Human errors are human. Human errors do always occur. This is how it always has been. But is this really true when we are talking about system thinking and operational excellence? Well, it’s a question of the perspective how you are looking at processes.
Identifying an error as human error is just easy and very comfortable, because you don’t have to think about the deeper root cause of the problem any more. So many times I have seen Pareto Charts of a failure analysis as shown in the figure below.
Human errors are always number one and typically this leads to following additional problems:
- Improvements of the processes will be seldom done.
- Employees will be blamed for errors.
- Employee engagement will drop.
- Fire fighting will become a daily routine.
There is a famous quote from W. Edwards Deming:
94% of problems in business are system driven and only 6% are people driven.
How does Deming’s observation fit to all the Pareto Charts I have seen? Well, as mentioned above, it’s just a question of proper root cause analysis and applying the right problem solving techniques.
By simply applying problem solving techniques like the 5 Why’s methodology the Pareto Chart will significantly shift from human errors to the actual root causes. These root causes might be:
- Insufficient or erroneous work instructions
- Insufficient training levels
- Insufficient maintenance strategy for the equipment
- … and so on
In some industries, such as pharmaceutical industry, aerospace industry and nuclear industry, a lack of system thinking may become very dangerous on top. Therefore authorities like FDA (pharmaceutical), FAA (aerospace) or IAEA (nuclear) are emphasizing a more strict system thinking since a couple of years.
For example, now the IAEA is shifting focus and acknowledging that the individual behaviors and processes in place will only be as good as the organizational structure which supports them.
As a conclusion, talking about human errors is misleading and does not reflect a correct system thinking at all.