Procedural Error Vs Human Error
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Sources Of Experimental Error
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from expected behavior. Under normal conditions, we can make between three to seven errors per hour. Under stressful, emergency, or unusual conditions, we can make an average of 11 errors per hour. But http://procedurenotfollowed.com/root-cause-human-error.html why do we make errors? Is it the individual’s fault? A recent presentation by the Idaho National Laboratory showed following: Latent organizational weaknesses include work processes, and, as the above shows, such work processes usually are behind human error. Why did the error occur? The procedure wasn’t followed. Why? Human error. Why was there human error? The work process needs improvement. Sometimes, human error proves just how good some workers experimental error are. At the beginning of a root cause analysis, it’s not uncommon to hear someone say: “Bob has been calibrating these instruments for 20 years and he just screwed up.” Though it may seem like finger-pointing, it’s actually the ultimate compliment, and the incident investigation facilitator should recognize it. Think about the math. Bob has performed this task twice a week, 100 times a year for 20 years. That’s 2,000 calibrations—and of experimental error this is his first significant error? Error rates of just 1/1000 are considered exceptional, and Bob beat this by a long shot. Does this warrant a root cause analysis at all? It may, because incidents rarely if ever have just one cause. Are we absolutely sure that Bob’s mistake was the only reason the incident occurred? Dig deeper and you likely will find there’s more to the problem than Bob’s once-in-an-eon snafu. Beyond Blame If we stop at “Procedure Not Followed,” the usual response is to blame a person. Blame is easy and does not focus on the process. Let’s face it—“Procedure Not Followed” is a simple (albeit oversimplified) explanation of confusing and complex problems. It also requires little or no work from anyone in an organization except the person who made the mistake. How does this make the person feel? Not listened to, unappreciated and, eventually, apathetic, which isn’t good for anybody. The key to getting beyond the procedure-not-followed conundrum in a root cause analysis is obtaining detail, and it’s here where the Cause Mapping facilitator plays a key role. During the brief kickoff meeting that can start an incident investigation, the facilitator asks the group about its objective along with general questions about the incident. Expect different pers