3. A few thoughts about human error

It’s widely recognized today that most airplane accidents and most hospital deaths are due to human error. And in a purely technical sense, where the word “error” refers to deviation from the desired path, this is accurate. But the common use of the word “error” presumes that the person or people involved are fully trained and competent, and that they merely made a mistake. In many cases, these attributed “errors” may not be errors at all, in that sense.

For example, if I try to play a Paganini violin concerto and screw it up because I’ve never played the violin before, that’s not an error. Likewise, if someone is involved in an incident or accident because they either didn’t mitigate a hazard or perhaps even caused it, it might be because:

• they lacked the training or skill needed;
• they had an erroneous belief about the situation or an invalid assumption that defeated whatever layers of protection assumed a proper understanding of it;
• they couldn’t resolve or were misled by conflicting cues;
• their training and/or experience predisposed them to react in a way that wasn’t appropriate for that particular situation.

Each of these has caused serious incidents and accidents, but none of them can really be considered an “error” in the common sense. Instead, I propose using the term “adverse action”, which simply describes the fact that whatever the people involved did either didn’t help the situation or made it worse. It’s also less judgmental than saying that they screwed up.