How Does Your Organization Handle Human Error?
By George Pitagorsky
Does your organization encourage candid reporting?
Is human error a punishable offense or a trigger for learning?
Do your leaders reward liars and those who deflect blame from themselves? Do they punish those who make mistakes? Retaliate against whistleblowers? Deny the seriousness of errors and omissions?
Is there anything wrong with admitting to being wrong?
A Story: Project Espionage
Years ago, I was leading a project at a large financial organization when I was called upon by my client, a senior manager, to investigate another project that he felt was in trouble even though the status reports were not raising any red flags.
It was a spy mission. I had mixed feelings about blowing the whistle, if needed, on a colleague. But as a project management enthusiast, I value truthful objectivity and continuous improvement, so I took on the clandestine assignment.
Knowing what I knew about the nature of projects and the people who make them work, I turned to the staff to get a sense of what was really happening on the playing field. The players have a realistic, less filtered understanding of what is going on.
Speaking informally to a few people on the project, including the person leading the testing team, I discovered that a central piece of software was riddled with bugs and the debugging was not going well. Each fix caused disruption and uncovered problems elsewhere in the product. My sources felt that the state of the project was not being reported accurately.
I took the findings to my client, who called for a project audit. The audit found that the product design was flawed and that much of the software had to be scrapped.
Why Hide Errors?
What would cause a project manager to hide the truth about the state of her project?
Mostly, it is fear of being fired or being seen as incompetent. This fear is reinforced by a culture that punishes and blames.
The fear of admitting mistakes may be self-imposed. Perfectionism leads to a need to hide or react badly when an error is made. The perfectionist will often seek to blame others or be oversensitive to being responsible for errors or poor performance.
Wishful thinking plays a role. An overly optimistic view of the situation and the ability to handle it quickly and easily can be used to justify not reporting what clients or senior managers could take as alarming news.
Organizational policy to hide the truth to keep unpleasant news from clients, shareholders, and regulators also plays a role. This trickles down to individual performers who are encouraged to hide anything that might be seen as negative.
What happened
In the story of the misreported project, the root causes of the failure to report the reality of the state of the project were in my client’s style of management and the project manager’s lack of courage to own up to the severity of the situation.
The senior manager was a highly competent technologist who had little patience for less than perfect subordinates. His reactions to errors and problems were consistently fierce. He was a blamer and deflected accountability.
A Learning Culture
Accountability for errors and omissions is a hallmark of a learning culture.
Learning culture acknowledges imperfection and promotes continuous improvement. Leadership recognizes that it is more productive to learn from mistakes than to hide them. In learning organizations, people continuously learn so they can improve performance and well-being. Central to Peter Senge’s Five Disciplines of a Learning Organization is systems thinking.
Systems Thinking
Systems Thinking means seeing the organization as a whole, a system, made up of objects interacting in complex relationships. The objects are people, organizational units, and anything else that can be identified as part of the system. Everything that happens is the result of the interactions among the people, places, policies, processes, and activities in the system.
Cause Analysis
Of course, performers who continuously mess up because they are incompetent or regularly fail to follow procedures or best practices may be the root cause of some errors. But blaming someone or ignoring and hiding the problem is too easy.
The learning organization accepts that its system is not perfect and that most troubles are caused by the system’s management style, policies, and procedures rather than individual performer behavior. Most possibilities for improvement lie in the system and not the individual performer. Individual errors are often the result of poor training, hiring practices, or a lack of effective supervision and controls.
When an error occurs, once its immediate impact is addressed, the learning organization investigates its cause. And the investigation is not satisfied with finding someone to blame. Human error becomes the starting point of the investigation to find the systemic causes of problems or errors, looking at procedures, training, quality assurance and control, management and supervision, hiring, onboarding practices, and personal work habits.
By finding causes, action can be taken to eliminate them and avoid future errors to improve performance.
Learning from Mistakes
In our story, hiding the project’s true status was caused by a combination of a blaming management style and a lack of courage.
The opportunity to uncover the causes of the project’s performance problem was not taken. They were two-fold: a lack of quality assurance (the design was not adequately reviewed and bugs were not adequately investigated) and poor project control and reporting (there were no details regarding testing results, effort on a task level, or granular task reporting).
The story ended with the project manager being removed from the project and rework being done.
Your Story
In your story, make sure there is a candid post-project analysis to enable improvement in management approach and project management performance.
What can you do to promote organizational learning?
Are project and design reviews adequate?
Is project reporting done well enough to make it impossible, or at least very difficult, to do anything but report objectively?
Do people feel safe enough to report their errors?
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