- People make mistakes
- Blame fixes nothing
- Context drives behavior
- Learning is vital
- Response matters
1. People are fallible, and even the best people make mistakes.
Error is universal. No one is immune regardless of age, experience, or educational level. The saying, “to err is human,” is indeed a truism. It is human nature to be imprecise—to err. Consequently, errors will happen. No amount of counseling, training, or motivation can alter a person’s fallibility. Dr. James Reason, author of Human Error (1990), wrote:
It is crucial that personnel and particularly their managers become more aware of the human potential for errors, the task, workplace, and organizational factors that shape their likelihood and their consequences. Understanding how and why unsafe acts occur is the essential first step in effective error management.
2. Error-likely situations are predictable, manageable, and preventable.
Despite the inevitability of human error in general, specific errors are preventable.16 Just as we can predict that a person writing a personal check at the beginning of a new year stands a good chance of writing the previous year on the check, a similar prediction can be made within the context of work at the job site. Recognizing error traps and actively communicating these hazards to others proactively manages situations and prevents the occurrence of error. By changing the work situation to prevent, remove, or minimize the presence of conditions that provoke error, task and individual factors at the job site can prevent or at least minimize the chance for error.
3. Organizational processes and values influence individual behavior.
Organizations are goal-directed and, as such, their processes and values are developed to direct the behavior of the individuals in the organization. The organization mirrors the sum of the ways work is divided into distinct jobs and then coordinated to conduct work and generate deliverables safely and reliably. Management is in the business of directing workers’ behaviors. Historically, management of human performance has focused on the “individual error-prone or apathetic workers.”17 Work is achieved, however, within the context of the organizational processes, culture, and management planning and control systems. These phenomena contribute to most of the causes of human performance problems and resulting facility events.
4. People achieve high levels of performance because of the encouragement and reinforcement received from leaders, peers, and subordinates.
The organization is perfectly tuned to get the performance it receives from the workforce. All human behavior, good and bad, is reinforced by immediate consequences or past experience. Behavior is reinforced by the consequences that an individual experiences when the behavior occurs. The level of safety and reliability of a facility is directly dependent on the behavior of people. Further, human performance is a function of behavior. Because the consequences workers experience influence behavior, what happens to workers when they exhibit certain behaviors is an important factor in improving human performance. Positive and immediate reinforcement for expected behaviors is ideal.
5. Events can be avoided by understanding why mistakes occur and applying the lessons learned from past events (or errors).
Traditionally, improvement in human performance has resulted from corrective actions derived from an analysis of facility events and problem reports—a method that reacts to past events. Learning from our mistakes and the mistakes of others is reactive—after the fact—but important for continuous improvement. Human performance improvement today requires a combination of both proactive and reactive approaches. Anticipating how an event or error can be prevented is proactive and is a more cost-effective means of preventing events and problems from developing.