Understanding Human Error: A Framework for Problem Solving
The world is a dangerous place. At the root of most of these dangers is human error and yet we don’t trust machines to take on some of our most critical decisions. It’s a paradoxical world. Nuclear power plant operators, air traffic controllers, pilots, and surgeons are all critical pieces of our economy and will never be replaced by machines, yet, all of them can make mistakes at any moment. It’s a paradoxical world. The impact of human error is pervasive. Quality issues on a production line, medical mistakes, plane crashes, and even nuclear meltdowns all hinge on humans and whether or not they will make correct judgements at the correct time. The stakes are well-known but what's often overlooked is the root cause of many of these issues: why are we so fallible? Why do humans make mistakes? In this article, we'll delve into the world of human error, exploring its predictability, typical forms, and how the Skills, Rules, Knowledge (SRK) framework can help us better understand and mitigate it.
The Nature of Human Error
When things go wrong, it's easy to blame external factors or unforeseen circumstances. However, studies have shown that the majority of problems stem from human error. These errors can be broadly classified into two categories: slips/lapses and mistakes. Slips and lapses occur when someone intends to do one thing but ends up doing something else due to automaticity or distraction. The Freudian slip is a well-known example 😉. Mistakes, on the other hand, involve incorrect decisions or actions based on flawed reasoning or inadequate knowledge.
Predictability of Human Error
It’s quite amazing that anything gets done successfully. For even the simplest tasks there are myriad ways for failure to occur. Consider the simple task of frying an egg. You could drop the carton, crack the egg to hard, forget to turn on the stove, turn the stove on too high, undercook it overcook it etc. And yet most of those failures rarely occur. You might forget to turn on the stove, crack the egg too forcefully, or overcook it. Despite the multitude of potential failures, human error is predictable because they stem from common cognitive patterns and behaviors.
Attention: slips and lapses often occur because of lack of attention. Either the person performing the task is distracted and forgets to monitor the task, or the person misses a signal to stop the current activity and begin another one.
Frequency and similarity: unlike slips and lapses, mistakes happen because of a more robust cognitive mistake. Either a misapplication of a rule is incorrectly applied to a situation, or the person does not have prior knowledge on how to resolve the current problem and infers solutions based on past, similar experiences. Both of these methods can lead to correct and incorrect judgements.
Skills, Rules, Knowledge
The Skills, Rules, Knowledge (SRK) framework, originally developed by Jens Rasmussen in the 1970s and 1980s, provides a valuable lens through which to understand human error. It categorizes human activities into three levels:
Skills-based behavior: These are actions performed automatically and effortlessly, relying on well-established patterns or habits. Think of tying your shoes or riding a bike. Errors in skills-based behaviors are slips and lapses, as discussed above. This is the lowest cognitive level of behavior.
Rule-based behavior: In situations where skills alone are insufficient, individuals follow predefined rules or procedures to guide their actions. This could involve following a recipe or adhering to safety protocols. Errors in Rules-based behaviors are the mistakes stemming from the misapplication of a rule to a particular situation.
Knowledge-based behavior: When faced with novel or complex situations, people rely on their understanding of underlying principles and problem-solving abilities to navigate through uncertainty. This is the highest level of cognitive behavior.
The number of errors for each level increases as the person moves up the cognitive ladder. Therefore, it’s vitally important for problem solvers to understand how error occur at each level, and what can be done to support behaviors at the lower level of cognition.
Conclusions from the SRK Framework
Armed with an understanding of the SRK framework, and to optimize human performance various proactive steps can be taken to prevent and minimize the impact of human error:
Standardize: Standardization we create an environment that is familiar to people doing work and making decisions. As a result, they will gain dexterity and proficiency in their tasks encounter fewer novel circumstances where higher levels of cognition are required.
Training and re-training: Train new employees on the correct work methods for key tasks. Use Subject Matter Experts to support new hires to identify common issues and apply rules to achieve solutions. Continue to retrain all employees in a case-based fashion as part of corrective action plans in order to develop and establish more situation-based rules.
Enhance attention: Integrate the system and environment into the decision making process. Use lights, alarms, signs, and signals to support decision making and prevent human error.
Conclusion
Human error is a constant challenge that organizations strive to overcome. By adopting the SRK framework as a guide, problem solvers can gain deeper insights into the nature of these errors and take proactive measures to mitigate their impact. Whether it's standardizing business operations, training employees effectively, or supporting decision making through the environment, there are myriad ways to empower teams to achieve higher levels of performance with confidence and resilience. By embracing the complexities of human behavior, we can turn obstacles into opportunities for growth and innovation.
