,” explains Moisés de Jesús Hernández.
3. TWI Job Methods: teaching how it is done… not just what is done
Many operational errors stem from a lack of concrete training. The Training Within Industry (TWI) program —created during World War II and still in use— offers a clear answer with its Job Methods module.
This approach teaches how to:
- Break tasks down into key steps.
- Explain each step with a clear purpose.
- Establish a standard method.
- Continuously improve that method together with the operator.
Instead of blaming the operator for an error, the TWI system asks you to review how they were trained, with what method, and how clear the instruction was.
This approach is key in regulated industries, with high turnover or complex processes.
4. Culture of shared resolution: building a living system
Beyond the methods, real change comes with culture. A culture of shared resolution is built when:
- Management stops looking for culprits and starts designing systems.
- The plant team is part of the analysis, not just the “accused”.
- Errors are treated as symptoms of the system, not of the individual.
- Improvement spaces are created where the operator contributes and makes proposals.
This does not mean eliminating individual responsibilities. It means balancing them with process, training and leadership responsibilities.
“Whoever makes a mistake without knowing why needs help. Whoever makes a mistake knowing why needs management,” Moisés sums up.
5. What you can apply in your company tomorrow
🔹 Apply the 5 Whys at the next incident
Don’t look for the culprit. Look for the cause. Involve the team and record what was learned.
🔹 Do an FMEA of a critical line
Identify the 5 most frequent failure modes and analyze how to prevent them.
🔹 Review the last operational error with a TWI focus
Was the method documented? Was it taught step by step? Is it audited?
🔹 Create an improvement space with the plant team
A monthly meeting where errors are discussed as opportunities.
🔹 Review internal incentives
If the only metric is productivity, nobody is going to slow down to prevent errors.
Final reflection
Errors on the plant floor are inevitable. But blaming the operator every time something fails is an industrialized way of denying the problem.
True operational maturity appears when companies stop pointing fingers and start systematizing. When the focus shifts from “who did it” to “how do we prevent it next time”. When leadership is measured not by how many dismissals it signed, but by how many systems it improved.
Proquinal Costa Rica Moisés de Jesús Hernández makes it clear:
“The system does not exist to find culprits. It exists so that things go right… even when someone makes a mistake.”
And you? Are you leading a system that learns or one that punishes?
🔁 Keru is a podcast created by Globalita.io, where we talk with those who lead Latin American industry from the inside.
Moisés de Jesús Hernández is General Manager of Proquinal Costa Rica, with more than 30 years of experience in financial, administrative and operations management in complex industrial environments. His approach combines strategic planning, global vision and leadership of teams focused on sustainable results. He has held key positions in organizations such as the Costa Rican Chamber of Industries and the Free Trade Zones Association. Under his leadership, he has driven models of efficiency, regulatory compliance and process transformation, applying a culture oriented toward operational order, rigorous root cause analysis and the strengthening of human capital.
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