The Hawaii False Alert: Is It Really Human Error?

Source: www.worldatlas.com

Don Norman has written an outstanding article for Fast Company about the false alert that caused panic in Hawaii over the weekend.  In the aftermath of the incident, we heard that "human error"  caused the false alert to be transmitted widely to citizens of the state. Norman challenges this initial conclusion. Norman writes:

When some error occurs, it is commonplace to look for the reason. In serious cases, a committee is formed which more or less thoroughly tries to determine the cause. Eventually, it will be discovered that a person did something wrong. “Hah,” says the investigation committee. “Human error. Increase the training. Punish the guilty person.” Everyone feels good. The public is reassured. An innocent person is punished, and the real problem remains unfixed. The correct response is for the committee to ask, “What caused the human error? How could that have been prevented?” Find the root cause and then cure that. To me, the most frustrating aspect of these errors is that they result from poor design. Incompetent design. Worse, for decades we have known how proper, human-centered design can prevent them.

Norman points out several egregious design flaws with this alert system.  First, why was a confirmation not required before the alert was sent?  Ideally, he notes, the confirmation should be provided by a second person working independently from the person who selected the alert message.  Second, when operating in test mode, the messages should all start with a clear indication that it is only a test.  That should be in bold!  It should be capitalized!  It should be crystal clear!   Finally, the system should be designed to enable immediate correction.   The delay was preventable with better design.  

In sum, you can look at any failure in two contrasting ways.  You can examine it individualistically, i.e. it is human error.  Or, you can look at it systemically, i.e. what systems, procedures, and situational factors contributed to poor actions or decisions?   The latter approach is much more likely to lead to learning, improvement, and future accident prevention.   We have shown that in our own research on tragic accidents such as the Columbia space shuttle accident.   

Do You Have a Mistake Diary?

The Wall Street Journal reports on an interesting new leadership phenomenon.  According to this article by
Rachel Silverman, "Some self-aware managers are trying out “mistake diaries” or “failure reports” to help minimize the chances that a problem happens twice – and to help foster an environment where it’s OK to try and fail."  

Silverman describes the efforts of Meebo co-founder Elaine Wherry, who has kept a mistake diary for a number of years.   Silverman writes that, "Using a series of sketchbooks, she started taking notes and making drawings to record her mistakes – such as time-management problems and hyper-perfectionism — as a personal way to remember them."   Wherry has even shared her "most common blunders" with her staff, since she noticed many young new employees making many of the mistakes that she had made earlier in her career.  (Take a look at a video created by Elaine Wherry by clicking here). 

Everyone should note the importance of reflection as a tool for improving as a leader.   We can't just focus on what's next, on the newest pressing problem.  We have to find a way to carve out some time for reflection if we are to improve and develop.   Of course, finding that time can be difficult in hectic schedules that many leaders keep.  So, before thinking about crafting a mistake diary, you have to take a hard look at your schedule.  Blocking out some time for reflection is hard, but necessary, if we are to identify and learn from our mistakes. 

What Does a Business Apology Mean in Different Cultures?

Yesterday, I taught my case on BP and the Gulf of Mexico Oil Spill here in Tokyo.   We had a very interesting discussion regarding BP's actions both before the accident and in the immediate aftermath.  Some Japanese executives felt that BP CEO Tony Hayward should have put forth a clearer, more direct apology immediately. Others were not so sure, pointing out that the US is a highly litigious society.

I brought up a study by Insead's William Maddux which he conducted along with Tetsushi Okumura of Japan's Nagoya City University as well as USC's Peter Kim and Northwestern's Jeanne Brett.  They have studied the meaning and function of apologies across cultures.   They found a difference between what they call "individual-agency cultures" such as the US and "collective" cultures such as Japan.  In the US, an apology means that one is taking the blame for a failure.  On the other hand, in Japan, apologies are "general expressions of remorse rather than a means to assign culpability."   Perhaps because of this difference in meaning, they found that the Japanese tend to apologize more often, even if they were not at fault for particular actions.  The findings definitely resonated with the Japanese executives with whom I discussed the BP case yesterday.   They acknowledged that apologies do take on a different meaning in their country.  As executives work and do business in different countries, they would be well-served to understand these key differences. 

Reviewing Organizational Failures: The Case of Medical Accidents

NYU professor Lucy MacPhail has earned a best paper award here at Academy of Management for her paper examining how an academic medical center conducts reviews of medical accidents. In healthcare, regulators dictate that certain types of errors must be subjected to a formal organizational review. MacPhail found that the hospital did indeed conduct systematic reviews in accordance with regulatory oversight. However, her research shows that the hospital did not review a number of incidents which had the potential to provide substantial learning opportunities. Why not? Those incidents did not fall under the regulatory rules. In other words, the focus on compliance may steer managers away from investigating failures which may yield key learning. I believe that similar experiences may exist in a number of other industries. MacPhail recommends that organizationals their own learning goals, independent of compliance concerns. Those learning goals should drive the selection of projects to review in a systematic manner.