Human Error

What is an "error"?


Figure 1: Error & Blame

According to Layman's terms,

  • an act or condition of ignorant or imprudent deviation from a code of behavior
  • an act involving an unintentional deviation from truth or accuracy
  • an act that through ignorance, deficiency, or accident departs from or fails to achieve what should be done (Mariam Webster)

Human error is a fixed part of the human condition and therefore cannot be totally eradicated. We all make hundreds of errors each day. Errors serve as a useful service in the trial-and-error learning process. Errors with no bad effects can be good. We must not confuse errors with the bad effects of errors. However, in aviation or any other sector, we cannot tolerate the bad effects of error. 

Being in the aircraft maintenance trade for more than 12 years I have experienced that whenever an error occurs in the maintenance system of an airline, the engineer who last worked on the aircraft is usually considered to be at fault. The engineer may be reprimanded, sent for further training, warning letters, or simply told to avoid making the same mistake again. 

However, to blame the engineers for all of the errors that are committed is perhaps giving them too much credit for their role in the airline's maintenance system in a negative way. 


Figure 2: Engineer at fault


Many errors are, in fact, committed due to other failures inherent in the organizational systems and the engineer involved is merely the source of one of the failures. The best way to explain how an error can occur & the factors contributing at different levels is to study the concept called 'The Swiss Cheese Model'.

Swiss Cheese Model (James Reason)


Figure 3: The Swiss Cheese Model(James Reason)



'The Swiss Cheese Model' of accident causation, originally proposed by James Reason, likens human system defenses to a series of slices of randomly-holed Swiss Cheese arranged vertically and parallel to each other with gaps in between each slice. Reason hypothesizes that most accidents due to error can be traced to one or more of four levels of failure:
  • Organizational influences (Latent Failure)
  • Unsafe supervision (Latent Failure)
  • Preconditions for unsafe acts (Latent Failure)
  • The unsafe acts themselves (Active Failure)

In the Swiss Cheese model, an organization's defenses against failure are modeled as a series of barriers, represented as slices of cheese. The holes in the cheese slices represent individual weaknesses in individual parts of the system and are continually varying in size and position in all slices. The system as a whole produces failures when holes in all of the slices momentarily align, permitting "a trajectory of accident opportunity", so that a hazard passes through holes in all of the defenses, leading to an accident. (James Reason HF Model)

However, what makes the 'Swiss cheese model' particularly useful in accident investigation, is that it forces investigators to address latent failures within the causal sequence of events as well. As their name suggests, latent failures, unlike their active counterparts, may lie dormant or undetected for hours, days, weeks, or even longer, until one day they adversely affect the unsuspecting aircrew. Consequently, they may be overlooked by investigators with even the best intentions. (HFACS by Scott & Douglas)




Blame-Free Culture at the Workplace

A blame-free culture is a vital component of a healthy and productive workplace environment. It fosters trust, encourages open communication, and promotes innovation by removing the fear of repercussions for mistakes. Furthermore, a blame-free culture promotes psychological safety and encourages individuals to take responsibility for their actions and decisions, but where mistakes are viewed as learning opportunities rather than grounds for punishment. In such an environment, employees feel safe to admit errors, take risks, share ideas, and collaborate openly without fearing negative consequences. (Edmondson, A. C. 2018)

Conclusion

Human Resources (HR) plays a pivotal role in shaping the organizational culture and can lead the charge in creating an environment where employees feel empowered to take risks and learn from failures without the fear of blame. By championing a blame-free culture, HR can create an environment that values transparency, learning, and collaboration. Through communication, training, and leading by example, HR professionals can cultivate a workplace where employees thrive, share ideas, and embrace challenges without fear.

Additionally, organizations should have clear processes in place for identifying errors, addressing them promptly, and implementing measures to prevent similar errors from occurring in the future.

References 

    Comments

    1. AnonymousJuly 12, 2023 at 12:19 AM

      This post flawlessly reveals the key elements to identify the symptoms & means behind 'Human Error'. Addressing such a crucial matter that every body in their work-life has the tendency to deal with, is indeed a matter to be appreciated. Moreover, the factors that have been pointed out to mitigate the negative scenarios are capable of drawing the attention of many. Thank you for sharing such a valuable insight.

      Madara Gamage (MBA-2023)

      ReplyDelete
    2. AnonymousJuly 16, 2023 at 12:44 PM

      While accountability and responsibility are important, it is critical to strike a balance and consider potential disadvantages. Overemphasis on individual responsibility may overlook systemic issues, and avoiding blame entirely may impede the identification of root causes for learning and improvement. Fostering psychological safety as well as addressing larger systemic measures are both critical in fostering a culture of continuous improvement within organizations.

      ReplyDelete
      Replies
      1. AnonymousJuly 16, 2023 at 12:46 PM

        While accountability and responsibility are important, it is critical to strike a balance and consider potential disadvantages. Overemphasis on individual responsibility may overlook systemic issues, and avoiding blame entirely may impede the identification of root causes for learning and improvement. Fostering psychological safety as well as addressing larger systemic measures are both critical in fostering a culture of continuous improvement within organizations.
        Mohamed Shihan E211227 MBA-28

        Delete
    3. I U K YaddehigeJuly 17, 2023 at 12:57 AM

      The article thoroughly emphasizes that an aircraft technical engineer is a job with a lot of responsibility. A slight mistake by that officer can lead to dire consequences. That duty gives a lot of stress. It is evident from reading the article that it is essential to maintain the mentality of a person in such a position at a high level, and it is very necessary to help bring the individual's mentality to a higher level through human resource management.

