Human Error and Human Factors
Human error is inevitable even for the most experienced individuals; effective root cause analysis should focus on designing systems that reduce the likelihood of errors and mitigate their impact.
THE IDEA
Human Error and the Evolution of Human Factors Thinking
Cockpit design, instrumentation, and information about weather affect how safely a crew can fly. Human factors examines how such conditions shape people’s actions and opportunities for error.
If you think about a plane crash in the early days of aviation, one of the things you might have heard on occasion was that the plane crashed because of a ‘pilot error’. But if effective root cause analysis (RCA) is about making recommendations that seek to avoid the same or similar problems, what do you say?: ‘Next time, choose an even better captain or pilot who won't make any mistakes’?!
Over the years, it became clear that even the most experienced pilot or crew member could make decisions that led to crashes. Going over information from ‘black box’ flight recorders, it became possible for air crash investigators to say: ‘At this point, five minutes before the crash, the pilot should have done X, rather than Y’. But the problem was that such an argument was being made with the benefit of hindsight after the significance of choosing X over Y was known.2
Thus, we arrive at an important point that has been ‘in the mix’ in many of the earlier case studies; human error may arise at any time when people are involved (i.e. no matter how well trained and experienced you are, you can still make a mistake, have a bad day or just lose your concentration for a few moments).3 Effective RCA says that human error is a fact of life when people are involved, so you need a working environment that recognises this possibility is always there, but seeks to reduce the odds of a mishap occurring and, if appropriate and possible, put in place measures to stop the worst from happening in the first place, (e.g. by engineering out human involvement).4
When to use it
Conducting root cause analysis in aviation accident investigations
Improving patient safety in healthcare by designing better medical devices and protocols
Implementing error-proofing mechanisms in manufacturing processes
Developing software with built-in safeguards against common user mistakes
FROM THEORY TO EVERYDAY LIFE
In practice
Aviation Black Box Analysis
Investigators reviewing flight-recorder data identify an action that might have prevented a crash. To understand the crew’s decision, they also reconstruct what information was available at the time. Knowing the outcome can make the better action seem more obvious than it was to the pilot.
Redesigning Cockpit Instruments
After recognizing that human error is inevitable, aircraft manufacturers redesigned cockpit instruments to be more intuitive and reduce the likelihood of pilot mistakes, taking a human factors approach.
A MOMENT TO REFLECT
Put it to work.
How can you apply the human factors approach to error-prone tasks in your own life?
What are some examples of hindsight bias affecting your past judgments?
How can you design a system to anticipate and mitigate inevitable human errors?
Often confused with
CONTINUE THE CONVERSATION
Source texts
- Beyond the Five Whys Root Cause Analysis and Systems Thinking (James C. Paterson)