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French Lesson in Human Error

Human Error (HE) has long been offered as an explanation for why accidents happen in complex systems. In fact, it is often suggested to be the leading cause of accidents in domains such as aviation and healthcare. As Jens Rasmussen has noted the human is in a very unfortunate position with respect to common explanations for system failures. This is because when you trace backwards in time along any trajectory of events leading to an accident, you will almost always find some act that someone did that contributed to the accident or an act that they failed to do that might have prevented the accident. This act or failure to act is typically labeled as a human error and it is typically credited to be the CAUSE of the accident.

Note that the behavior is only noticed for consideration in hindsight (if there is an accident), otherwise it is typically just unremarkable work behavior.

However, many people (e.g., Dekker, Hollnagel, Rasmussen, Woods) now understand that this explanation trivializes the complexities of work and that blaming humans rarely leads to safety improvements. In a previous blog I noted the parallels between stamping out forest fires and stamping out human error. Stamping out forest fires does not necessarily lead to healthy forests; and stamping out human error does not necessarily lead to safer systems. And in fact, such approaches may actually set the conditions for catastrophic accidents (due to fuel building up in forests, and due to failure to disclose near misses and to learn from experience in complex systems).

While I fully appreciate this intellectually, I had a recent experience on a trip to France that reminded me how powerful the illusion of Human Error can be.

Shortly after my arrival at Charles de Gaulle Airport, as I managed the trains into Paris, my wallet was stolen. It had all my cash and all my credit cards. I was penniless in a country where I didn't know the language. It was quite an experience. The important thing relative to this post was my powerful feeling that I was at fault. Why wasn't I more careful? Why didn't I move my wallet from my back pocket, where I normally carry it (and where it is most comfortable) to my front pockets (as I normally do when I am in dangerous areas)? Why did I have all my money and credit cards in the same place? What a fool I am? It's all my fault!

The illusion is powerful! I guess this reflects a need to believe that I am in control. I know intellectually that this is an illusion. I know that life is a delicate balancing act where a small perturbation can knock us off our feet. I know that when things work, it is not a simple function of my control actions, but the result of an extensive network of social and cultural supports. And I should know that when things don't work, it is typically the result of a cascade of small perturbations in this network of support (e.g., the loss of a nail).

The human error illusion is the flip side of the illusion that we are in control. It is an illusion that trivializes complexity - minimizing the risks of failure and exaggerating the power of control.

Fortunately, I got by with a lot of help from my friends, and my trip to France was not ruined by this event. It turned out to be a great trip and a valuable learning experience.

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