Human Error Part 2: Management Error

You arrive at home after a long day and you rush to prepare food. You turn-on the burner but oups !, you realize that you activated the wrong burner. You feel frustrated and tell yourself “I should have paid more attention”. If it is a new stove, you might tell to yourself “I should have look at the instructions”. Some might even blame themselves for this error.

Sounds familiar, you’re not alone. Almost all users of the classical stove design, as showed in figure 1, activate the wrong burner at one time or another.


Why? It is in the human nature to associate objects that are side by side. As showed in the figure 1, the controls of the back burners are closer to the front burners. We cannot tell witch control activates what. This layout is highly error prone. To ensure we activate the right burners, we need to pay attention and look at the instructions. See also Don Norman’s Design of Everyday Things.


Figure 1. Classicl Stove Layout
Fig.1 Classical Stove Design

Figure 2. New Stove Layout
Fig 2. New Stove Layout


With the layout presented in figure 2, there is no confusion. Association of control with the burner is now easy because the layout of control is compatible with the layout of the burner.

This example demonstrates design can play an important role in preventing human errors. A design that respects human’s nature and limitations will reduce the likelihood of errors.



Human error in managing human error

After having done hundreds of interviews with managers, we observed when discussing employee’s errors, most managers:

  1. Blame employees for lack of attention or for lack of training (practice).
  2. Overlook the possibility of preventing errors by a redesign of workstation or processes.

In our highly advanced technological society, we are still at the Stone Ages in term of human errors management

The stove example is the tip of the iceberg. Human errors are everywhere; from day to day errors such as trying to pull a door that should have been pushed to high impact errors such as: being attentive on the wrong signals and crashing a plane killing hundreds of people, having the wrong information and making bad investments, forecasting the wrong economics figures, misjudging intelligence report and brining a nation to war, making the wrong medical diagnosis, underestimating a budget for a project and being insouciant of consequences of our action on the environment.

Most of those errors, boils down to a combination of human errors that are at the cognitive level. They are errors of detection, attention, planning, estimation calculation, judgment, decision, comprehension, discrimination and execution.

Although aircrafts are still crashing, the safety record of the aviation industry is impressive when compared to other industries. At the end of World’s War 2, the aviation industry realized, following the pioneer work of Alphonse Chapanis and Paul M. Fitts, that human errors were caused by subtle inherent human cognitive limitations. The Aviation industry stopped blaming pilots or maintenance personnel for human errors decades ago. They tried to understand the inner cause of human errors.

This demonstrates it is possible to move away from the stone ages in a few decades. Managers need to stop limiting explanation of human errors to the lack of attention, lack of training or poor personnel selection and expand their analysis of to the real nature of human errors.



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