“It’s not how we make mistakes, but how we correct them that defines us.” — Rachel Wolchin
One of the most common recommendations made as a result of incident safety investigations is “improved training,” especially when the investigation concludes that the incident was the result of an error. It is not because training is so universally inadequate that it needs to be recommended. Instead, it is because incident investigation procedures require recommendations and “improved training” is easy to recommend.
However, sometimes training is no help.
Errors
Trevor Kletz identified three types of errors that describe doing the wrong thing: lapses, mistakes, and violations. (He also discussed “mismatches,” which are not errors so much as the inability to do what is needed.)
Lapses occur when someone knows what they should do, wants to do what they should do, are capable of doing what they should do, and yet, do not do what they should do. They occur, not in spite of, but because of being well-trained. Have you ever found yourself half-way through an intersection when you realized that you had just run a stop sign? That is a lapse.
Mistakes occur when someone wants to do what they should do but does not know what they should do. The key feature of mistakes is ignorance.
Violations occur when someone knows what they are expected to do and yet decides to do something else instead. While it is possible that a worker makes this choice because of some character flaw, that is usually not the cause of an incident. More likely, it is because they didn’t understand the basis of the expectations or because they understood the basis of the expectations perfectly well and disagreed. It is even possible that they were correct in disagreeing.
What Good is Training if the Error was a Lapse?
Lapses are part of the human condition. We lapse when our train of thought goes off the rails, not because we don’t know where the rails are. Usually, we are able to get back on track with no ill-effect, but sometimes, we are not. Training, to make sure that we know where the rails are, does nothing to prevent derailment. Training does not address the conditions that lead to lapses.
Not sure? Let’s go back to the stop sign example. If a lapse leads you to run a stop sign, and you do it in front of a police officer, you can expect to get pulled over and to get a ticket. Will that ticket prevent a lapse in the future? What if a traffic court judge decides that you need to go to a traffic safety class? What are you going to learn? Did you run the stop sign because you didn’t know that the red octagonal sign meant stop? Did you run the stop sign because you didn’t know how your brakes worked? Did you run the stop sign because you believed stop signs are for suckers, but not for you?
To insist on training when the error leading to an incident is a lapse is to use training as a punishment. When we devalue some training by using it as punishment, we devalue all training. When employees see some training as a form of punishment, it is not much of a leap to see all training as a form of punishment. At that point, training has lost any value.
What Good is Training if the Error was a Mistake?
If the error was a mistake, it was because someone did not know how to diagnose the problem correctly, or if they did, did not know the correct way to respond. In other words, the mistake was because of ignorance. Not stupidity. Ignorance. And ignorance is the result of inadequate training.
How do we cure ignorance? Improved training!
What Good is Training if the Error was a Violation?
The trickiest call to make if an error was a violation is whether improved training required.
Before deciding how to respond to a violation, it is important to understand why there was a violation. Kletz has posed a set of questions that should be pursued before drawing any conclusions and making any recommendations about a violation:
- Was the expected action misunderstood?
- Was the problem beyond the scope of the expected action?
- Was the expected action unnecessary or considered unnecessary?
- Was the expected action incorrect or considered incorrect?
- Was the expected action not possible in the time allowed, or considered not possible in the time allowed?
- Was the expected action not possible at all, or considered not possible?
- Have similar violations been ignored or rewarded in the past?
Only after considering each of these questions should a resolution be recommended. If the answer to any of the questions was “Yes” then the problem is either with the instructions or with the training. Sometimes the expected action is wrong, whereupon violations may even prevent incidents.
Only if the answer to all of these questions is “No” should an explanation of flawed character—laziness, spitefulness, vengefulness, arrogance—be considered. If the answer is that the root cause of an incident was a flawed character, it then raises the question, “What training is likely to cure that character flaw?” Because without curing the character flaw, the incident is likely to reoccur.
How Will More Training Help?
When the cause of an incident is a lapse, training will not help.
When the cause of an incident is a violation due to systemic problems, training will not help.
But when the cause of an incident is a violation due to an under-appreciation or misunderstanding of the purpose of expected actions or is a mistake, then improved training is exactly the right answer.
Before recommending improved training, ask, “How will more training help?” Until you can answer that question, you don’t know what kind of training is needed, or if training is needed at all.
