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People or process: Where lies the error?

Error in the simplest of terms is a difference between the expected output and the actual output received. Our civilisation is designed and built around errors. For example, humans have designed traffic lights to prevent judgement errors, seatbelts in automobiles to prevent unexpected errors, safety harnesses on construction sites, and many more. However, these concepts that prevent error rely on the cognitive ability of humans to follow structures and routines to perform any given task. I refer to such structures and routines as a process. But where does the error originate? The people or the process? Let’s find out.

The lecture by Stephen Wright on "Human Factors: Why we screw up - learning from aviation and experience" and the supporting videos on human error by Professor James Reason provided a very good understanding of human errors and the lessons learned from accidents in the aviation industry. One of the key points mentioned was that people who are very familiar or rather experts with routines are more likely to be the cause of errors. I will elaborate a bit more in the following parts.

“To err is human, to forgive is divine” is a popular English quote, the first part of which implies that humans will inherently make mistakes. The second part of the quote implies that humans seek value from their time and energy and thus, forgiving errors (humans that cause the error) that affect them is a rare virtue. However, errors are not necessarily bad. Case in point are many ground-breaking discoveries over the years such as X-Rays, Penicillin, and quite recently, the effective dose of the Covid-19 vaccine by AstraZeneca.

So then, the question arises, how much error is tolerable and can be forgiven? This is the point where the process comes into the picture. Processes such as codified structures and routines are created to mitigate the most prominent causes of error. But as mentioned earlier, these processes rely on human cognitive ability to follow the routine. As Mr. Wright and Mr. Reason explain, eventually people become so proficient in the process such that it become an integral part of the person wherein the performance always matches the standards set by the process.

In doing so, a new notion comes into place wherein, to not err is human. What I mean here is that supervisors of the process may simply “trust” this highly proficient person to do the right thing. However, as the process itself relies on human cognitive ability, even a single day where the highly proficient person experiences mental distress or impaired cognition arising from daily activities, may lead to an error. Such an error which goes unchecked due to “trust” can trigger a chain of other related errors, thereby leading to disastrous consequences. Such chains of errors were explained by Mr. Wright, giving examples of air crash investigations.

Now, consider the “to forgive is divine” quote. In many scenarios such as manufacturing, driving, flying, etc., errors can be expensive. In these cases, it is possible that the person committing the error is held liable. This may prevent the people from highlighting their own error, even if they notice it in time, hoping that the error and thereby liability, will be lost in the subsequent chain of events. However, as mentioned earlier, errors trigger a chain of other events and thus, it is very important to identify an error in time and rectify the same. These concepts are better understood by exploring the error theories such as the SHEL theory, Error Chain theory, and Swiss Cheese Model, which were introduced by Mr. Wright in his lecture.

Thus, it is extremely important to tolerate errors, but only to a reasonable extent wherein the error is occurring due to exigent circumstances and not due to a lack of competencies or skills. For example, I was reading experiences of people from the Toyota Production System (TPS) wherein a new employee committed a mistake and knew it, but he did not alert the supervisors. Another worker noticed the mistake and immediately pulled a cord (Andon) to stop a production line.

The fault was traced back to its origin and instead of reprimanding the new employee for the fault, the supervisor expressed disappointment because the Andon cord was not pulled in time. A few weeks later, the same employee committed a fault again but this time he pulled the cord. Later, the supervisors and the other employees applauded the new employee for pulling the cord. The whole point of the Andon system is to trace the root cause of the error using the 5 Whys principle which tries to reach the root cause of the error. The root cause of the error is rarely assigned to a person but rather to the process or circumstances surrounding the process.

My research focuses on business cases for automated and digitalised heavy duty machinery. The insights from this lecture are important for me because errors cost money and without money, the business cases are limited. While analysing the different technologies and processes, I hope to utilise the insights from this lecture to visualise the future and account for sources of errors, thereby ensuring that my research results are strong, robust, and free of error while we are still on the topic.

Coming to the original question then, where lies the error? The answer according to me is always going to be the people. The process exists because of the people. The process makes assumptions to accommodate the unknown. To quote the movie Shooter, “The moment you think you got it figured, you’re wrong!”. However, people are smart and resilient. People learn from past errors and respond quickly too. However, to learn from errors, to err is human but to forgive should be human too.

Note: All images are sourced from Pixabay

- Tyrone Machado, Doctoral Researcher, MORE-ITN

The project MORE-ITN has received funding from the European Union’s Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No. 858101.

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