How Could This Happen? Managing errors in organizations
24th April 2019
There's a potential paradox here: the desire to learn is tempered by the urgency of implementing corrective actions to prevent the accident re-occurring. Get the balance right, and we start towards a "just culture". Get it wrong, and blame behaviours begin. As a result, for many organisations the reality of error management is simple: "Don't make mistakes. And if you do, you're on your own unless you can blame them on someone else." The advent of impossible targets, such as "zero accidents" and six sigma projects (see IOSH Magazine, March 2019, p 24) that seek to eliminate errors, serve only to reinforce the problem.
To err is human. And how we deal with our mistakes is crucial to our success -- in life and at work. On one hand, mistakes add to our sense of orientation and allow us to learn and grow as humans. On the other, there are mistakes that make us deeply unhappy. These we want to forget quickly and move on, avoiding guilt and shame. It's these emotionally charged errors that are the true challenge for organisations, as they're swept under the carpet for fear of embarrassment.
For too long human error has been accepted as an unavoidable part of life that must be managed after the event
In How Could This Happen? Professor Jan Hagen has carefully curated 17 chapters, each around 20 pages which together thoroughly explore the evolution of error management. There are solid arguments for embracing -- and indeed creating -- uncertainty; erudite analyses of workplace safety communications; robust discussion on psychological safety, organisational learning and innovation; and the role of senior leadership in driving safety culture.
Deeper dives into complex and highly demanding work environments, including flight operations, the military and the nuclear industry, add specificity and help to illustrate key points. Each chapter is well set out, richly referenced and concludes clearly with key points for the reader's further consideration. The book is a fantastic mix of academic research and practitioner perspectives that results in an eminently readable and perfectly practical text that advances thinking on error.
For too long human error has been accepted as an unavoidable part of life that must be managed after the event. But this has encouraged unnecessary compromise at all levels of an organisation. Yes, to err is human, but so too is learning, improving and growing. Every organisation makes mistakes. But not everyone learns from them. This book will show how you can and is highly recommended.