The expectations of customers and other stakeholders is that organizations will design robust processes, and if failures occur the response will be sufficiently effective so that there will not be recurrence. Unfortunately, problems involving human error often don’t get the attention they deserve.
Diagnosing human error should not be a random search, but instead an organized process conducted using flowcharts, typologies and/or checklists. This webinar will provide examples of the use of these techniques in order to have a more sound investigation.
Time after time the solutions to human error are not based on sound data, but instead on the need to close the investigation (either due to lack of interest or unrealistic timelines). Unconsidered are cognitive, physiological, environmental, and equipment issues, either temporary or permanent, that can interact to cause decision or physical errors.
Just because a single individual made an error does not mean the problem is necessarily unique to the individual; it may be just a bad "luck of the draw." The problem will often be due to the design of the work process in which the individual works, but in order to identify the causes there must be a consideration of person-process interaction to understand why the individual misperceived, misunderstood, decided wrongly, or acted wrongly. Only then can the solutions be properly aligned to the causes.
While process improvement and increases in equipment reliability have certainly reduced the rate of failure in many organizations/applications, the design of human beings hasn't really changed. Given that there are "normal" rates of human error it is important to be able to better identify the specific causes.
If a corrective action report indicates that the cause for a problem was human error and the solution was to retrain the individual, almost for sure it was simply a knee jerk response in order to get the CAR off someone's desk. Instead we need to know what type of human error it was and its cause. And if retraining is the right solution then doesn't that indicate that there was something wrong with the training process (e.g., a deeper level of cause)?
So what are the typical causes of human error and how does one go about determining which one(s) are relevant to a particular situation? It requires thinking about the process of an individual as they interact with the work environment (e.g., equipment, other people, materials).