Human Error

When it comes to safety, a focus on ‘human error’ gets you and your  organization to do almost all the wrong things. You can, however, use a perception of a ‘human error’ problem to your advantage. If people are worried about a ‘human error’ problem, you can grab the opportunity to lead your organization and others toward more constructive ways of thinking about safety and risk.

Here are some of the reasons for leading people away from the label ‘human error:’

• The focus on ‘human error’ very quickly becomes a focus on humans as the cause of safety trouble, and on humans as the targets for intervention. But this has long been shown to be a limited safety endeavor, as getting rid of one person does not remove the conditions that gave rise to the trouble they got into.
• A focus on ‘human error’ tends to feed on itself. We find novel names by which to call those ‘human errors.’ As one manager said to me, most of the injuries on her plant are caused by workers’ carelessness, lack of attention, non-compliance and distractions. Many investigations now say that people “lost situation awareness” rather than more blatantly blaming operator error. One popular model is organized around workers’ “unsafe acts.” None of this says anything new. Those are all ways of saying ‘human error.’ Another way in which ‘human error’ feeds on itself is to find other people to blame for error. Some ‘human error’ management tools or books, for example, will tell you to go look for deficient supervision, inadequate maintenance, fallible decision makers or incompetent managers. Fair enough-these see ‘human error’ at the operational end as an effect, rather than a cause of trouble. But the effect of what exactly? Of other ‘human errors,’ by other defective humans. Such logic is a bit imprisoning. It doesn’t get you very far.
• ‘Human error’ requires a standard. For the attribution to make any sense at all, it requires the possibility of actions or assessments that are not, or would not have been, erroneous. That standard often becomes visible only with knowledge of outcome, in hindsight. It is the outcome that allows us to say that other ways of working would have been smarter or better. If that outcome would have been different, the assessments and actions that are now deemed erroneous would likely have remained invisible (as normal work) or might even have been deemed constructive, heroic, resilient, innovative.
• The growing legitimacy of ‘human error’ as a psychological research concept has driven the development of tools and techniques for its measurement and management. What these tools do, though, is simply count and tabulates attributions-how often somebody makes a negative judgment about somebody else’s performance.
• ‘Human error’ is not, as we once thought, a separate category of human performance. Yet this is the way that psychology has thought about it for a long time, and the media and politicians, too. And investigators. Even in popular imagination, ‘human error’ is often a fascinating and separate category of behavior-something to be feared, and fought. As Steve Shorrock commented, “the popularization of the term ‘human error’ has provided perhaps the biggest spur. When something goes wrong, complexity is reduced to this simple, pernicious, term. ‘Human error’ has become a shape shifting persona that can morph into an explanation of almost any unwanted event. It is now almost guaranteed to be found in news stories pertaining to major accidents. Interestingly, some reports specify that ‘human error’ was not the cause. The reverse implication being that ‘human error’ would otherwise have been the cause (for example, “Paris train crash: ‘human error’ not to blame,” Telegraph, 13 July 2013). Since the term suffices as explanation, little or no mention of findings in psychology or human factors, including the context and conditions of performance, is required.”
• This leads to nonsensical statements like “85 percent of our incidents or accidents are due to ‘human error’.” ‘Human error’ is not only seen as the cause of trouble. Such statements assume that these ‘human errors’ indeed represent a countable generic category of behavior-rather than attributions that we put on observations of behavior after the fact. They assume that there is no problem adding apples and oranges: all ‘human errors’ are essentially the same: countable, comparable. They can add up to 85 percent. And people then assume that ‘human error’ can be meaningfully separated from the otherwise blameless context (organizational, engineered) in which these varieties of behavior occurred.
• Safety and risk are made and broken the whole time, throughout your organization. You are not the custodian of an otherwise safe system that you need to protect from erratic human beings. A focus on ‘human error’ simplifies the enormously complex story of how people everywhere help create safety. How people have learned to cope, mostly successfully, with the pressures, contradictions and complexities of real work. The interesting story, which is masked by all this focus on ‘human error,’ is how in the resource-constrained and goal-conflicted worlds in which people work, their activities mostly contribute to success rather than failure.