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Two Special Events 1. Stopping Human Error Course on September 29-30 2. 2025 Global TapRooT® Summit – Improving Human Performance Track on October 1-3 Both events are being held in Knoxville, Tennessee, at the Knoxville Convention Center. Would you like to improve human performance at your facility? Would you like to learn proven ways to help stop human errors? I’ve had people tell me that it is impossible to stop human errors, but I’ve seen research that stopped a frequently occurring human error (and that will be part of one of the special events). To learn more about these special […]
What is Stopping Human Error All About? When I wrote a book titled Stopping Human Error, several people told me: You can’t say that! They said that it was impossible to stop ALL human errors. Of course, they were right. But the title of the book isn’t: Stopping ALL Human Errors. The point of the book and our course (also titled “Stopping Human Error“) is that you can stop some human errors and thereby prevent major accidents, significant losses, patient safety incidents, and other costly failures. The History of Human Performance Improvement In the 80s, after the accident at Three […]
Hurrying through a task is an error precursor and an example of at-risk behavior. When does hurrying present a danger, a risk? When should you compromise safety? Of course, the only correct answer is, resoundingly, never. Yet, we encounter many compromises of safety in the workplace every day: shortcuts, error-prevention violations, or well-intended actions in the effort to improve performance efficiency. It’s easy to become distracted on the job—whether you’re performing routine job functions or something outside normal operating functions—perhaps, especially for less familiar tasks. What should you do when distraction occurs and/or you feel you need to hurry? One idea […]
Here is a great example of a communication breakdown between two or more people which caused a problem. It’s a fun story to tell after the fact. It did cause stress while it was happening. I conducted an Advanced TapRooT® RCA Training for Team Leaders in Denmark last week. Part of the training is to find root causes for verbal communication problems. If someone makes a mistake because verbal communication wasn’t effective, TapRooT® RCA provides a framework for analyzing the miscommunication and finding the underlying root cause(s). I want to thank Brit Olejasz for sharing this with me. She is […]
In Root Cause Analysis, we frequently emphasize data-driven decisions and analytical skills. However, an equally important factor that warrants attention is Emotional Quotient (EQ). While Intelligence Quotient (IQ) assesses cognitive abilities, EQ reflects our capacity to understand, utilize, and manage our emotions effectively—essentially, it represents our emotional intelligence. This distinction is crucial in RCA, as human behavior significantly influences incidents and their resolutions. Before delving into why emotional intelligence matters more, let’s first clarify what emotional intelligence encompasses. Understanding Emotional Intelligence Emotional intelligence under Daniel Goleman’s (1995) model has 5 key components: 5 Reseasons Emotional Intelligence Matters More Balancing EQ […]
A pilot overflies the destination. The pilot — unresponsive to air traffic control calls for 40 minutes — had fallen asleep due to fatigue likely exacerbated by mild hypoxia from the intermittent use of supplemental oxygen. You may be asking, Why does a pilot fall asleep? The pilot was conducting a ferry flight of a Cessna 208B Caravan aircraft from Cairns, Queensland, to Redcliffe on the afternoon of July 2, 2020. While cruising at 10,000 feet, the pilot encountered unforecast icing conditions and poor visibility due to cloud and climbed to 11,000 feet and began using the aircraft’s supplemental oxygen […]
Welcome to the fourth and final installment in my series about skill, rule, and knowledge-based mistakes. This series is based on the Skills, Rules, Knowledge (SRK) Model developed by Jens Rasmussen, and the Generic Error-Modelling System (GEMS) developed by Dr. James Reason, (Part 1). I’ve also posted about skill-based errors, (Part 2), and rule-based errors, (Part 3). Today, I’m focusing on knowledge-based mistakes. These models teach us about the capabilities and limitations of a worker’s cognitive processes. This is significant because we tend to blame workers for mistakes instead of considering his or her decisionmaking process and factors beyond the […]
Remembering James Reason James Reason, author, professor, and developer of theories that influenced thinking on human error and safety, died in February at the age of 86. His work will be missed by all in the field of human error and performance improvement. Swiss Cheese and More I never got the chance to talk face-to-face with James Reason, but I followed his writing. James Reason had his own model of errors (the Swiss Cheese Model) and his own analysis method (shown above). Some of these models were influenced by Donald Norman’s and Jens Rasmussen’s work (GEMS), and some were influenced […]
You’ve trained your team. You’ve reinforced safety procedures. You’ve invested in the best equipment. So why do experienced, intelligent employees still make unsafe decisions? Every day, workers take shortcuts, ignore warning signs, or hesitate to report concerns. Most of the time, they don’t even realize they’re doing it. When an incident occurs, people often ask: • “What were they thinking?” • “They knew better than to do that.” • “We’ve gone over this a hundred times—why did they ignore protocol?” It’s easy to assume that errors happen because of carelessness or poor judgment. But the reality is far more complex. […]
Welcome back to my series about skill, rule, and knowledge-based mistakes. This series is based on the Skills, Rules, Knowledge (SRK) Model developed by Jens Rasmussen, and the Generic Error-Modelling System (GEMS) developed by Dr. James Reason, (described in Part 1). Last week, I posted about skill-based errors, (Part 2). Today, I’m focusing on rule-based mistakes to give us better insight into what these models can teach us. These research models reveal that workers will make mistakes due to normal thought processes. This is significant because many times we want to “correct” a worker’s perceived poor behavior with ineffective methods. […]
