My Son’s Tears Were My System Failure

As the youngest of four, I recall with detail the feeling of helplessness when everyone did everything for me. I wanted to do it myself. So, when I heard my 7-year-old son, Wim, run upstairs crying after a loud crash in the kitchen…I knew he tried to do something on his own. However, it was a system design failure causing those tears, not his own failure.


Hearing my son run up the stairs I immediately went into “youngest kid recall” & “mom-mode,” simultaneously. My intentions, in running upstairs to comfort him, were to relate to him as the youngest kid.

I laid in bed with him while he sobbed. My words of, “I know exactly what you’re feeling,” did the trick. He eventually slowed down in crying to tell me two key points: he can no longer find the step stool and I keep putting the kid cups on the upper shelves when I unload the dishwasher.


Enter my new world of HPI thinking…


Many would view this as an isolated failure and move on; he didn’t fail attempting to get a cup! Viewing the event in isolation is short-sided, never addressing the real error that occurred at the system level. I failed at designing a system where my 7-year-old can function in my home independently.


What a remarkable feat - my son could articulate this so well. #mombrag


A technique, new to me and well established in the OPT Space, is S.A.F.E. If I had applied this to my kitchen setup & dishes duty, my son’s tears would have been avoided.



S – Summarize the Critical Steps

A – Anticipate Error Traps

F – Foresee the Consequences

E – Evaluate the Defenses


Summarize Critical step - putting the kid’s cups away


Anticipate the Error trap - placing the cups on a shelf that my Son cannot reach without stretching or using a step stool


Foresee the Consequence - my Son has to climb on the counter & reach too far to get a cup, leading him to either knock the cups out of the shelf or falling off of the counter injuring himself


Evaluate the Defenses - remember to keep the step stool in the kitchen - and place cups on the bottom shelf of the cabinet where he can reach them without getting on the counter


Remarkable how Wim saw all of this and I did not. Looks like what the team has been telling me all along is true…


HPI is a mentality not a system.


While my kid knocking a bunch of cups down is not the same as an event in the ESH&Q field…events often trigger a change in systems. But the question is, are these changes being made from a holistic view or simply trying to fix for the one perceived error causing condition?


I challenge managers and decision makers to be S.A.F.E. in their system development!


I’ll be sure to do the same.