Root Cause: Human Error?

Because even the best and brightest make mistakes, its easy to pin the root cause as human error.
It certainly happens often enough. Technically, an error is defined as a human action that
unintentionally departs from expected behavior. nder normal conditions, !e can make bet!een three
to seven errors per hour. nder stressful, emergency, or unusual conditions, !e can make an average
of "" errors per hour.
But !hy do !e make errors# Is it the individuals fault# $ recent presentation by the Idaho %ational
&aboratory sho!ed follo!ing'
&atent organi(ational !eaknesses include !ork processes, and, as the above sho!s, such !ork
processes usually are behind human error. )hy did the error occur# The procedure !asnt follo!ed.
)hy# *uman error. )hy !as there human error# The !ork process needs improvement.
+ometimes, human error proves ,ust ho! good some !orkers are. $t the beginning of a root cause
analysis, its not uncommon to hear someone say' Bob has been calibrating these instruments for -.
years and he ,ust scre!ed up. Though it may seem like finger/pointing, its actually the ultimate
compliment, and the incident investigation facilitator should recogni(e it. Think about the math. Bob
has performed this task t!ice a !eek, ".. times a year for -. years. Thats -,... calibrations0and
this is his first significant error# 1rror rates of ,ust "2"... are considered exceptional, and Bob beat
this by a long shot.
3oes this !arrant a root cause analysis at all# It may, because incidents rarely if ever have ,ust one
cause. $re !e absolutely sure that Bobs mistake !as the only reason the incident occurred# 3ig
deeper and you likely !ill find theres more to the problem than Bobs once/in/an/eon snafu.
Beyond Blame
If !e stop at 4rocedure %ot 5ollo!ed, the usual response is to blame a person. Blame is easy and
does not focus on the process. &ets face it04rocedure %ot 5ollo!ed is a simple 6albeit
oversimplified7 explanation of confusing and complex problems. It also re8uires little or no !ork from
anyone in an organi(ation except the person !ho made the mistake. *o! does this make the person
feel# %ot listened to, unappreciated and, eventually, apathetic, !hich isnt good for anybody.
The key to getting beyond the procedure/not/follo!ed conundrum in a root cause analysis is obtaining
detail, and its here !here the 9ause :apping facilitator plays a key role. 3uring the brief kickoff
meeting that can start an incident investigation, the facilitator asks the group about its ob,ective along
!ith general 8uestions about the incident. 1xpect different perspectives.
:ake sure everyone can see !hat is being !ritten by using a !hiteboard, flipchart, or a laptop and a
pro,ector. $sk ho! this incident impacted the organi(ations overall goals 6that is, goals everyone
agrees on, like (ero safety incidents7, and start developing a top/level 9ause :ap.
+ome situations may involve reprimand or discipline. The root cause analysis facilitator must
emphasi(e this is a technical incident investigation, not a disciplinary action. The steps taken are
relevant; !ho did !hat isnt. %o names, no blame.
3ifferent approaches to incident investigations !ork better than others, depending on the facilitator
and organi(ation. If people tell me a certain technician made the error, I may not al!ays meet !ith
that person first. In my mind, the person didnt cause the error; hes simply the one closest to the
incident and, for that reason, probably kno!s some important detail. But because finger/pointing
pervades our culture, he might not share the necessary information if I come to him !ithout
developing a simple version of the !ork process.
If I come to that person after talking !ith managers, supervisors, and others further removed from
the incident, and sho! him the information I already have, he likely !ill fill in further details and
perhaps even correct some information. I also try to obtain a copy of the procedures 6if available7 and,
from it, dra! out a process map. :ost important, focusing on information I already have dra!s
attention a!ay from the person and to!ard the detail on the 9ause :ap' causes, effects, and
supporting evidence. )e try to come into these meetings !ith enough information so !e can use the
time available as efficiently as possible.
