2018 HPRCT Conference

Because people have different models of how to explain a problem there are many different approaches to what’s called root cause analysis.  How an organization digs into a problem affects their set of available solutions from which to pick.  If a problem explanation is inaccurate or incomplete, the solutions can be off, perhaps just slightly.  The organization may be unaware that better solutions are even available.  You can’t miss what you’ve never had.

It’s common for investigations to terminate with human error or procedure not followed.  Everything in the job was going fine until a person did (or did not do) something.  The bottom line is, the person made an error.  That error and that person becomes the focus.  How do we do fix him or her?  This is the mental model of many organizations.  It’s true, the person made a mistake.  It’s just not the whole truth.  The error only a symptom.  Details need to be dissected.

The terms procedure not followed, human error and training less than adequate are related to people performing tasks.  All three falls under the human performance umbrella.  They’re also signals, not conclusions.  Companies spend time learning performance tools, studying human factors, reading books on human error and listening to experts.  Yet people are still leaving valves open, closing the wrong switch, and selecting the wrong item.  Companies know they’re supposed to work on the process, not the people.  But even when the process is improved people are still making errors.

There are completely different levels of human performance across industries and jobs.  Yet, organizations still search for that elusive human performance fix to make error rates lower.  People’s mental models for explaining a problem may be restricting their ability to see the other solutions.  Fundamentals lessons and basic concepts can sometimes get nudged aside in an organization by things that are newer and shinier.  This paper will review some common misconceptions about both root cause analysis and human performance and provide some simple examples of what high reliability systems look like.