When things go wrong in the workplace, one recourse is to cite ‘human error’. By this, the intention when categorising certain issues to refer to something having been done that was not intended by the actor; not desired by a set of rules or an external observer; or that led the task or system outside its acceptable limits.
While it is easy to categorise an event as ‘human error’ and event to add an additional influencing descriptor, such as ‘lapse’, ‘mistake’ or ‘deliberate action’, this does not get to the root cause. Neither does this assessment enable a preventative action to be put in place. According to the quality standard ISO 9001: 2015, this means devising a suitable “action to eliminate the causes of potential nonconformities in order to prevent their occurrence.”
Therefore, it can pay dividends to invest in root cause analysis. This is a process, using a set of tools, to find out the actual reason for the error. For example, the reason could have been attributed to poor process design, badly written procedures, insufficient training or assessment, under resourcing, or a distraction.
Methodologies like human factors can assist with dissecting a problem down to find the root cause and with formulating an appropriate response to correct the issue (such as workplace design or coming up with a simpler set of instructions). One definition of human factors is the “environmental, organisational and job factors, and human and individual characteristics, which influence behaviour at work” (a definition favoured by the UK Health and Safety Executive).
Taking a more specific example, a study of air traffic incidents found that ‘human errors’ mostly likely sprung from sensory misperception (for instance, spatial disorientation), mental awareness (cognition and attention), and the technological environment (such as the design of cockpit displays and controls). To this, external pressures were added like supervisory or organizational influences that could contribute to fatigue and which could lead to mistakes with decision making.
Another interesting finding, applicable to all businesses, was when workers were unexpectedly put in a position of shared expectations that someone else was responsible for a particular task, when risk situations emerged it became common for workers not to speak up or intervene. This was because the social and technical conditions discouraged it.
A different study looked at similar pressures, where workers were endeavouring to comply with requirements for quality control in manufacturing, but they were doing so under circumstances of stricter budgets as well as being under managerial pressure to perform well. This inevitably led to a rise in lapses and mistakes.
These approaches also demonstrate the importance of collecting and analysing data about business issues (perhaps in the form of non-conformances or deviations). The usefulness of this will depend on an organisation’s measurement and data processing capabilities, but it may be time well spent in terms of investing in a suitable database.
It also stands that endless checking and verification ultimately does not pay off and this does not prevent faultiness. Instead, a structural, ergonomic, or people-centric change is required.
