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I realized that the How Bad Things Happen diagram is a two-dimensional plot (four quadrants) with the spectrum of error-to-violation on the y-axis (top, down) and the systems-to-individual on the x-axis (left, right). It wasn't obvious when explaining this to others in the organization but now it makes sense with the overlapping 90% of systems-driven errors and violations, with the remaining 10% individual-driven on the 10% of violations goes to ~1% individual-driven violations. I would be interested in the source / data set that the chart was constructed from.

Elliot - I have sent a message to your email with some sourcing. When we do the leader-centric session here in FIT Online we will focus on this. Appreciate the input! Rob

When you wake up in the middle of the night reciting performance modes, you might be an HP Advocate! :) I shared this with our procedure excellence team and thought I would post here to provide additional perspective and how the design of everyday things can influence behavior.

I'm guessing that most of us have forgotten our mobile phone somewhere, at some point in our daily routines either inside the home (low consequence event) or outside in the public (high consequence event). Occasionally, I will leave my phone in the closet before going to bed. Lately, I noticed a subtle design constraint that enables me to RECOGNIZE the error sooner rather than later…you may be thinking a CHECKLIST on the door or a Pre-Sleep Safety Review (the other PSSR). Those would certainly be effective and we do have checklists scattered in other areas of the home but this design aid is more inherent…it is the charging cable on the nightstand which triggers a thought to remember that I need to plug in the phone. If a charging cable was not positioned next to the bed, I would most likely forget altogether and go to sleep, or remember several minutes later…the dreaded crawl out of bed and march to the closet! This design “feature" provides a RECOVERY mechanism earlier in the process from the memory lapse error.

RECOGNIZING hazards and more importantly the error precursors leading to hazardous events, RECALLING information from short-term and long-term memory, RECOVERING from slips or lapses before adverse events occur, and RESPONDING to people in an empathetic manner are all important attributes of a RESILIENT organization.

If forgetting to perform a field action (e.g., close a drain valve) is the (more critical) workplace equivalent of forgetting a mobile phone, then what is the "charging cable" that tethers the memory lapse to a recovery mode? A key element of Error-Proofing is understanding the RECOVERABILITY of a task if the action is executed incorrectly (deviation from step). The concept of a Forcing Function (UX, Design Thinking) or Systems Constraint are effective tools to increase human reliability for a given task, beyond typical administrative or individual controls. Recall that CRITICAL STEPS are those actions (or steps) that are UNRECOVERABLE and if performed incorrectly will cause significant harm to people, environment, equipment, or quality.

The UK HSE has a guide (https://www.hse.gov.uk/humanfactors/topics/types.pdf) for identifying Human Failure Types, Typical Control Measures, and examples to develop sustainable corrective actions. Before developing corrective actions or solutions, one must better understand the general error types and the precursors (WITH model) that drive them; the first two listed here from the guide are Skill-based Errors:

LAPSE (Error of Omission): Short-term memory lapse; omit to perform a required action (e.g., forget phone).
SLIP (Error of Commission): A simple, frequently-performed physical action goes wrong (e.g., return the coffee pot to the refrigerator instead of to the coffee machine).
Rule-based Mistake: If behavior is based on remembered rules and procedures, mistake occurs due to mis-application of a good rule or application of a bad rule (e.g., parking on the wrong side of the driveway for convenience).
Knowledge-based Mistake: Individual has no rules or routines available to handle an unusual situation; resorts to first principles and experience to solve problem (e.g., troubleshooting and repairing a broken appliance without instructions).

Sigmund Freud and Memory Slips - adapted from The Design of Everyday Things by Don Norman

"A colleague reported that he went to his car to drive to work. As he drove away, he realized he had forgotten his briefcase, so he turned around and went back. He stopped the car, turned off the engine, and unbuckled his wristwatch. Yes, his WRISTWATCH, instead of his seatbelt."

This story, from The Design of Everyday Things by Don Norman, illustrates both a MEMORY-LAPSE slip and an ACTION slip. The forgetting of the briefcase is the MEMORY-LAPSE slip. The unbuckling of the wristwatch is an ACTION slip.

There are different varieties and classifications of slips or mistakes…most everyday errors are slips. Intending to do one action, you find yourself doing another. The study of slips is the study of the psychology of everyday errors - what Freud called "the psychopathology of everyday life". Freud believed that slips have hidden, dark meanings, but most are accounted for by rather simple mental mechanisms.

An interesting property of slips is that, paradoxically, they tend to occur more frequently to SKILLED people than to NOVICES. Why? Because slips often result from a lack of attention to the task. Skilled people — experts — tend to perform tasks automatically, under subconscious control. Novices have to pay considerable conscious attention, resulting in a relatively low occurrence of slips.

CAPTURE SLIPS - a situation where, instead of the desired activity, a more frequently or recently performed one gets done instead: it captures the activity. Capture errors require that part of the action sequences involved in the two activities be identical, with one sequence being far more familiar than the other. After doing the identical part, the more frequent or more recent activity continues, and the intended one does not get done. Capture errors are partial memory-lapse errors.

Coincidentally today, I committed a CAPTURE SLIP error reading an Excel spreadsheet (something I do often). After reviewing about 60 rows of cells with numbers referring to causal factor 'nodes' (e.g., nodes 85, 97, and 225) on our Root Cause Map, the very last line instead of referring to a node, it referred to a 'line' in the spreadsheet (e.g., lines 31, 32, and 33). My mind interpreted the last 3 numbers as nodes when it should have recognized the reference to lines…a clear memory-lapse.

KEY LEARNING: Designers and writers need to avoid PROCEDURES (instructions) that have identical opening steps but then DIVERGE. The more experienced the workers, the more likely they are to fall prey to capture. Whenever possible, sequences should be designed to differ from the very start.

Thanks for the discussion on Critical Steps and Recoverability on the HOP In podcast! Another way I have been explaining the difference between Recoverability and Reversibility is that in football you RECOVER a fumble (an action DURING the play) but you REVERSE a call (an outcome AFTER the play)…a subtle difference in language but another way to make the concept of Critical Steps more "sticky" with people. The recoverability of the task is in process, whereas the reversibility is more related to the consequence / severity of the outcome. The idea that critical steps have ZERO recovery time is important and leads the user to think about how tightly coupled the system is to deviation.

Good stuff Elliot - I love the extended discussions. We don't use a lot of the "slip & lapse" because it is not as transferrable to the fried thru practical application. You may have noticed it is a bit subversively used as opposed to outright talking about it. Much of the previous writings are predictive in nature and explain well the philosophical elements. Where it gets fun is transferring that to what this person on this task at this time needs to know and do to recognize the real risk and to reduce their probablity. Keep them coming - Rob

Awesome thanks