How is such a statistic possible? Is the staff really that incompetent?
Obviously, the answer is no, as the problem oftelies in the design and poor user interface.
Devices, software, and hardware continue to be developed that require users to maintain constant attention for long hours or to memorize complex and seldom-used procedures.
This can force people to stay in monotonous environments for extended periods, interrupted only by sudden and precise interventions. Such a complex and overloaded environment increases the risk of human errors, often caused by interruptions during the execution of simultaneous tasks.
A significant problem is the attitude towards errors committed: inquiry commissions are often established that, instead of solving the problem, identify culprits to punish with fines, dismissals, or even imprisonment. However, this punitive approach does not address the root causes of errors and does not prevent them from recurring.
To avoid the recurrence of errors, it is necessary to study their causes and redesign products or procedures so that errors are minimized or, preferably, eliminated. It is crucial to adopt an approach based on learning from errors and correcting the underlying causes, rather than focusing solely on punishing those responsible.
Adequate tools can be Root Cause Analysis (RCA) and Toyota’s 5 Whys.
The “Root Cause Analysis” (Analysis of the Deep Causes) is a structured process for Identify the underlying causes of a problem rather than just focusing on the symptoms superficial. It involves detailed analysis of the events that led to the problem to identify the root cause or underlying causes.
The “5 Whys” are an investigation technique based on five fundamental questions: Who (Who), What (What), When (When), Where (Where), Why (Why). These questions help you explore an issue or event comprehensively and systematic.
The two methodologies are intertwined as the “5 Ws” provide a structured framework for conduct an in-depth analysis during the “Root Cause Analysis”. The questions help guide the investigation towards a complete understanding of the events and the circumstances that led to the problem, thus helping to identify the root causes of the problem itself. In essence, the “5 Ws” provide an organized method for performing the “Root Cause Analysis”.