Human Error

Errarehumanumest (To err is human)

In 1960, American psychologist George Armitage Miller defined errors as all deviations of the actual state of an object from the target state. Why did he say exactly that?

To dive into the topic, it is necessary to define the terminology.

An error is:

• In engineering: the deviation of a measured value from its true value.
• In law: a misconception by the person committing an act regarding the factual circumstances that determine the nature and degree of social danger of the act or its legal characteristics.
• In medicine: an unintentional misconception by a doctor (or any other medical professional) in the course of their professional activity.

All these definitions share a common feature: misconception/ignorance, a deviation from reality in the "expectation/reality" format. I suggest using the generalized term "error" in the following interpretation:

An unintentional deviation from correct actions, deeds, or thoughts; the difference between the expected or measured value and the real value ("Wikipedia")

People make mistakes — it is our nature. But for us, it is important that they make mistakes in the workplace, sometimes with extremely negative consequences.

How can we see an error? Until we learn to read minds, an error is a specific action, an element of human behavior in the workplace.

Kurt Lewin (a psychologist who studied social psychology and the theory of cultural development) derived a very clear formula in 1936: human behavior (B) is a function of their identity (P) and environment (E): B = ƒ(P,E)

By identity, we will mean personal aspects (beliefs, stereotypes, narratives, habits, experience), and by environment — the employee's workplace and how it affects them, including their identity.

This narrowing of the funnel of definitions is necessary for us to understand the nature of an error. A person does not err for no reason; it is a matter of the relationship between identity and environment. The behavior formula at the moment of an error can be interpreted in different directions and social narratives. For example, people make mistakes because:

• 95% of actions and thoughts are performed automatically — habit (Robert Cialdini) (link: https://ru.wikipedia.org/wiki/Психология_влияния);
• The environment can change identity beyond recognition in a short time (Philip Zimbardo) (link https://ru.wikipedia.org/wiki/Эффект_Люцифера);
• Cognitive bias: Survivorship Bias (link https://ru.wikipedia.org/wiki/Систематическая_ошибка_выжившего);
• Solomon Asch's experiment — how we yield to social pressure (link https://ru.wikipedia.org/wiki/Эксперимент_Аша);
• Cognitive biases and perception errors (https://ru.wikipedia.org/wiki/Список_когнитивных_искажений)
• Milgram experiment — obedience to authority (link https://ru.wikipedia.org/wiki/Эксперимент_Милгрэма)

Intermediate conclusion. Errors have always been and always will be; the environment or a person's identity leads to deviations from the target state, i.e., error-free behavior. Let's see if it's possible to influence this rather complex process, for example, through society's reaction to errors.

In this article, we will not touch upon issues of changing the environment, social and corporate culture (in a broad sense), motivation, upbringing, or physiological deviations in the human brain — otherwise, it would be a book, not an article.

How do we react to errors?

"Every accident has a name, a surname, and a job title." This quote belongs to L. M. Kaganovich, the People's Commissar for Railways of the USSR. This artifact of cultural heritage quite accurately reflects reactive approaches to human errors as such, not only in the event of an accident.

In many companies, a so-called "penitentiary system" is applied to workers in case of their error. These include fines, disciplinary sanctions, public censure, and other tools. But there is one nuance, namely:

The Themis Paradox — to what extent is the person guilty of what was done, and to what extent is the society that created them?

The reaction to errors is, in essence, feedback from the system to the person.

What if a person made a mistake due to inexperience, ignorance, or under pressure from a supervisor? On the other hand, what if it was not an error, but a conscious act by a person who understood the consequences? Often, when we don't have time to delve into such subtleties, an identical approach is applied. This creates a number of problems.

If a worker could not have acted otherwise, did not know exactly how to act, or if the punishment is disproportionate to the deed, they lose trust in the system as such because, from their point of view, it is unfair.

In many animals, including humans, the issue of personal justice is embedded at the genetic level. In such a position, a person cannot draw adequate conclusions from the situation because the logic and cause-and-effect relationship are unclear to them, and they make a clear summary for themselves: it's better just not to get caught and not to contact "them."

In addition to the aspect of justice, the very fact of applying "punishment":

• leads to fighting the consequence rather than eliminating the cause of the error;
• causes emotions such as resentment and aggression in the person;
• prompts the person to lie and manipulate instead of working on their mistakes;
• provokes an avoidance of responsibility on the part of the person: "Since the boss knows how I should act, what's the demand on me?";
• cultivates fear in the team, which is especially harmful from the perspective of a safety culture, where we want to reach a level of trust-based interaction with employees.

Often, no one delves into the person's explanatory notes because a culprit must be found. The descriptive part of the approaches used is mostly quite vague and convoluted; the worker rarely understands the principles of the measures applied and is therefore unable to assess their adequacy.

On the other hand, we have a person who knew exactly how to perform the work, was trained, certified, and experienced, and was not under pressure. It is already difficult to say that it was a misconception or an unintentional action, which means that with a high degree of probability, it is no longer an error. Perhaps it is a habit for which no one gave feedback, or luck that nothing happened to the person. In such a situation, the issue of accountability must be considered, especially if there were previous warnings.

What to do if "no one is to blame"?

Having considered the issue from different points of view, the system of "punishments" at enterprises can be improved:

• Clearly define the principles for applying punishments:

– If a person's action or inaction could have led to a fatal or severe accident, and the person had the skills and tools to perform this work safely and there was no coercion from the supervisor and they did not refuse to perform the work — this is a reprimand, according to the Labor Code of the Russian Federation;

– If the error or choice is related to a fatal risk in specific tasks where fatal accidents occur most often (Cardinal Rules), the result is one — dismissal, provided that the person knew about the consequences;

– Next, consider alternative branches and, depending on the situation, the approach and measures:

– Define a clear algorithm for finding the root causes of gross or systemic errors; look for the imperfection of the system rather than the culprit.

This system needs to be built in the form of a very simple and accessible algorithm, involve employees in its development, and conduct a competent information campaign so that employees accept and understand the system of measures applied.

• Define the principles of employee motivation:

• Get rid of punishment as the prevailing measure of feedback from the system. There are companies in the Russian Federation where punishments are practically not applied (except for Cardinal Rules) and there is a low injury rate. According to statistics, there is no clear correlation between the number of punishments and a decrease in injuries. In particular, it is necessary to determine the ratio of punished to motivated individuals required for the company.

In this article, the concept of error, the reasons for its occurrence, public perception and experiments, the system's reaction to errors, and suggestions for improvement were considered. The topic of error in the workplace itself is very global; we have only considered the part described above.