News Flash! Human Error Is The Cause

One of the benefits of frequently traveling to conferences as a speaker is the opportunity to attend other sessions and to learn new or different concepts.

Recently, I learned more about the phenomena called “normalization of deviation”. There is a workplace reality related job or task procedures. Work procedures or methods are established with the installation of new equipment or the initiation of a process or new system. These procedures are usually established before actual work is performed. As work begins,the procedures are followed as written, but over time the workers involved naturally tend to deviate a bit from the original steps or methods of the procedure. This deviation is almost always well intended and done to improve efficiency, often based on previous experience and observed outcomes.

Over time, unless procedural deviations are corrected or redirected by supervisory management they become the new norm or normal way of completing the work. Usually, nothing bad happens. Or on the contrary the job is more efficient and workers are praised and rewarded.

Here’s the trap. Efficiency improves, nothing goes wrong, workers and supervisors are rewarded. Now they think they can go faster, take a few more shortcuts, until a momentary lapse or the wrong tool is used, a reach misses it’s mark and a hand is pulled into the machine. Now everything changes because there’s an incident with injury that must be investigated. We need to find out what happened, who was involved, the extent of the injury, what the person involved was doing, and if they were following work rules and procedures. You know the routine. Somewhere along the line we’ll naturally want to determine responsibility and hold someone accountable. It’s usually the injured person who violated a procedure, even though there may have been a new “normal” procedure, condoned by supervisors, engineers and others who may have oversight.

One of the reasons we react to find responsibility and often place blame is something we all do as humans. It is called “Fundamental Attribution Error”, another human phenomena that leads us to explain our behavior by that of others. When we see others in action we assign attributes to their behavior. In so doing we have the tendency to over estimate the intent and underestimate the external factors that result in or explain behavior. Through this window we see errors or mistakes as failures resulting from poor choice. The resulting thought process is to project oneself as better than the person who committed the error.

The combination of our lack of understanding normal work deviation and our tendency to view error as the result of conscious choice, often leads us to an inappropriate response. Unfortunately, this combination starts the blame cycle, feeds the disciplinary process, creates bad feelings and fosters a poor safety climate and negative culture.

What we must continue to strive for is a work climate that recognizes the good in all individuals, their desire to do well, and their need for recognition or praise. This type of climate fosters teamwork and the attitude of looking out for each other, resulting an improved sense of well-being that is more likely to lead to the achievement of higher goals and levels of performance not previously experienced. A culture like this doesn’t look to place blame, but works to define and learn from mistakes. Then when human error occurs and an incident results, an effort is made to define where the system and its defenses failed. The result is better work system design, leading to improved efficiency, increased productivity, and better safety overall. In the end the organization reaps benefits well beyond safety through a better culture that can learn and work to continuously improve, and the workers can focus on doing their job as a valued part of the organization.