According to the old way of thinking , ‘human errors’ are the root of most of your trouble. People, in this view, are a problem requiring control. Their behavior is something that you need to modify. You might believe you have to start with people’s attitudes because those influence their behavior most. Maybe you try to shape those attitudes with posters and campaigns, and sanctions, which you hope will impact their behavior and reduce their errors. You might even elect to sanction some people under your ‘culture’ policy – even though there is generally no evidence that any of this works.

With the new approach, human error is not actually a source of trouble. It is the consequence, the effect, or the symptom of trouble deeper inside your organization. This new approach assumes that people do not come to work with the intention of doing a poor job. So, when there are negative outcomes, you must look beyond those people, and focus on the conditions in which they worked at the time. You and your organization may well have lent a hand to those conditions. Leave those conditions in place, and the same bad outcome may just happen again—no matter how many sanctions you impose, posters you put up, or safety attitude campaigns you launch.

Understanding Human Error

To understand human error, one must recognize the factors that contribute to errors in human performance. Errors can occur in various domains, including medicine, aviation, engineering, and everyday life. Some common factors that can contribute to human error include:

• Lack of knowledge or experience: Humans may make mistakes due to insufficient knowledge or experience with a particular task or situation.
• Distractions and interruptions: External factors such as noise, interruptions, or distractions can divert attention away from the task at hand, leading to errors.
• Fatigue and stress: Physical and mental exhaustion can impair cognitive and motor skills, increasing the risk of errors.
• Communication breakdown: Poor communication or misunderstandings can lead to errors, especially in complex situations involving multiple individuals.
• Biases and heuristics: People may rely on mental shortcuts or biases when making decisions, leading to errors or flawed judgments.

Understanding the factors that contribute to human error can help organizations and individuals develop strategies to prevent errors and improve performance. This can include implementing systems and procedures to reduce distractions, providing training and education to improve knowledge and skills, and promoting a culture of continuous improvement and learning. Additionally, it’s important to recognize that humans are fallible, and mistakes are inevitable, so it’s crucial to have systems in place to detect and correct errors before they lead to serious consequences.

Exploring Human Fallibility

Human fallibility insinuates that humans are prone to making mistakes or errors. No one is perfect, and everyone is capable of making mistakes, no matter how intelligent or experienced they are. Fallibility is a natural part of being human and can be caused by a range of factors, including lack of knowledge, distractions, fatigue, emotions, and biases.

Despite our fallibility, humans have developed a range of strategies to minimize errors and improve the quality of decision-making. Additionally, we can learn from our mistakes and strive to continuously improve our knowledge, skills, and abilities.

Recognizing our fallibility is an important step towards improving our decision-making and reducing errors in our personal and professional lives. It’s important to approach complex problems with humility, an open mind, and a willingness to learn from others, as well as from our own mistakes.

Investigating Human Error

The aim of a ‘human error’ investigation is to try to understand why it made sense for people to do what they did—against the background of their physical and psychological work environment. The reason for this is simple. If what people did made sense to them at the time (even if it led to a bad outcome), then this may well make sense to others like them as well. If it does, and if we leave in place the conditions that make it so, then we will very likely repeat the bad event. The point of this investigation is not to assign blame or responsibility but to learn, to learn, and improve. It should, in that sense, not even be seen as an investigation but as a learning review or a learning opportunity.

What if you are asked to do a human factors investigation for something that happened—for example, in your organization? These steps will lead to useful and verifiable results:

• Getting human factors data; Human error’ is not just about humans. It is about how features of people’s tools and tasks and working environment systematically influence human performance.
• Building a timeline; Time is a powerful organizing principle, especially if you want to understand human activities in an event-driven domain.
• Putting data in context; Understanding ‘human error’ means putting yourself in the shoes of the people whose behavior you are trying to understand.
• Constructing causes; Cause is not something you find. Cause is something you construct. How you construct it, and from what evidence, depends on where you look, what you look for, whom you talk to, what you have seen before, and likely on whom you work for.
• Making recommendations: If you want your recommendations to get organizational traction, you may want to consider running them by the following criteria (which constitute the SMART acronym). Human error is not just about humans. It is about how features of people’s tools and tasks and working environment systematically influence human performance.

In short, recognizing human fallibility and investigating the root cause of errors are crucial steps towards reducing avoidable errors and improving performance. Ultimately, a shift in mindset towards a learning-oriented approach can lead to a more effective and sustainable approach to making improvements across the board.