Is your Organisation Adrift?

People are fallible, and even the best people make mistakes.

A study by the World Association of Nuclear Operators (WANO) published some years ago discovered that humans, on average, make 5 errors every hour.

It’s quite a challenge to get your head around this fact – particularly when you start to consider the potential impact on your business of the cumulative affect!  Fortunately for us, the majority of these errors are inconsequential, we often don’t even realise we’ve made an error at all. Unfortunately, as we are all too well-aware, some of them can result in catastrophic consequences.

So, what are these human errors? And most importantly, how can we get rid of them? 

Here’s the rub – you cannot eliminate human error. In fact, as our great friend and mentor T Shane Bush, of Bushco HPI will tell you, “Two things will happen to you if you try to eliminate human error – 1. You will go broke and 2. You will go insane!”

Put simply, human error is something you didn’t intend to do! So, can we punish human error out of the system?  No!  Can we reward human error out of the system?  No!  It is pretty much like gravity, weather and Brits queuing.  You have to accept that it is there and work with or around it.

As Dr James Reason, author of Human Error (1990) wrote: “It is crucial that personnel and particularly their managers become more aware of the human potential for errors, the task, workplace, and organisational factors that shape their likelihood and their consequences.  Understanding how and why unsafe acts occur is the essential first step in effective error management.”  

Error-likely situations are predictable, manageable, and preventable.

A good thing about human error is that the conditions in which it thrives are predictable. And therefore, with some good analysis of our existing data; a little bit of forethought and sound planning, we can predict its’ likelihood, understand the consequences of it and do something to reduce its impact.

A great example of this in practice is the humble USB stick.  Every time we try to plug a USB stick into our computer, what happens?  Yep, we try to put it in upside down!  However, the great thing about the design of the USB is that you physically cannot insert it the wrong way up!  It has a built in ‘forcing function’ which prevents you from actually doing it.  Now interestingly enough the USB design does not reduce our ‘Error Rate’ but it does reduce the ‘consequences of error’.

Just as the banks were able to predict that people withdrawing cash from a cashpoint machine might take their cash and leave their card, similar predictions can be made within the context of work.  By changing the work situation to prevent, remove, or minimise the presence of error-likely situations, task and individual factors at the job site can be managed to prevent, or at least reduce the consequences of error, i.e. we can ‘fail safely’.

Individual behaviour is influenced by organisational processes and values.

The culture of an organisation comprises all the values, attitudes, beliefs and behaviours of the people who work in it – coupled with the rules, policies, processes and procedures which are developed to make sure that the work of the organisation gets done in the desired way.

Add to the mix the management style for the organisation and you can begin to see why culture in one organisation can differ so greatly to that of another.  This established culture of the organisation then starts to drive the behaviours of the workers and managers and suddenly we can find ourselves in an organisational drift scenario.

This principle is the antithesis of the theory that bad attitudes, misaligned worker values and peer pressure are major influencing factors when undesired behaviours are displayed; there is almost always some underlying organisational weaknesses or latent conditions at play.

People achieve high levels of performance because of the encouragement and reinforcement received from leaders, peers, and subordinates.

And this can be a double-edged sword!  Notice that the principle does not say ‘good’ performance.  All human behaviour, good and bad, is reinforced, whether by immediate consequences or by past experience.  A behaviour is reinforced by the consequences the individual experiences when the behaviour occurs; where the consequences are positive the behaviour is repeated.

In my work I encounter many instances of leaders unwittingly reinforcing undesired behaviours – for example, the pat on the back for a job well done, without asking whether or not all the rules were applied and the procedure followed.  These are not bad leaders, they are people with good intent trying to do the right thing.

We must ensure that we do celebrate and encourage the correct, desired behaviours and in doing so we must consistently observe, question and intervene to stop unsafe undesired behaviours even when they result in the desired outcome!

Events can be avoided through an understanding of the reasons mistakes occur and application of the lessons learned from past events (or errors).

The most traditional source of organisational learning and improvement comes from the analysis of events, non-conformities and problem reports.  Whilst this retrospective look-back is important for continuous improvement, the ability to anticipate mistakes and intervene to prevent them or reduce the consequences of them is clearly the preferred approach.  Human performance improvement requires a combination of both proactive and reactive approaches.

We are very often contacted by new or prospective clients after the event.  At the point when they are scratching their head wondering how this could possibly have happened (perhaps again) and are looking for a solution to the ‘problem of human error’.

Root Cause Analysis is typically poor, if done at all.  Causal Factors are rarely identified accurately, and identification of Critical Steps only starts to appear in investigation reports after we have introduced the concept to our clients!

Unless you have defined these things, there is a very real risk that the Corrective Actions you put in place will not have the desired effect in preventing a repeat or similar outcome in the future.  This principle directs us to focus attention on the people at the sharp end of our business to understand their map of the world.  Human Performance Improvement shows us that people are the solution to be harnessed, not the problem to be solved.

Written by Teresa Swinton, the Founder and Managing Director of Paradigm Human Performance Ltd (UK) and Paradigm Human Performance Inc (USA). Teresa has spent her career in high hazard industries such as Railway Engineering, High Voltage Power Distribution and Power Generation – both fossil fuel and nuclear.

Teresa truly understands people, organisations and the challenges of leadership. Not only is she well qualified in her areas of expertise but her significant experience and practical approach means she is capable of adapting complex theory, academic models and management systems into easy to understand, straight-forward practices at all organisational levels to drive true transformational change. 

Teresa loves to work with progressive organisations who really understand the power of good stakeholder relationships and how they can be a catalyst for lasting performance improvement and operational excellence.