(104bi) Reducing the Systemic Risks of Human Error Through Root Cause Analysis

Disciplinary action -- like retribution and punishment -- is widely used to control human behavior and error.  While discipline may periodically alter behaviors and reduce risk in the short term, misapplication can lead to a long-term increase in systemic risk and play a role in creating a “punitive” work environment.  An effective Root Cause Analysis method identifies and addresses causes that effectively control systemic risk, and helps proactively identify the causes of successful actions.

Disciplinary action is used to punish those who make choices that are incongruent with acceptable norms and to warn others not to follow the same path.  Many leaders do not know what else to do.  Discipline is occasionally warranted – usually when people are aware of the risks to which they are subjecting themselves, their coworkers, or their company – and decide to proceed anyway.  However, discipline has limited success because most workplace errors are not intentional – they are caused by gaps in attention, knowledge, skills, or procedures.  When an investigation focuses on finding the person who committed the error, the solution will likely focus on disciplinary action.  This will have a negligible long-term impact on the error rate.  Instead, it will lead to increased risk that future errors will be committed.  It will also encourage people to cover up errors.

By providing people with a more robust way to identify causes of an event, solutions will more likely be identified that fix the problem permanently and reduce risk.  In addition, when discipline is taken off the table, the result is greater participation by those who have direct knowledge of the error, and movement away from a “punitive” culture.

Specific Learning Objectives:

• Understand what risk is, and how risk relates to the work environment
• Understand the role of human error in an undesirable event
• Understand the critical elements of an individual causal analysis, including identification of conditional causes
• Understand which causes provide the greatest opportunities to reduce risk
• Understand how to obtain buy-in for effective solutions