Is 'Operator Error' as Root Cause ever acceptable?

I have grown up in an enviroment, the Canadian Airforce, where Human Performance in Maintenance (HPIM) is a huge consideration when finding out what went wrong. This is a growing field of study especially in the Aviation world. When doing an analysis into human error, one must remember we are not conducting Salem Witchhunts, we never name names, but if a human caused the problem then a human caused a problem. The only time I have found out that there is not an underlying system problems (Managerial issues, Policy, procedures, Work instruction errors, trainging etc) is when an individual wilfully commited a policy breech. ie: they did what they did on purpose (because it was a short cut to coffee break or hometime), and they got caught.

Otherwise you have to look at training, time on shift, shift durations, education, graveyards shifts produce tremendous opportunities for error, because while your awake, your biosystem is going to sleep regardless, (aka circadian rhythm). I found the absolute worse time to work my men in the airforce was around what I called the witching hours, 1-2 am in the morning. I usually called for tools down at that time. Attidude of the individual and the company mentality are also to be considered. Then you must also address the issues around tooling, enviroment, staging, sequencing of work, etc.

So to make a long story short, human error is a valid response, it is how we correct the human error and approach the RCA of the human error that is of utmost importance. If you are familiar with the concept of flight safety windows, an open window is an opportunity for an error to occur or that an error has occured, as long as these windows are not aligned, or closed if you will becuase we corrected a problem, nothing occurs, but if we fail in our RCA then these windows start lining up and when enough of them line up we loose a plane or a pilot or both.

AirdrieQPA said:

I have grown up in an enviroment, the Canadian Airforce, where Human Performance in Maintenance (HPIM) is a huge consideration when finding out what went wrong. This is a growing field of study especially in the Aviation world. When doing an analysis into human error, one must remember we are not conducting Salem Witchhunts, we never name names, but if a human caused the problem then a human caused a problem. The only time I have found out that there is not an underlying system problems (Managerial issues, Policy, procedures, Work instruction errors, trainging etc) is when an individual wilfully commited a policy breech. ie: they did what they did on purpose (because it was a short cut to coffee break or hometime), and they got caught.

Otherwise you have to look at training, time on shift, shift durations, education, graveyards shifts produce tremendous opportunities for error, because while your awake, your biosystem is going to sleep regardless, (aka circadian rhythm). I found the absolute worse time to work my men in the airforce was around what I called the witching hours, 1-2 am in the morning. I usually called for tools down at that time. Attidude of the individual and the company mentality are also to be considered. Then you must also address the issues around tooling, enviroment, staging, sequencing of work, etc.

So to make a long story short, human error is a valid response, it is how we correct the human error and approach the RCA of the human error that is of utmost importance. If you are familiar with the concept of flight safety windows, an open window is an opportunity for an error to occur or that an error has occured, as long as these windows are not aligned, or closed if you will becuase we corrected a problem, nothing occurs, but if we fail in our RCA then these windows start lining up and when enough of them line up we loose a plane or a pilot or both.

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Airdrie,

But, as you say, human error is usually caused by the system. This would make human error a symptom not a cause.

In a controlled work environment we must seek and eliminate or mitigate the causes from the system.

Blaming the humans in the system does not do that.

John

AirdrieQPA said:

I have grown up in an enviroment, the Canadian Airforce, where Human Performance in Maintenance (HPIM) is a huge consideration when finding out what went wrong. This is a growing field of study especially in the Aviation world. When doing an analysis into human error, one must remember we are not conducting Salem Witchhunts, we never name names, but if a human caused the problem then a human caused a problem. The only time I have found out that there is not an underlying system problems (Managerial issues, Policy, procedures, Work instruction errors, trainging etc) is when an individual wilfully commited a policy breech. ie: they did what they did on purpose (because it was a short cut to coffee break or hometime), and they got caught.

Otherwise you have to look at training, time on shift, shift durations, education, graveyards shifts produce tremendous opportunities for error, because while your awake, your biosystem is going to sleep regardless, (aka circadian rhythm). I found the absolute worse time to work my men in the airforce was around what I called the witching hours, 1-2 am in the morning. I usually called for tools down at that time. Attidude of the individual and the company mentality are also to be considered. Then you must also address the issues around tooling, enviroment, staging, sequencing of work, etc.

So to make a long story short, human error is a valid response, it is how we correct the human error and approach the RCA of the human error that is of utmost importance. If you are familiar with the concept of flight safety windows, an open window is an opportunity for an error to occur or that an error has occured, as long as these windows are not aligned, or closed if you will becuase we corrected a problem, nothing occurs, but if we fail in our RCA then these windows start lining up and when enough of them line up we loose a plane or a pilot or both.

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Sorry to disagree - Human error in the context of FMEA is NOT an acceptable definition of of error cause.; and I feel you have provided an inappropriate analogy.

Human Error can be categorized in several areas and in doing so we closer identify the potential cause and therefore are in a position to do something about it; should the occurrence history, and serious of the potential failure warrant it.

We are NOT saying humans do not cause problems; we are saying that humans cause problems for a variety of REASONS and it is those potential reasons that must be identified and addressed.