      ReplyDelete
    4. Chaminda PereraJuly 19, 2023 at 9:12 AM

      Error can be happend in minimum impact but certain industries error cannot be allowed to happend because loses are very high. Error proofing and prevention is utmost importance.

      ReplyDelete
    5. Rampragash MBA 2023July 28, 2023 at 2:34 AM

      Human error is an action that has been done but that was "not intended by the actor; not desired by a set of rules or an external observer; or that led the


      Thank you for sharing your information, it is really very significant for organisations.

      ReplyDelete
    6. Dimuthu Edirisinghe - MBA28July 31, 2023 at 5:08 AM

      Considering the history of any subject, human errors have been caused for implementing new options and for further developments. Nowadays, organizations use many strategies to minimize human errors. Thanks for the important content.

      ReplyDelete
    7. Nimantha WickremasingheAugust 1, 2023 at 6:16 AM

      Interesting read. I've noticed human errors firsthand that perfectly align with the Swiss Cheese model you have described here. And more often than not leaders are there to take credit for successes but not the fall for the failures in organisations. However, there are two types of errors I have noticed: genuine errors and careless errors. While I agree that leaders and organisations need to be open to accept genuine errors and focus on improving processes, I think employees have part to play as well. Employees need to be mindful about what they are doing and the outcome of it instead of simply executing an action and expecting everything to go well. If something is not clear, they can be proactive to reach out to others, raise their doubts, and clarify them before execution, even use a bit of common sense so to speak. Genuine errors can be used for continuous improvement, but repeated careless errors must have no place and be dealt with strongly for the betterment of organisations. The Chernobyl disaster in 1986 is a great example that caused an irreversible damage of great extent due to a multitude of human errors (World Nuclear Association, 2022). I would argue that Chernobyl disaster could have been averted or even contained to some level if at least some of the people who were directly involved in it thought differently about what they were doing on that day.

      References

      World Nuclear Association, 2022. Chernobyl Accident 1986. [Online]
      Available at: https://world-nuclear.org/information-library/safety-and-security/safety-of-plants/chernobyl-accident.aspx
      [Accessed 1 August 2023].

      ReplyDelete
    8. Lakshani N UlladupitiyeAugust 12, 2023 at 10:28 PM

      Mistakes are common when implementing a new plan, and it doesn't work for everyone.
      Using strategies to minimize errors is a big task.

      ReplyDelete
    9. Madara Gamage ( MBA-2023)August 14, 2023 at 8:29 AM

      While human error cannot be entirely eliminated, organizations can create an environment that promotes learning, supports employees, and implements strategies to minimize errors. By taking proactive measures, organizations can reduce the frequency and impact of human errors, leading to improved performance, safety, and overall effectiveness.

      ReplyDelete
    10. Dinesh Chamira WijesinghaAugust 15, 2023 at 2:02 PM

      Human error is a mistake made by people that results in an unfavorable outcome. It is a normal by-product of workplace activity.
      One could reasonably argue that all failures are the fault of human design because we cannot stop them from happening.

      ReplyDelete
    11. Prabath MudaligeAugust 19, 2023 at 8:30 AM

      The blog post provides a comprehensive overview of human errors, the Swiss Cheese Model, and the importance of a blame-free culture. While the content is informative, here are some critical points to consider:

      Complexity of Errors:
      Legal and Ethical Aspects:
      Mitigation Strategies
      Long-Term Effects

      ReplyDelete

    Post a Comment

    Popular posts from this blog

    Talent Management

    Image
    Figure 1:Talent Management Components The definition of talent management is the carefully planned, strategic process of bringing on the right personnel and assisting them in reaching their full potential while keeping organizational objectives in mind. Thus, the process entails identifying talent gaps and open positions, locating and onboarding qualified candidates, growing them within the system and developing necessary skills, training for expertise with a future-focused approach, and successfully engaging, retaining, and motivating them to achieve long-term business goals. The definition highlights the broad scope of talent management, showing how it pervades all facets of human resource management at work while ensuring that the firm achieves its goals. Thus, it is the process of bringing on the appropriate personnel and preparing them to help the firm as a whole (Ghosh, 2021). Figure 2: Talent Management Model The numerous roles and procedur...
    Read more

    Cooperate Social Responsibilities (CSR)

    Image
    Figure 1: Corporate Social Responsibility Corporate social responsibility (CSR) is a strategy used by businesses to not only increase profits  but also to play an active and constructive social role in their local and global communities. The  phrase is connected to a similar phrase called corporate citizenship. A corporation may make a  difference in the world and help to enhance social order, according to its CSR strategy. As CSR  reflects business practices and corporate culture, it is a subject that might interest the board of  directors of an organization (Kerner, 2023).  The majority of companies operate to make a profit,  either for their owners or the shareholders who own them. CSR vigorously contests this model.  Companies are considered to exhibit CSR if they understand that they have a duty to protect the  environment and implement policies to guarantee that they are doing more for society than just  generating a profit. The pr...
    Read more

    Job Rotation

    Image
    Figure 1: Job Rotation What is job rotation in HRM? Job rotation through numerous employment responsibilities, enriching their skills, ability to  perform in diverse tasks, and experience. It is an effective HR technique to raise employee  understanding of all sorts of jobs conducted in their sector. Job rotation is a management technique  that involves shifting employees from one job to another in order to familiarize them with all of  an organization's verticals. The goal of job rotation is to improve workers' work experience, cross-train  them, and increase their job satisfaction. The job rotation program entails the temporary  assignment of an employee in a position or department to undertake the exact tasks of another  position for a certain period of time. This is usually a voluntary assignment in which the employee  considers the provided tasks to be part of his or her regular job. After carefully evaluating other  potential workforce ...
    Read more