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Human error is not a passing phrase.

Human Error is not a Passing Phrase

Risk management is subject to its share of shibboleths, or catch-words, just like any other discipline. The most harmful risk management shibboleth of all must be the words "human error."

We incant the phrase regularly during an accident investigation. We give them prominence in the report on the causes of the accident. We always urge management to take steps to reduce the scope for human error in the future. As a result of doing these things, we can feel complacent that the function of accident investigation has duly been met.

The way to tell that "human error" has achieved the status of a risk management shibboleth is by the irrational way we all respond to these words. The effect of any mention of human error in the context of accident investigation is invariably to trigger a shutdown switch in the brains of those within earshot. There may be no other way to explain universal acquiesence when reports, which have taken hours of work and much expense, end with a conclusion such as, "A common element in each of these incidents was human error."

Would we otherwise repond to such an investigation by pointing out that every accident, if it is not an act of God or deliberately caused, must be the result of some type of human error? Do we profit from being reminded that the sun rises every day?

An accident is an unexpected or undesirable event; as such, it can only come about by act of God, deliberate human intervention or human error. The latter implies that either the threat was overlooked or adequate preventative measures failed to be taken.

The point of an accident investigation is not to spend time and money to tell us at the end what we knew at the outset--that human error was involved. Rather, it should briefly explain what type of human error, and more importantly, the extent to which the factors of the work environment contributed to the likelihood that the human error would occur.

Unfortunately, accident investigation seems to make the classic error of mistaking the effect for the cause. The human error in accidents should be regarded as an "effect" of faulty risk management. The poorly designed working environment may, of course, also be attributed to human error, but generally people do not have this in mind when they use the term. When a person makes a mistake, this is only human and to be expected; the "cause" of the accident, if his mistake develops into one, is the set of circumstances which failed to neutralize his error. This is not to say that he is always blameless; he may indeed be grossly negligent, but we should wonder whether work systems should be designed to be foolproof. If a human error disaster occurs, who is negligent--the operative or the person responsible for the work system--since avoidance depended on an operative never being grossly negligent?

Even through learning and education, we will never reach the point where human beings do not make mistakes. Thus, the emphasis of accident investigation should be shifted from discovering who was responsible for an accident to what it was in the work system which allowed the mistake to have disastrous consequences.

Management's Role

Management has always readily accepted "human error" because it places the emphasis of blame on individuals rather than on work systems. In becoming a shibboleth, the term human error has lost its purpose; it has come to mean simply the mistakes of those most close in time and place, but not necessarily in responsibility, to the accident. Thus, the aircraft pilot gets the blame for a disaster, and the badly designed control panel gets an overhaul.

If the term human error were to have any meaningful content, it would have to embrace all the human errors which can ultimately cause accidents. So, the designer of the aircraft control panel would be as likely to be considered the perpetrator as the pilot who is at the controls when a crash occurs.

This is the logical conclusion of my earlier stated view: That all accidents are caused by some type of human error. It is difficult to get people to recognize just how wide the range of human error really is. And if we really appreciate that human error is all-pervasive, we would never use the term to describe the cause of an accident, as if in so doing we had narrowed the range of possibilities by selection. We would instead go straight to the examination and discussion of the particularity of human error in the given accident.

Chris F. Best is the editor of Foresight, a London-based risk management and insurance journal published by Risk and Insurance Group Limited.
COPYRIGHT 1989 Risk Management Society Publishing, Inc.
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Copyright 1989 Gale, Cengage Learning. All rights reserved.

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Title Annotation:risk management
Author:Best, Chris F.
Publication:Risk Management
Article Type:column
Date:Jun 1, 1989
Words:793
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