Getting to Know Human Error to Control and Develop Innovation

When we look back at various problems that occur in organizations, we often find that one of the main causes of errors in organizations is human error, or what we call Human Error. This is a cause other than errors caused by unstable machines, substandard raw materials, or inappropriate work environments. However, if we really consider the problems caused by other organizational resources, such as machines, work methods, and substandard raw materials, they are all related to “people” as well. Therefore, in this article, the author would like to discuss the characteristics of errors in organizations that may be caused by people, causes, and prevention methods to help reduce problems that have already occurred or may occur, as well as invite readers to think about the issue of Human Error and innovation development in today's world so that readers can see that “errors may not always be a bad thing in the innovation development process.”

Many organizations categorize human errors or Human Error by separating them into dangerous errors and errors that are not dangerous to the organization. However, in the past, we found that almost 90% of accidents that occur in work processes that increase costs and affect overall organizational productivity are often caused by: “Human error”

Basic concepts in studying Human Error

Human error is something that cannot be avoided in every step of life.
The way people perceive, learn, and express their behaviors can all lead to errors in work.
Human error refers to events that occur related to the actions or inactions of workers, resulting in the work not being completed as intended. Therefore, the characteristics of human errors can be divided into (1) not acting when it is time to act, (2) acting when it is not wanted to be done, (3) incorrect actions, (4) actions that do not follow the work procedures, and (5) delayed actions.

Types of Human Errors

Human Error is considered part of the cause of human accidents (Human Causes). However, a deeper analysis of the causes of human errors will help determine whether the action, inaction, or omission was intentional (Intended actions) or unintended (Unintended actions). The results of the analysis can help us identify what caused the error, such as inadequate training, insufficient employee skill training, or inappropriate work procedures.

1. Slips: This is a mistake in any work that is familiar with the work, has a level of skill, but sometimes is done unintentionally and unconsciously (Unintended), such as intending to step forward on the accelerator, but stepping backward instead. Slips are errors from attention failure or accidentally skipping work steps, misprioritizing work tasks, or making mistakes in timing, etc.

2. Lapses: This is an error caused by the operator's memory loss, forgetting standard operating procedures, or forgetting to perform activities according to the plan that has been set. Lapse is an unintentional and unconscious action. Lapse is an error due to memory failure, such as a mechanic forgetting to remove the tape from the static port when the job is done, or a mechanic forgetting to check the brake system before releasing the car from the inspection center.

3. Mistakes are errors caused by intentional actions but the results of the actions are not as intended. The operator does not know that the intended action is incorrect, but thinks that what he did is correct. Mistakes are errors related to planning, analysis, problem diagnosis and decision-making. They can be divided into 2 types:
(1) Errors based on the use of rules (Rule-based) for work that has a framework for operations or steps, guidelines, but are not used correctly, not appropriate for the situation. Many times, errors in this form are errors that occur from not understanding the rules, procedures and methods involved, or following the rules incorrectly.
(2) Errors based on knowledge (Knowledge-based) are wrong actions or wrong decisions due to lack of knowledge and understanding. Which will occur in unfamiliar work or situations and there is no clear framework or procedures to support it.

4. Violation is a violation of the rules. Errors in this category are the result of intentional actions not to follow the guidelines or rules that have been set, which are not considered natural human errors. Violations can be divided into 4 types:

(1) Routine Violations are violations that are done habitually and frequently and accepting risks as normal.

(2) Situational Violations are violations according to specific events between the operator and the environment due to time pressure, lack of supervision, lack of tools, and insufficient personnel.

(3) Optimizing Violations are violations to make the job interesting or exciting due to the boredom of the job.

(4) Exceptional Violations are failures to work according to rules, procedures, or lack of sufficient knowledge and skills to perform the job.

In summary, we will find that many times in work that we are familiar with without intention or being disturbed by various variables It can become a weakness that leads to carelessness and mistakes from forgetting some steps of the operation unintentionally. While talking about making mistakes, we mostly find that mistakes often occur when employees are working on too many complex tasks at the same time or working on complex tasks at a time when they are under a lot of pressure, such as making a wrong decision in a high-stress competition field or from the urgency of having to cook a special dish and the fish sauce in the bottle runs out, so they pick up a similar bottle of vinegar to replace it. Therefore, as a “communicator for innovation management”, it is very important for us to consider all relevant factors, especially in terms of understanding the work system and truly getting to know our own innovation development team so that we can monitor, control, and prevent mistakes that may occur from the innovation development team with the highest efficiency.

TIPs – Thought-Provoking Issues

Many times in the world of innovation development or the world that sees the importance of innovation, it is often seen that human errors or Human Error may not always be a bad thing. Because in some unintentional mistakes can lead to the discovery of new things by accident. From the perspective of innovation scholars, we call this incident of accidental discovery a serendipity.

Such as the case of Alexander Flaming who discovered penicillin in 1928 while he was experimenting with Staphylococcus bacteria, which causes septicemia or bloodstream infections. In this experiment, he grew this type of bacteria in a type of sea plant on a laboratory dish, closed the lid to prevent foreign objects from falling in, and kept it at 37 degrees Celsius (which is the same temperature as the human body) and assigned his assistant to oversee this experiment. But then one day, his assistant accidentally left the laboratory dish on a table near the laboratory window without closing the lid. When Fleming returned, he found that a type of gray-green mold, similar to the mold that grows on bread, had grown all over the plate. The area around the mold had become a clear ring, and the staphylococcus bacteria had been killed in large numbers.

However, Fleming did not abandon the faulty lab plate, but conducted further tests and found that this mold could eat staphylococcus bacteria, which were later discovered to be in the Penicillium family, called Penicillium umrubrum. He used this knowledge to further develop it into an antibiotic called “penicillin”, which we know and use widely later on.

By.. Dr. Phatthira Thirasawat
Lecturer, Department of Communication for Innovation Management
College of Social Communication Innovation, SWU