The !orst approach, perhaps, is to march directly to the person !ho supposedly committed the
error 6eerily close to committed the crime7 and ask, )hy did you not follo! the procedure#
$ns!ering this, the technician likely !ill rebuff. I dont kno!. I !as having a bad day. In his mind,
the more he says, the more hes liable. *is goal often is to emerge from this incident investigation
unscathed. )ithout enough information, the 9ause :ap stops at 3id %ot 5ollo! 4rocedure, !hich
ultimately helps no one.
4rocess details, on the other hand, help everyone, and to get them re8uires some intervie!ing skills.
$s a facilitator, I often introduce ignorance. In other !ords, I ask people to explain !hat may seem
obvious. $fter they describe it, I sometimes ask them to explain certain aspects again. I may have
understood them, but the more details they introduce, the better. It also gets the conversation a!ay
from !ho did it and to!ard !hy did the incident occur#
Sensitive Circumstances
:istrust and miscommunication may make it difficult to dig deeper than 4rocedure %ot 5ollo!ed. $s
a previous industrial person, Im guilty of this. 1arly in my career, !hen a breakdo!n occurred, in the
back of my mind I !ould think the operators !ere actually trying to break the e8uipment. But rarely
do people sabotage an organi(ation. In fact, most !ant to do good !ork, if not for organi(ational
loyalty then at least for personal pride. 5or this reason, incident investigations should al!ays start
from a perspective that people in the organi(ation did not intend to do a bad thing. 4eople !ant things
to go !ell; some ,ust put more effort into making things go !ell.
This can be difficult to get past in sensitive circumstances. 9onsider the $ir 5orce mishap in -..< in
!hich cre!s actually lost track of six live nuclear !arheads for about => hours. $ B/?-* bomber fle!
across the nites +tates !ith six live !arheads under its !ings. The bomber !as transporting cruise
missiles designed to carry the !arheads from :inot $ir 5orce Base in %orth 3akota to Barksdale $ir
5orce Base in &ouisiana for disposal. The plane carried "- missiles in the open air, six under each !ing.
$ll "- !ere supposed to have dummy training !arheads. +ix did, but the other six had live !arheads,
!hich together had >. times the po!er of the *iroshima bomb.
The bombs had safeguards on them to protect against detonation, so the risk of an explosion !as
slight. The real danger !as that these !arheads !ere parked overnight in :inot for "? hours and,
upon reaching Barksdale, left to sit for nine more hours !ithout special guard.
Thats scary stuff, and it certainly made for splashy headlines. If you read the media coverage, you
can see ho! finger/pointing and talk of punishment dominated early, !hile procedural changes !ere
considered only after a series of exhaustive incident investigations. 1arly on the +unday Times 8uoted
one $ir 5orce official saying, This !as an unacceptable mistake and a clear deviation from our
exacting standards.
4ut another !ay' The procedure !asnt follo!ed. $ much larger revie! of procedures ensued, not only
for this event but for all nuclear !eapons handling procedures. 1motion and drama engulfed the event
for understandable reasons. @ust imagine, though, if the initial reaction !asnt so dramatic but instead
focused on the procedure at hand. The process map might have looked something like this'
%o names; no blame; no punishments; no colorful language used by ne!spaper reporters and finger/
!agging politicians. $ process map has no personality and no bias. It ob,ectifies the incident
investigation and gets people focusing on the process. &ooking at such a map, the eyes go right to the
8uestion box !ith the 8uestion mark, the unkno!n. Theres the focus0the steps involved, !hat
happened.
%ote that this linear map ,ust covers the process0!hat happened, not the !hy. But !hen a process
map is used together !ith a 9ause :ap, the approach can uncover some 8uestions. )hy are nuclear
!arheads and the dummy training !arheads stored in the same bunker# )hy, at a cursory glance, do
training and dummy !arheads look identical# )hy are the missiles transported externally, instead of
inside a transport vehicle# 5or that matter, !hy do the missiles need any !arhead0real or fake#
It turns out there are valid reasons for most of these 8uestions, but the point is this' The process and
9ause :aps turn focus a!ay from blame to allo! an organi(ation to go beyond 4rocedure %ot
5ollo!ed. It boils do!n everything to the steps taken, causes, and effects, and deemphasi(es
individual personalities and emotions.