Human Error and Uncertainty

May 31, 2018 10:43 am || || Categorized in:

Why competent people make costly errors, and how to address it.


What causes competent people to perform below their potential – making errors or inhibiting productivity?

WAIT!  Before answering too quickly, think about the purpose of automation.  We automate processes to reduce variability, thus reducing delays and errors to ultimately save cost.  Automation replaces human actions with programming logic.  So, what is it about human actions that programming removes?

One answer:  uncertainty.

If we could prescribe certainty of choice under all conditions within the minds of each person, then we would reduce the primary cause of human error and delay.

So, let’s get started…

Step 1:  Identify the sources of uncertainty by asking, “How does a person’s mind differ from a program?”  Your responses may include:

  • Unclear task definition – the task logic hasn’t been fully programmed into the mind. A person in this situation may simply freeze up, make an error while trying to do the right thing, or move to a more comfortable task of lower priority.
  • Unclear or competing priorities – the programmed logic has multiple, and possibly divergent, inputs. Executive: “It’s all about quality…get it right the first time!”  Supervisor: “We’re behind schedule…get it moving!”  The performer is forced to make a trade-off decision, and likely under pressure.
  • Uncertainty on how to proceed during abnormal circumstances – the program does not consider all possible paths. A person’s choices are less predictable, with a higher probability of error.
  • Ambiguity regarding responsibility or authority to proceed – as if the program simply ends when a decision is not pre-determined. Not my job; that’s above my pay grade.  Again, the person may either proceed with insufficient perspective, or, more likely, not proceed.  This leads to significant delays while seeking clearer permission.
  • Insufficient or inaccessible guidance in the moment – can’t access the data or instruction to proceed. I’m sure you’ve seen poorly written or absurdly complex SOPs.  A person will often rely upon personal experience, which is highly variable and open to error.

Step 2:  Address these sources of uncertainty:

  • Define: People need to know what is expected of them.  Ensure all stakeholders are aligned on the purpose of each role, i.e. what outcome this person is assigned to achieve.  Then, determine the critical tasks and priorities that enable the person to achieve the outcome.
  • Communicate: Ensure the critical tasks and priorities are clear to the person assigned to the role.
  • Train: Ok, so we all know that training is not the catch-all solution for human error.  That doesn’t mean it’s never the solution.  In fact, impactful, behavior-changing training must be part of the solution.  Trainings often fall short due to lack of clarity of purpose and lack of exposure to real circumstances.  One key objective of training is to prepare the performer to handle a variety of circumstances, thus addressing the uncertainties described above.  Here is where training can deliberately overcome uncertainty.
    • Lack of knowledge

      •      A lack of specific knowledge of the task or process leads to errors. These are to be expected while learning through performance, yet they should diminish with experience.  Training should accelerate this process.
      •      Since perfection is unachievable, a lack of awareness of priorities and their relative impact leaves the performer to make risky trade-off decisions. Training should provide clarity of priorities and a focus on desired outcomes amidst competing distractions.
      •      A lack of broader knowledge inhibits one’s ability to handle abnormal or unfamiliar situations. Training should provide a breadth of useful perspectives (think system or process knowledge).
    • Lack of experience
      •      Good training is not conceptual, it is practical. Attendees should learn how to perform functions to achieve expected outcomes.  Attendees should also be exposed to all aspects of the equipment, system, processes, and workflows, such that a qualified person can overcome an abnormal condition or outcome.
    • Qualify: Good training provides the people with knowledge, exposure, and a certain degree of controlled experience.  A rigorous qualification program confirms understanding and the ability to apply in the real world.  While qualifying, the person performs under steadily decreasing guidance.  Apprenticeship is an ancient and effective approach, and a model that is still relevant today.
    • Guide: The supervisor’s most important role is to maintain the focus of the performer – removing barriers and distractions from the critical tasks and priorities.  When uncertainty inhibits performance, readily available guidance provides relief.

Try following this logic with a human error situation you know well.  See if you can identify sources of uncertainty.  Does this broaden your perspective of the root cause and help bring focus to your solution?

Will you be at BIO2018? Make sure to visit us at Booth #1735 to discuss your ideas surrounding human error and uncertainty.

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