Let’s set the scene…
There was a big incident in your team, and boy was it costly. It got a lot of attention and an official post-mortem was conducted. Remediation steps have been recommended. You sit down with the team to read through the document.
Following a very detailed explanation of what happened, you flip to the Root Cause section and find just two words “human error”.
A little surprised you scan down to the remediation steps and see something like “We have reminded employees to be more careful and follow proper procedures in this situation.”
A week, month, or year later a similar incident occurs. Everything in the post-mortem looks the same except this time the “remediation steps” read; “We have instituted a 4-eye check to catch these types of errors”. And so the loop continues…
“Human Error” is a Trap
The above example is one that occurs repeatedly across the corporate world, and illustrates why “human error” is the least helpful (and most frequently identified) source of error in systems and processes. No joke, I’ve seen serious “solutions” that amounted to an 8-eye check (meaning after employee A completes a task, employees B, C, and D review it to check for errors).
Why do we do this? Because it’s correct, partly. Human error is part of the reason for almost any system or process failure. The problem is not in identifying human error, but in stopping our analysis once we do.
It’s like a pathologist, conducting an actual port-mortem, putting their hands on their hips and stating; “Well folks, looks like their heart stopped beating.”
This is true, but unhelpful, and prematurely ends the analysis – leaving a TON of learning left on the table.
Redefine How You Approach Error
Let’s start with a statement, an almost axiom. People are never the problem.
People are too easy to blame. Of course our beautiful process wouldn’t have failed if only the people involved had exercised a little common sense right?! (as a side note “common sense” actually = “cultural context” – see our post two weeks back for more on how cultural bias holds us back from improving)
That type of mindset will limit your ability to see the structural issues leading to your errors however. Start with the below premise and abandon it ONLY if every other option has been eliminated:
Our people are smart, genuinely want to do a good job, and are doing the best they can.
This isn’t just being nice, it’s also the most pragmatic way to actually solve the underlying issues at work in a system. If you start here each time an error is discovered you’ll dig deeper and discover more opportunities than 90% of improvement professionals ever do.
Let us know how you’re team has succeeded or failed at moving beyond dead-end “human-error” identification, Bill and I would love to hear your thoughts!
Love error analysis? Check out some of these awesome additional resources:
- Human Error – Great short paper on PubMed Central – 10 min. read
- The Field Guide to Understanding ‘Human Error’ – A bit dense at times but a great in-depth treatise how to move past the “human error” trap – 247 pgs