In regard to the Military - to say we MIGHT fail because of human error - is simply unacceptable - at least in the RAF we believed that was the case- and our record speaks for itself!

Richard Pike said:

Sorry to disagree - Human error in the context of FMEA is NOT an acceptable definition of of error cause.; and I feel you have provided an inappropriate analogy.

Human Error can be categorized in several areas and in doing so we closer identify the potential cause and therefore are in a position to do something about it; should the occurrence history, and serious of the potential failure warrant it.

We are NOT saying humans do not cause problems; we are saying that humans cause problems for a variety of REASONS and it is those potential reasons that must be identified and addressed.

In regard to the Military - to say we MIGHT fail because of human error - is simply unacceptable - at least in the RAF we believed that was the case- and our record speaks for itself!

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I am not going to argue but I believe you skimmed the portion on willful violation. If someone wilfully commits an error how does that point to the system as being at fault? If you willfully commited an error at work, with the intent of creating a fault or took a short cut which resulted in a defect, where in the system do you point at. I have spent 28 years in airforce, sometimes we need to stand up and say I made a mistake and stopping trying to blame the system. Canada and the CAF have tremendous flight safety records and our records do speak forthemselves. Finally I guess the point I failed to convey is that regardless as the source of error, we must learn from our mistakes and if one human can make a mistake, it will happen again uless we learn from it and adapt.

AirdrieQPA said:

I am not going to argue but I believe you skimmed the portion on willful violation. If someone wilfully commits an error how does that point to the system as being at fault? If you willfully commited an error at work, with the intent of creating a fault or took a short cut which resulted in a defect, where in the system do you point at. I have spent 28 years in airforce, sometimes we need to stand up and say I made a mistake and stopping trying to blame the system. Canada and the CAF have tremendous flight safety records and our records do speak forthemselves. Finally I guess the point I failed to convey is that regardless as the source of error, we must learn from our mistakes and if one human can make a mistake, it will happen again uless we learn from it and adapt.

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Both,

Sure, as responsible individuals we should quickly admit when we make a mistake.

As humans we need help from our system so it is simply not possible to make the most common and costly mistakes.

John

I think what AirdrieQPA is trying to say is, people make mistakes.

We must make every effort to analyze the 'system' to ascertain the root causes of problems. Most of the time it is process related. However, as no quality system is perfect, neither are humans. While some may not like it, to make a generalized statement that human error is NEVER the root cause is nothing less than naivete. Before anyone jumps on me, I never look to put blame on an individual, as most of the time the system should have done something to support them, most of the time. Throughout my relative young career I have had to deal with the 'old school' mentality in regards to what I call 'head hunting'. All that does is create an environment of fear, causing problems to go unnoticed due to fear of reproach. It's difficult to teach old dogs new tricks, and instill modern approaches to managers who have been conducting business in the same manner, with success, for years.

I would never put 'human error' on a report, it looks like a cop-out, and gives the appearance that a 1/2 A$$ investigation was conducted (not serious). When I receive CA with this as a root cause (internally), I always politely return the report and work with the responsible person to show them how to do a proper investigation, and why it's important. To this day, it's never been singularly human error, but it has been a major contributor.

If a disgruntled employee intentionally sabtoges something, lets say during an audit, then walks-out (I know it's far fetched) and what they did resulted in an finding, that would not have happened otherwise, it's human related. If that person was a high level employee that had access and authority, it's hard to prevent that situation. How could you prevent that? Not allow anyone access to anything?

We must admit, human error is a possible root cause, humans run the system, systems are not perfect (hence continuous improvement), nor are people (with the exception of Jesus). Just don't write that in your reports. A good system and management team will always look at the system exhaustively first, before it's people, in regards to blame

AirdrieQPA said:

I am not going to argue but ......


I guess the point I failed to convey is that regardless as the source of error, we must learn from our mistakes and if one human can make a mistake, it will happen again uless we learn from it and adapt.

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I think perhaps you are not familiar / experienced with FMEA.

FMEA is a prevention exercise - NOT a correction exercise.

You stated that you down tools at around 1-2 in morning - because of various reasons. Therefore you recognized the potential "human" problem - and prevented it! Had you not done so - then any potential consequences would have been your fault and NOT the fault of the Operator!

Deliberate sabotage (manufacture of defects) is not considered during FMEA as in the industrial context it is virtually non-existent.

Deliberately not following instructions - is an issue - and the cause/s can be; inadequate instructions - excess workload, etc, all of which are beyond the control of the Operator.

Nobody wants to - molly coddle - the Operators; but if they are prone to making mistakes - (and there are many "types" of mistakes) it is managements job to recognize this and make the system robust against such mistakes.

The point that is being made is that discipline whilst a factor in making the process robust, is not the only factor and the FMEA Team MUST recognize this.

To what extent does pride stop us from taking the procedures seriously?

John Broomfield said:

To what extent does pride stop us from taking the procedures seriously?

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To whom is this question directed?

Jim Wynne said:

To whom is this question directed?

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Jim,

It is directed to anyone who can answer it.

To what extent does pride stop employees from using their procedures?

John