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Human Factors

Designing systems instead of assigning blame

February 28, 2018

In the immediate aftermath of any newsworthy accident, we often hear the words "human error" or "user error".

Consider the recent missile alarm scare in Hawaii. The idea that a human was responsible for an accident has inherent appeal. However, this person-focused approach of error causation is at odds with a systems-based approach. In a systems-based approach, several factors give rise to a situation that leads to an accident in which the human is just one part, usually at the end of the situation.

The appeal of the person-based approach lies in its simplicity. A sentiment like "someone was not doing their job" is beautifully simple to visualize and has the crime and punishment encoded into it. Most times, this sentiment is also wrong.

A systems-based approach not only considers the task that a user has to perform but also the user’s capabilities, environment, the tools available, and the organizational policies that can affect task performance. It tries to analyze not only the how but also the why behind an error and to address the underlying issues.

James Reason, psychologist and a safety expert, wrote informatively and exhaustively on the person vs system approach to error attribution in his 1990 paper titled Human Error: Models and Management. One line in that paper has stuck with me: “...we cannot change the human condition, but we can change the conditions under which humans work.”

This statement is not an indictment of human beings, but more of a recognition that errors are to be expected in the best of systems with the most well-intentioned individuals. Being cognizant of such a possibility helps in developing safeguards that can avoid error-generating situations in the first place.

... we cannot change the human condition, but we can change the conditions under which humans work.

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