Root cause concepts and methods have been around forever, but investigating the humane aspect of human error has only recently evolved into having its own methodology. By not only focusing on the hardcore facts of cases but also including more subtle aspects such as the work environment, motivation, and individuals involved, deeper and more credible root causes can be found.
Let me tell you a true story: A machine operator starts running his line and immediately realizes it is running in the wrong direction. The following few seconds determine the enormity of the financial consequence: millions of euros.
Colleague 1: We could see that coming a mile away.
Colleague 2: Really?
Colleague 1: Sure, there was no way it could have been avoided.
Colleague 2: Really?
Colleague 1: No one could have prevented it.
Colleague 2: Really? I guess you're right. Is there no methodology to investigate such issues?
Imagine being able to listen in on all meeting room conversations after such an incident has occurred, regardless of magnitude. It may often result in some of the following phrases: "Everyone makes mistakes, right? To err is human, right? It could happen to anybody."
But it didn't. It happened to an unfortunate operator who just happened to start the line at that moment. It could have been you! How would you have felt if it were you? And what if you knew it could have been avoided? What if a mechanism was developed to prevent such human errors?
How do you avoid human errors?
Investigating human error is not an easy task, with resistance, sensitivities, regret, etc., all being part of the experience for both the investigator and the person being interviewed. In many cases, human error led to material and financial consequences, and in more serious cases, even loss of life.
Over the past few years, I've been involved in many investigations, and through intellectual collaboration with Ginette Collazo, PhD at Human Error Solutions, we have developed an investigation model that helps ease the investigation process and, more importantly, can be used to prevent human errors from occurring. The model can be easily applied in a general operational process setting to assess potential risks and eliminate them. When used "after an incident," it requires a higher level of objectivity from the investigator. Further collaboration with Joakim Bjurström at Business Through People (BTP) aligns our model with Hoshin Kanri, Toyota Kata, and the Training Within Industry (TWI) programs.
The model provides valuable insights ranging from procedures to training, supervision to individual performance. It utilizes distinct approaches to delve deep into opportunities (preventive mode) and root causes (reactive mode). The model then delivers an overview summary and report, as well as a recommended action plan to mitigate or drastically reduce the highlighted risks.
Please note that some changes have been made for clarity and coherence, but the overall meaning of the text remains intact. If you have any specific concerns or further questions, feel free to let me know!
In order to avoid human errors, we have utilized ChatGPT to proof read this article.