Why You Shouldn’t Blame People for Human Error
By Mark J. Steinhofer, CUSP, CHST, CSP
Manager of HSE Services, Safety Management Group
The first lineman scaled the pole and tried to perform the task on the conductor. After a minute or so, the supervisor yelled, “You’re doing that wrong!,” told him he was incompetent, and sent the second lineman up the pole in his place. He started the task only to hear “You idiot … that’s not how it’s done!” before returning to the ground. The third lineman took a deep breath before he climbed. He looked the job over, and started to work. Soon, the supervisor bellowed, “What’s wrong with you? That won’t work!”
This scenario illustrates the way the utility construction industry has traditionally dealt with human error: blaming people instead of flawed processes. It’s what we call the Person approach. It assumes that people are free agents who make deliberate choices between correct and incorrect behavior. The supervisor assumed that the linemen were making mistakes instead of reasoning that there must have been a fundamental flaw in the task or in their training.
What exactly is human error?
We define human error as inappropriate or undesirable human decisions or behaviors that reduce or have the potential for reducing effectiveness and safety. Errors tend to fall into one of four categories:
• Mistakes result from ignorance of the correct task or the correct way to perform it.
• Mismatches occur because the tasks are beyond the physical or mental ability of the person asked to perform it.
• Noncompliance (or violations) happen because someone decides not to carry out a task or not to carry it out in the way instructed or expected.
• Slips and lapses result from forgetfulness, habit, fatigue or similar psychological causes.
The System approach
Instead of focusing on individual shortcomings, the System approach assumes that humans are fallible and errors are something to be expected. It views errors as consequences rather than causes, originating not in human behavior, but in the conditions under which individuals work. Since we can’t change the human condition, we need to change the conditions under which humans work by building defenses or trying to mitigate the effects of those errors.
The System approach assumes that you could put multiple people in the same position with the same conditions, and they’ll fail because the system is inherently flawed. Utility construction is full of complexities and unclear design aspects, and construction workers are accustomed to compensating for that. But that can create errors, because humans can misperceive situations and then take flawed courses of action. By analyzing processes and leaving less up to chance, the System approach reduces the potential for incorrect actions.
The Swiss cheese model
Think of the elements of your company’s safety program as slices of Swiss cheese. One represents training, another is documentation, another is engineering controls, another may be personal protective equipment, and so forth. Each slice has some random holes that you can’t prevent, and some slices have more than others. For example, if your safety training is excellent, that slice may have only small holes, but if PPE enforcement is lax, it may be full of larger holes.
Each slice is part of your defense against errors and incidents, but those holes allow errors to sneak through. When you line up the slices, a gap in one is probably covered up by another. Your crews might not have all the correct PPE, but your safety training is so good that it compensates for that. Still, it’s possible that even with all the slices stacked together, there’s enough of an opening that something can slip through. So your efforts should focus on identifying and eliminating the holes in your defenses. As each layer (or slice) becomes stronger, the overall potential for incidents declines.
Where do the holes in your defenses come from? There are two sources. One is unsafe acts committed by people, including slips, lapses, fumbles, mistakes, and procedural violations. The other is latent conditions, which arise from decisions that have been made by designers, builders, procedure writers, and top-level managers. Latent conditions can lead to error-provoking conditions in local workplaces, such as understaffing, unrealistic deadlines, inadequate equipment, inexperienced workers, and fatigue. They can also create long-lasting weaknesses such as unworkable procedures, and design and construction deficiencies.
Managing human error
Keeping human error to a minimum involves two goals. First, limit the incidence of dangerous errors. Second, create systems that are better able to tolerate the inevitable occurrence of errors and contain their damaging effects. The better your error management system, the better you’ll be able to stop the threat early in the chain of events.
Taking the time to review objectives and responsibilities for each task may seem to slow things down, but it actually prevents problems and delays. When workers make assumptions about what is going to be done instead of having clear knowledge, mistakes are inevitable.
A crucial element of effective error management is establishing a reporting culture in which workers are unafraid to report not only mishaps and incidents, but also near misses. Without those reports, there’s no way to uncover and identify recurring errors that may grow into incidents. You cannot achieve an effective reporting culture without having a strong safety culture and management systems that support it.
By combining the System approach to preventing and mitigating human error with a solid reporting culture, you can expect a significant reduction of incidents, along with an increase in worker satisfaction and productivity, because everyone will clearly know what to do — and what to avoid.