Human Error is NEVER the Root Cause

Recently, while teaching Safety Basics, an attendee asked the facility’s health and safety engineer, “John, honestly, don’t you think safety accidents are 99.9 percent caused by careless behaviors? We can’t control carelessness!” John then asked the class how many folks agreed with this person and everyone in the room raised their hands.

Although John was the only person in the room who disagreed with this sentiment, he fully understood why this attitude is so prevalent. How many times have we heard press reports and the official political explanations or statements associated with accidents—you’ll find “human error” to be the root cause.

Mistakes Happen
We humans are fallible. Mistakes happen. So when we hear that a forklift collided with a wall or racking and that human error was the root cause, we humans generally feel like the investigation is complete. “Oh, there it is again, that dreaded human error. Great investigation. Time to move on.”

Overlooking Real Causes
To this explanation, we’ll take issue—the same issue we would have with an arson investigation concluding “flame” to be the root cause of a house fire. At best, it is an unhelpful explanation; at worst, it is an attempt to overlook the real causes.

Human Error
With little doubt, we would all quickly reject flame as the root cause of a house fire. We would want to know what caused the flame. The same should go for human error. It should be a basic requirement of safety event investigations that any human error requires the search for preceding causes.

Commit to Investigation
It’s OK to use the term, mistake, error, slip, or lapse. They are not words of blame-—they are only words to describe one immutable aspect of the human condition—to err is human. Yet, when we use them, we need to commit to further investigation to explain the errors we see. Human error cannot be the end of the search for causes, and it’s up to us to hold investigations accountable for their choice to stop the investigation short at “human error.”

If we, as investigators, are willing to point the finger at a human being for making a mistake, we should be willing to go the next step to understand why the error occurred. Risky behavioral choices are precursors to an event, but what about the system designed for that employee that allowed the sequence of at-risk choices?

Eliminate Risk
There’s always more to the story than mere human error. Don't let someone’s proclamation of human error as the root cause fool you into missing the underlying causes that need to be addressed. Don’t let human error be the root cause. If we do, we are missing an opportunity to truly eliminate and prevent an unsafe risk. After all, if it’s just “human error,” we only need to tell one “not to do that again,” and we all know how well that works. 

 

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