Aside

Root Cause

Human error is never a root cause, but systems can always be improved upon and made to be more resilient.

When analysing an incident or problem, it can be tempting to use human error as a root cause. If we dig in deeper, though, what appears to be human error is caused by an underlying failure of process or environment. How can that be? Here are some possibilities:

– A fragile, poorly instrumented, or overly complex system can cause humans to make mistakes

– A process that doesn’t take into account human needs, such as sleep, context or skill can also cause humans to make mistakes

– A process of hiring and training operators may be broken, allowing the wrong operators into the environment.

Furthermore, “root cause” itself is a problematic statement, as there is rarely a single issue that leads to errors and incidents. Complex systems lead to complex failures, and adding humans into the mix complicates things further. Instead of thinking in terms of root cause, I suggest you consider a list of contributing factors, prioritised by risk and impact.

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