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Error occurs for many reasons. The most common is in the nature of the tasks and procedures that require people to behave in unnatural ways—staying alert for hours at a time, providing precise, accurate control specifications, all the while multitasking, doing several things at once, and subjected to multiple interfering activities. Interruptions are a common reason for error, not helped by designs and procedures that assume full, dedicated attention yet that do not make it easy to resume operations after an interruption. And finally, perhaps the worst culprit of all, is the attitude of people toward errors.

When an error causes a financial loss or, worse, leads to an injury or death, a special committee is convened to investigate the cause and, almost without fail, guilty people are found. The next step is to blame and punish them with a monetary fine, or by firing or jailing them. Sometimes a lesser punishment is proclaimed: make the guilty parties go through more training. Blame and punish; blame and train. The investigations and resulting punishments feel good: “We caught the culprit.” But it doesn’t cure the problem: the same error will occur over and over again. Instead, when an error happens, we should determine why, then redesign the product or the procedures being followed so that it will never occur again or, if it does, so that it will have minimal impact.

Root cause analysis is the name of the game: investigate the accident until the single, underlying cause is found. What this ought to mean is that when people have indeed made erroneous decisions or actions, we should determine what caused them to err. This is what root cause analysis ought to be about. Alas, all too often it stops once a person is found to have acted inappropriately. Trying to find the cause of an accident sounds good but it is flawed for two reasons. First, most accidents do not have a single cause: there are usually multiple things that went wrong, multiple events that, had any one of them not occurred, would have prevented the accident. This is what James Reason, the noted British authority on human error, has called the “Swiss cheese model of accidents”  Second, why does the root cause analysis stop as soon as a human error is found? If a machine stops working, we don’t stop the analysis when we discover a broken part. Instead, we ask: “Why did the part break? Was it an inferior part? Were the required specifications too low? Did something apply too high a load on the part?” We keep asking questions until we are satisfied that we understand the reasons for the failure: then we set out to remedy them. We should do the same thing when we find human error: We should discover what led to the error. When root cause analysis discovers a human error in the chain, its work has just begun: now we apply the analysis to understand why the error occurred, and what can be done to prevent it.

Excerpted from ‘The Design of Everyday Things’ by Don Norman