June 4, 2020
Human Factors and Mistake Proofing
David Wilbur, CEO, Vegergy Group
Attendees will be introduced to human error as a tool for improving organizational safety and environmental protection. We find that, as a rule, people do not set out to cause failure; rather, they aim to contribute to the larger success of their organization. Nevertheless, as part of a multi-dimensional operating framework, individuals are sometimes shepherded by complex events into making decisions that instead contribute to failures. We view organizations as complex systems with emergent behavior, unforeseen from a reductionist view of individuals’ behaviors. Instead of blaming individuals for error, we ask why the system responded the way it did. Human error is inevitable and serves as a symptom of systemic failure. As with all symptoms, it becomes a signal spurring systemic change. The idea is to welcome human error as an indication that leadership should investigate the dark, murky, uncomfortable cultural issues that made the error seem like a good idea at the time.