The four key barriers to learning from error

Hi ,

Today I want to explain why so many organisations fail to learn from errors that occur in their workplace. It’s a BIG subject so I’m just going to highlight a few key nuggets.

Essentially, it goes like this: We’re often set up wrong to properly evaluate errors. We don’t have the right response to error because we all carry (wittingly or unwittingly) a few personal biases that seem to naturally work against us.

Here are the four biggest biases that can get in the way of learning about error and how to resolve it:

1. Outcome bias:

We assume that when things have a good outcome then everything is normal and uninteresting, after all… it is all working as intended.

However, when we experience a bad outcome, we tend to assume that something bad and abnormal must have happened to cause it; i.e., what happened here is very different to all the other times that it has gone right.

Outcome bias can inhibit learning because we treat the process with the poor outcome as an outlier, and the people involved as bad apples, when instead there could be systemic issues and vulnerabilities that persist day-to-day.

This is a biggy. When something goes wrong we have the benefit of knowing the outcome. From our privileged vantage point we can look back on the accident and all the events leading up to it, and it all looks so simple.

It’s obvious then to see that Person A should have not done Action X, which was compounded by Person B not checking Action Y. However, at the time it was not so obvious. People do not come to work to make errors. At the time, what they did made sense to them.

That’s why it’s crucial to understand a person’s perspective at the time they were involved in an accident, to better assess the factors leading to the accident.

The big ‘who dunnit?’ It almost seems like human nature to want to know who was involved in the error or accident when we hear about it. We have a bias towards attributing what went wrong to someone: Someone wasn’t paying attention, or following procedures, or made a decision they shouldn’t have done.

Organisations might point the finger at someone, blame them and retrain them as a minimum. But this kind of response can drive an open learning culture underground.

This limits the scope of investigation and scope of learning.

We want to instead focus on HOW and not WHO. HOW could such an error happen given the wider system factors that were at play? What role did things like the design of the interface, the demands of their work, poor procedures, lack of support and training have to play?

This is where we already think we know what happened and implicitly seek out and emphasise that account... and de-emphasise things that go against that account. This can narrow the scope of learning and response further as we “confirm” what we already know and don’t find what we weren’t looking for.

These biases need awareness. They need to be challenged. Because we have a natural tendency towards them, we need to constantly try to think beyond them.

It’s not our fault we seem to be set up this way. Blaming ourselves and others seems to be a natural way of going about things.

However, it doesn’t have to be this way.

There is another approach, a different way to tackling human performance issues, which can lead to better learning and a more effective organisational response to things that have gone wrong and could go wrong.

But that is it till the next email ☺

Dominic

Dominic Furniss
Senior Human Factors Consultant
Human Reliability Associates