February 23, 2012 | Mark Paradies

Stopping Human Error

Recently, I read an article by a human factors expert that said human error can’t be eliminated but that errors could be managed. The article covered the common information about Skill-Rule-Knowledge based behaviors and preventing slips and rule-based errors.

Just a couple of days later, I heard a talk about a method to “self-trigger” and recognize when a mistake was just about to be made so that you could stop yourself in the nick of time and not make a mistake.

The theory was that people are more error prone when they are rushing, fatigued, frustrated, or complacent. And when this is true, they are more likely to take their eyes and mind off a task, put themselves in the line of fire, or lose balance, traction, or grip.

All you need to do is to constantly observe your own state of mind, and if you become complacent, frustrated, rushed, or fatigued, you alert yourself to be careful and watch/think about what you are doing. Take a break to reduce fatigue. Stop rushing and realize that your frustration is counter-productive.

Simple, right?

You can also work on habits to self-check for errors when you might be in an error likely situation (like being distracted).

What’s wrong with this?

It requires people to exhibit behaviors that aren’t “human.”

People are really bad at self-monitoring.

It’s unlikely that if you are hurried, fatigued, frustrated, or complacent that you will notice it “just in the nick of time.”

However, afterwards if you admit you were hurried, fatigued, frustrated, or complacent, then the condition seems like an obvious precondition and you failed to notice. Thus, your failure is the “cause” of the accident.

What’s a better idea? To use human factors tools to improve the human reliability of the tasks and use mistake proofing to trap or prevent errors that can’t be tolerated.

Whenever your performance improvement initiative requires people to be like machines, my bet is that the program will fail.

Instead, use humans where their skills are needed and use automation where unvarying performance is needed.

(Written by Mark Paradies in the February Root Cause Network™ Newsletter, Copyright © February, 2012 by System Improvements. Reprinted by permission.)

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