Many readers would agree that if an investigation concludes an event was due to ‘human error’, it only tells part of the story. In fact, you could argue that such a conclusion should actually be the start of an investigation. If we are to learn, we need to understand why people did what they did, or perhaps didn’t do what was expected.
In an earlier article I discussed a new way of thinking about human error. A view where human error is not seen as a cause, but as a symptom of failure. Investigations should aim to understand why people behaved the way they did, attempting to understand ‘why things made sense’ at the time to those people involved in an event.
To help change the mind-set of investigations and investigators, I’ve produced the following 12 questions to ask in an investigation. These will need adapting to your industry and circumstances, you’ll have to ask them of several people, and of course, they aren’t the only questions that you will need to ask.
The purpose of these questions is simply to encourage getting behind the label of ‘human error’ and to better understand the ‘why’. I used similar questions when investigating incidents as an Inspector working for the UK Health & Safety Executive – I found them to open up interesting areas for discussion, besides building an understanding of why people took the actions that they did.
- What was your understanding of the process/situation at this time?
- What information or data was available to you at this point?
- What did that information mean to you at this time?
- What was the process/system doing at this time?
- What changes in the process/situation required you to change your behaviour?
- What were other people doing at that moment?
- What were you trying to achieve or accomplish at that point?
- What assumptions were you making?
- What options or alternatives did you have?
- What were you focusing on?
- What did you expect to happen?
- At what point did you realise that the situation was different from what you believed it to be previously?
Once we have a picture of the events unfolding through the eyes of those involved, we’re less likely to give the incident a label of ‘human error’ and more likely to learn the wider lessons that can lead to real improvements.
I’ve created a briefing note containing these 12 questions that you can download – see below.
Heading picture credit – http://www.flickr.com/photos/digitalcj/8275532051