What about human error? Part 1 of 2

It's a commonplace in the Quality business that any time we start a problem investigation, we insist that "there is no such thing as human error." I say it in this post here. But what does that mean, anyway? And is it true?

At a superficial level, at any rate, it looks like there is something wrong. About a month ago the topic came up in this post and this one on LinkedIn. If the links don't open for you, the basic point is made by Christopher Paris, who points out that obviously all errors are made by humans! After all, they certainly aren't made by space aliens.

Obviously Paris is right that errors are made by human beings and not space aliens. But sometimes I think he's a little too hard on those of us in the Quality industry.* For myself, I've always taken the principle about human error as a motivational slogan rather than a statement of fact, and I think that in a pragmatic sense it performs two roles.

First, if you want to do a decent root-cause analysis, you have to get all the facts. This means getting the cooperation of whoever was there on-site when the problem happened. Now if this employee thinks you're going to blame the whole thing on him and his errors, he's not going to tell you a thing. So you start off by saying that the problem has to be with the system, not with him, and you just need his help to figure out how to improve the system. With luck this will put him at his ease, so you can make progress.

Second, sometimes when your problem-solving team is in the middle of its work, you'll have someone who really wants to get back to his desk to work on something else instead. So he says, "Look, this whole accident was caused by human error. Next time we just have to try harder, that's all. So can we wrap it up and get back to our real jobs?" The problem is that "trying harder" has never solved anything. Often — nearly always, in fact — there is something that can be improved in the system to make it easier to do the job right and harder to make a mistake. So to keep your team from giving up too early, you remind them that "there is no such thing as human error," and if they really believe in "trying harder" then the problem-solving team should try harder to find a systemic cause.

What do I mean by a "systemic cause"? It's the kind of thing I talked about here (and then expanded on in the next two posts here and especially here). If someone made a mistake out of ignorance, see if you can improve your training system. If someone made a mistake because his hand slipped, see if you can get him a tool that makes the work easier. If someone forgot that those drums were filled with nasty waste until he almost dropped his lunch in one of them (let's say it was a "near-miss" and nothing bad actually happened to the lunch), see if you can label the drums or put up signs. Those are all system-level improvements.

At the same time, it's important to notice something else. You remember that there's no such thing as a perfect process, and in the same way there's no such thing as a perfect system. There's even an old joke that says, "You cannot make things foolproof because fools are so ingenious." So while the problem-solving team always has to look for additional system improvements, the organizational management has to emphasize improving the overall competence of every employee. This is because, as we discussed a couple months ago, good people can work under bad processes a lot better than bad people can work under good processes. So the best way to error-proof your operation, so far as you can, is to strengthen both.

Next week we'll look at a typology of human errors, and at the preventive measures which work for each one. It turns out there are several different kinds of human error, and the measures which prevent this kind are no help at preventing that kind. Join me.     

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* In fairness, his stated purpose is to motivate us to pull up our socks on a number of basic issues, so it's to be expected that he not go easy on us.