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Business Process Improvement

The question of human error

There is a tendency when for searching for the root cause of a problem to stop at human error and congratulate ourselves that we have found the culprit who is clearly the root cause of our problem and proceed to discipline or retrain some unfortunate individual in the hope that this will stop it happening again.

This approach may or may not mean that this individual never makes this error again but it will not prevent someone else from making the same mistake. Statistics tell us that the majority of our problems contain an element of human error so it is important that we give serious thought to this issue. To start with when we do indeed find an instance of human error the first question to address is ‘Why and how did our system allow human error to occur in our process at that stage, on that occasion, at that time and with that operator?’

Once we have the answer to this question we can make changes to our system or process to prevent a recurrence of the error. Over the years I have listed all causal factors of human error I have encountered which you will find below and ideas to prevent human error which you will find here. There is some duplication under different headings.


• Poor task design or change to task requirements not handled correctly

• No management system/procedures or instructions, task not organised properly

• Complexity of work instruction or process, either too complex or too simple

• Inaccurate assignment of task (i.e. to wrong individual)

• Not following task instructions or procedure

• Unclear delegation of authority (too much, too little or simply unclear)

• Shift working or night working; isolation

• Repetitive and boring tasks

• Misunderstanding the risks associated with the task


• Unclear or incorrect instructions or requirements

• Inadequate standards or specifications

• Inadequate horizontal communication between peers

• Inadequate vertical communication between supervisor and person

• Inadequate communication between work groups

• Inadequate communication between shifts or at holiday handover

• Inadequate communication at handover of tasks/assignments

• Inadequate communication methods

• Inadequate communication due to job turnover or language barriers


• Lack of appropriate resources leading to making do with alternative material, equipment, plant, facilities, etc.

• Equipment too little, too old, unserviceable, etc

Work environment and organisational culture

• Too hot/too cold, poor ventilation, lack of light (S.A.D)

• Too noisy (mobile phones, loud radios, music, etc)

• Cultural norms drive errors, or resistance to change (always done it this way)

• To much distraction or poor housekeeping

• A culture of fear (junior staff feeling they cannot ask, comment, criticize, simply obeying orders)

• Religious influences

• Uncertainty of continuing employment


• Bullying or victimisation by team, conflict within team, personality clash

• Horseplay, too much distraction

• Excessive dislike or like for colleagues (workplace romance/affairs)

Work planning

• Insufficient time to complete task; too much haste; too much time to complete task; complex workload

• Inadequate planning of work, inadequate time management, too much work


• Lack of understanding importance of own role and where it fits into the bigger picture

• Poor supervision and motivation; ineffective or no performance review

• Inappropriate or inadequate reward/remuneration

• Improper performance is rewarded as it saves time or effort, avoids discomfort or gains attention

• Improper supervisory example

• Inadequate identification of critical behaviours to achieve desired result

• Inadequate reinforcement of critical behaviours to achieve desired result, e.g.

- proper performance is criticized, poor performance criticised excessively

- inappropriate peer pressure

- inadequate performance feedback

- inadequate disciplinary process

• Inappropriate aggression, victimisation, pressure or discrimination

• Management focus on cost/delivery rather than quality of product / service

• Improper use of production incentives; unrealistic targets

• Supervisor implied haste to complete task, e.g. as a result of late programme

• Employee perceived haste to complete task or management pressure to complete early

Person selection

• Wrong competency set of individual

• Wrong experience of individual

• Wrong attributes of individual

Personal mental and emotional condition

• Distraction/wrong focus/preoccupation/non-work concerns (money/family)

• Inadequate attention span or memory failure (senior moments)

• Low learning aptitude

• Boredom/repetition

• Inappropriate attitude, pride, not prepared to ask, couldn’t care, lack of conviction, lack of belief in self

• Emotional condition, anger, resentment, loss of emotional energy through arguments with colleagues/family

• Stress, e.g. inappropriate personal targets

• Poor judgment; ‘I know better’ attitude

• Lack of confidence or alternatively over-confident, complacency

• Poor coordination or reaction time

• Emotional disturbance, fears or phobias, feeling of not being wanted

• Influence by medication

• Family problems; bereavement; money problems; too active social life

Personal physical condition

• Unfit, tired, hungry, fatigued or physical discomfort, etc

• Vision, hearing or other sensory deficiency

• Other permanent physical disabilities

• Temporary disabilities

• Substance sensitivities or allergies

• Inappropriate  size or strength

• Diminished capacity due to medication

• Excessive commute to work either in length or stressfulness


• Inappropriate training of individual

• Inadequate knowledge transfer

- inability to comprehend

- inadequate instructor qualifications

- inadequate training equipment

- misunderstood instructions

• Inadequate recall of training material

- training not reinforced on the job

- inadequate refresher training frequency

• Inadequate training effort

- inadequate training program design

- inadequate training goals / objectives

- inadequate new employee orientation

- inadequate initial training

- inadequate means to determine if qualified for the job

• No training provided

- need for training not identified

- training records incorrect or out of date

- new work methods introduced without training

- decision made not to train

Not classified as human error

• Violation, sabotage and deliberate non-compliance with procedure