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By Dean Wiseman

Human Failure – Finding the Right Solutions

In HSG 48, Reducing Error and Influencing Behaviour, Figure 2 – ‘Types of Human Failure’ separates them into the two general categories of ‘Error’ and ‘Violation’ (see figure below).

Reflecting on this diagram, as I have many times, we can begin to differentiate between the mechanisms of failure. We can then see a relationship between the mechanisms of failure and what would be appropriate solutions for each different failure type.

Recently I have been considering the efficacy of actions taken in response to the various failure types. It has been my experience that when an investigation raises ‘Human Failure’ as a potential Root Cause then either systems (which lack the capability), or investigators (who lack the understanding) default to training or retraining the people involved.

A training course may be the right response for ‘Knowledge Based Mistakes’ but will be a complete waste of time and money for either ‘Slip of Action’, ‘Lapse of Memory’ or ‘Routine Violation’.

Implementing the wrong solution, as in this example, not only wastes time and money but it can lead us to think we have ‘fixed it’ when the actual problem has not been addressed.

Human Failure Mechanisms

Reflecting again on the above diagram, we can see a line appear between the two. I call that line ‘Intention’. The categories in the zone above ‘the line of intention’ are Skill Based Errors (broken down further into Slips of Action and Lapse of Memory) and Mistakes (broken down further into Rule Based Mistakes and Knowledge Based Mistakes). We can safely consider these categories unintentional but there are still unique and discreet contributory factors that lead to each type of error so they must be clearly defined and accurately identified in order to implement the appropriate solution.

For example the implementation of a first class Competence Management System should hopefully mitigate Knowledge Based Mistakes but on its own it will do nothing for Lapse of Memory. The mechanisms of failure for a Lapse of Memory are more likely to be brought on by contributory factors such as distraction, stress or overload/underload.

The categories below ‘the line of intention’ fall into the collective term ‘Violation’. A term which some people, quite rightly, are a bit uncomfortable with. When investigating violations I find the question ‘Why?’ fits very well since we usually find, in terms of behaviour or action, options were available and a choice was made. This is one of the key mechanisms involved in this type of human failure. The three categories ‘Routine Violation’, ‘Situational Violation’ and ‘Exceptional Violation’ will all have additional contributory factors and so once more must be clearly defined and accurately identified in order to implement the appropriate solution.

Although there are a number of shocking examples that suggest otherwise – in general very few people actually set out to do the wrong thing intentionally and most Human Failures fall into the unintentional category.

Human Failure Mechanisms – Slips and Lapses

So far in this blog we have looked at the contributory factors which lead to failure, whether unintentional errors such as slips, lapses and mistakes or routine, situational and exceptional violations which, by definition, are considered to be intentional. Within each of these categories there are mechanisms which are both unique to the relevant cause and in some cases, may determine the outcome.

We have also considered the importance of the accuracy of the investigation process in order to identify solutions which a) effectively address the root cause and b) don’t waste valuable resources.

The category called ‘mistakes’ presents its own challenges. Rule based mistakes are addressed by having clear, unambiguous procedures and processes for all activities which are clearly communicated and complied with i.e. the rules are defined, shared and followed. Knowledge based mistakes are mitigated by the implementation of a Competence Management System (CMS). If we consider the term ‘Competence’ to be the skilful application of knowledge then the inputs are training to develop knowledge and coaching to enhance skills.

As far as ‘solutions’ go these examples may not necessarily be very complicated but this does not mean for one moment that either of them are easy to implement and maintain. In any organisation, the diversity of activities alone will make developing and maintaining comprehensive, and detailed procedures and processes a massive task. Likewise, managing the competence of all staff across a broad range of roles to the required standards along with all the administration of the relevant evidence and assessment records is also no small undertaking.

Processes, procedures and competence management however are generally well understood and well established in industry (with varying degrees of success). The ‘slips and lapses’ categories are where I would like to focus as they are arguably the most common causes of human failure.

In discussion with highly experienced and well educated HSEQ and Management professionals I have been faced with statements such as “Ah!…but you can’t do anything about that…it just happens…always will!” Often backed up by “…but that’s the human element!” These beliefs demonstrate a lack of understanding of the involvement of mechanisms in the slips and lapses categories.

In an earlier article, I mentioned that the mechanisms of failure for a slip of action or a lapse of memory are more likely to be enabled by factors such as distraction, stress or overload/underload. This is often referred to as ‘a loss of situational awareness’. Much of the material available on the topic, including the training, discusses the subject but rarely goes into what goes on ‘behind the scenes’ (so to speak) when this takes place.

It is a very complex subject to even attempt to address within a short article but some good examples of the subject are very accessible. Steve Peters’ work on the ‘Inner Chimp’ theory is very well published and has been very successful in some areas of sport. My own preference is Daniel Kahnemans ‘Thinking Fast and Slow’ which looks at System 1 thinking – fast, instinctive, emotional…and System 2 thinking – slower, deliberate, logical. These processes heavily influence the use of heuristics (cognitive shortcuts) and biases. These functions are carried out by different parts of the brain, something which we are blissfully unaware of during the experience. When we delve deeper into this process the mechanisms at play and the contributory factors which influence them become very clear. Again, this does not make the ‘solutions’ easy…but at least they are now within reach!

At FQM we are planning a series of Lunch and Learn sessions over the next 6 – 8 weeks to share some of this understanding with anyone who may have an interest in, or who might benefit from a new approach to this topic.

For dates and availability

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