This is a keynote address from Velocity Europe 2014 in Barcelona on 17 November. I wanted to give a fairly light presentation (it was first slot in the morning!) to summarise some key issues in moving on from a focus on human error when explaining failure – and normal work – in complex systems. Here’s a summary:
When things go wrong in organizations, one thing is almost always found in the post-mortem: ‘human error’. No situation is too complex to be reduced to this simple, pernicious notion. ‘Human error’ has become a shapeshifting persona that can morph into an explanation of almost any unwanted event. With its various guises – ‘misjudgment’, ‘lapse of concentration’, ‘carelessness’ – it seeps into headlines and news reports. Twitter outage or train crash, the human is the culprit, error the cause.
But one only needs to look a little more deeply at the nature of system failures to see that things are not so straightforward. What seems to make sense as a causal catch-all for our everyday slips and blunders in life snaps when stretched; it fails to capture the context and complexity of our work and systems, and fails to help improve how things work. If the ‘human error’ explanation does not serve safety and business continuity, what does it serve? Perhaps it serves society’s need for simple explanations and someone to blame, while absolving it for its demands.
There is a better way, but it means that we have to refuse to oversimplify. Life after ‘human error’ means taking a road to recovery that takes a more nuanced and considered view of the person, system conditions, system behaviour and system outcomes. The good news is that the road is paved with concepts that help explain success as well as failure. A blend of humanistic thinking and systems thinking can improve both performance and wellbeing. This keynote will take a journey through the steps of recovery, from explaining away events to understanding how your system really works.
Thanks to the Velocity crew (especially @allspaw and @audraORM)! I was so impressed with the WebOps community. They are a progressive crowd, and are doing it for themselves – but that’s another post.
Watch more from Velocity Europe 2014: http://goo.gl/Hl7fvj
Visit the Velocity website to learn more: http://velocityconf.com/velocityeu2014/
On ‘human error’…
- Human error’: The handicap of human factors, safety and justice
- The HAL 9000 explanation: “It can only be attributable to human error”
- Maslow’s hammer: How tools bias attention and straightjacket thinking
- Occupational Overuse Syndrome – Human Error Variant (OOS-HEV)