Human error is an unintended mistake made while carrying out a task. In an organization, it may expose a weakness in a manual workflow or contribute to a service failure. Reducing the opportunity for mistakes can help without requiring a wholesale change to how people work. section 2.3.3 section 7.2
When an error causes an incident, a manager should take responsibility rather than blame the person publicly. Avoid intimidation, insults, and immediate termination. First establish enough of the cause to stop the problem continuing; then plan how to prevent a repeat or limit its impact. section 7.2.1
Investigate the conditions around the mistake before choosing a remedy:
- Distinguish a genuine mistake from a lack of foresight or planning. The five whys can guide questioning, though an incident may have several causes. section 7.2.2
- Ask whether training was adequate, the case was unusual, distraction or stress played a part, or steps were missed. section 7.2.2
- Choose proportionate safeguards, such as checks, software guardrails, retraining, or additional reviews. Record what happened, why, and how to rectify it. section 7.2.2
Small changes that prevent errors
A shared Google Sheet replaced emailed spreadsheet versions that people could accidentally update out of order, without disrupting a familiar workflow. In another incident, an operator deleted production web servers while believing a terminal window was connected to development; production windows were subsequently given a conspicuous color. section 2.3.3 section 7.2.2
