At the operational level, most organizations can be boiled down to three key elements. The organization produces an output (a product or service). The organization has systems and processes with which to create the output, and employs and manages people who utilize the systems to produce the output, some of which may be defective or unacceptable. These could involve errors, mistakes, inefficiencies, or defects, which may cause injuries or losses. The operational system resides in a larger system called the organization. It, too, has systems and people. 

To differentiate between the two, the people at the operational level are the producers, and the people and the organizational level are the managers. The systems at the operation level may be the plant and equipment as well as practices, processes and procedures focused on producing the product or rendering the service. At the organizational level, the systems are policies and procedures designed to run the business efficiently and manage the employees so that they are productive, effective and operate safely and injury free.          

Performance management

Traditionally, performance has been managed by setting goals for employees to achieve or accomplish. Sometimes when goals are not achieved, mistakes made or accidents supervision occur the cause is attributed to a deficiency such as inattentiveness, poor judgment, lack of focus, capability, or negligence on the worker’s part. In the operational model described above there are two sources of failure risk: people and/or systems. Since producers’ work utilizing the system, it influences them and may cause them to take actions, or make choices that may results in errors, discrepancies, accidents or injuries and so lead to errors, failures or losses. 

This prevents looking into the systems, process, procedures, and practices of the organization for the causation of the negative outcome. Human error is simply a difference between an actual state and a desired state. All human errors do not result in catastrophic outcomes (serious injuries or deaths); in many cases, the negative results may be tolerable, inconsequential, or may even turn out to have inadvertent beneficial results. To understand failure, we must also understand our reaction and response to failure. People do not operate in a vacuum, where they can decide and act all-powerfully. To err or not to err is not a choice. Instead, people's work is subject to multiple factors or constraints.

The human error factor

Human error impact on organizations can be far-reaching in terms of productivity, customer service, quality, teamwork, execution, injury, profitability, and/or loss. There is little in terms of national statistics for most of these categories except for accidents. In many of the most serious accidents in the last 50 years, almost all initial findings attributed the failures primarily to human error. As examples:

  • 1978, West Virginia, power plant cooling tower construction collapse killed 51 workers.
  • 1984, Bhopal, India, Union Carbide plant explosion released cyanide gas, 20,000 people killed
  • 1988, Piper Alpha oil platform explosion killed 167 and resulted in a major oil spill.
  • 1989 Phillips explosion in Pasadena, Texas, killed 23.
  • 1989, Exxon Valdez oil spill in Alaska was a major environmental disaster.
  • 1991, Hamlet Chicken processing plant fire in North Carolina killed 25 workers.
  • 2005, Texas City BP refinery explosion killed 15 workers.
  • 2006, Sugar refinery explosion in Georgia killed 42 workers. 
  • 2010, BP Deepwater Horizon environmental disastrous oil spill in the Gulf of Mexico killed 11

The operational system resides within the organization which also has people (managers) who devise all the systems. Being human, they are prone to make mistakes creating latent risks in the systems. These involve the organization's hiring, training, and promoting practices, task design and assignment practices, communication and supervisory practices, performance requirements, work climate and conditions.

The producers at the operational level have to utilize the systems in order to function so the latent risk factors influence the employee's) choices and decision making. Latent conditions or risk factors are discrepancies in the systems that facilitate error on the part of the producers. When the worker makes the wrong choice or makes an error, these may lead to failure, which may or may not have adverse effects on whatever is being managed (production, quality, or safety, etc.).   

Read part two of this two-part article here