CLPEX Chat Board

At the beginning of the Weekly Detail it says “Because of the recent activity surrounding defining and classifying error, this new version of HFACS related to latent print examination was developed.”

I see this article as a list of why errors can occur but I don’t see where an error is ever defined. This seems to be the most important part, did I miss it?

Michele, are you sure you didn't post this topic in error?

With all due "respect," I think the staff at NIST has too much time on their hands.

I have quite a few questions about this system but I’ll try to limit it.

1) Is this from the Human Factors Group? Is uses the phrase ‘Human Factors’ and NIST but I can’t tell if this is from them or another system. If it’s another system, is it being accepted by the Human Factors Group or have they looked at it?
2) As I said before, I think you need to define an error before you can classify why it happened. I see this as a vital part that’s missing.
3) As someone that looks into errors, looking at over 150 factors doesn’t seem practical or needed. Has this system been used to evaluate past errors? Did it work?
4) I tried to use it and although it’s long, that doesn’t mean that it’s specific. I don’t quite understand what some items mean or how they relate to errors. I think some of the factors need more of an explanation to be useful to the user. As an example, how does 1.2.2.2 (Promotion polices were lacking) lead to an error? How does 3.1.2.1 (There were problems with the ergonomic design (desk / chair)) lead to an error? These things might create bad morale and bad attitudes but I don’t see them as a direct factor in why an error occurred. Can someone tell me how an uncomfortable chair might create an error? It could make someone less thorough but then the reason for the error is a lack of thoroughness, not because of the chair. Even if someone wasn’t thorough, how could you ever prove it was due to the chair?

From one of my favorite leadership and management gurus, Peter F. Drucker:

"Nobody learns except by making mistakes. The better a man [or woman] is, the more mistakes he will make—for the more new things he will try. I would never promote a man into a top-level job who has not made mistakes, and big ones at that. Otherwise, he is sure to be mediocre. Worse still, not having made mistakes he will not have learned how to spot them early and how to correct them." from the 1954 landmark book, "The Practice of Management."

On Excellence:
"One should waste as little effort as possible on improving areas of low competence. It takes far more energy and work to improve from incompetence to mediocrity than it takes to improve from first-rate performance to excellence. And yet most people--especially most teachers and most organizations--concentrate on making incompetent performers into mediocre ones. Energy, resources, and time should go instead into making a competent person into a star performer."

"The most serious mistakes are not being made as a result of wrong answers. The truly dangerous thing is asking the wrong questions."

"We all have a vast number of areas in which we have no talent or skill and little chance of becoming even mediocre. In those areas a knowledge workers should not take on work, jobs and assignments. It takes far more energy to improve from incompetence to mediocrity than it takes to improve from first-rate performance to excellence."

And one of my favorites . . . . . "There is nothing so useless as doing efficiently that which should not be done at all. "

Michele,

To clarify a few things:

The list was not a direct product of the Human Factors working group, but several of the members did produce a draft document that was used as the majority of the Detail this week. All the descriptive paragraphs within the outline were created by that group. The NIST working group decided to take a higher level approach to the relevant chapter they are writing, so none of that text will appear in the documents from the group. Instead of letting the text "go to waste" I obtained permission from the main author to use it. I thought I was clear about that in the Detail, but hopefully that clarifies it a little more.

Even the working group had a hard time defining what is latent print examination error. The system is meant to be of assistance regardless of how error is defined - which is why it has so many entries in it.

You mention a key word in your response: "not a direct factor in why they occurred". Many of these are indirect factors that line up and all contribute to the error. In this model, error isn't diagnosed to a single factor - it can be attributed to factors within the organization, the management, the indirect "pre-conditions", as well as the examiner's actions. The key word is "and"... you can have causes in all 4 categories that may not be a direct cause, but they can be viewed as failures in the system that set up the preconditions for error to occur. You could technically do a root cause analysis on each category to find the most relevant organization factor, manager factor, pre-condition, and examiner factor. But the real value of the system would be to complete as comprehensive a picture as possible as to why the error occurred, taking into account each category.

This list is still in draft format, so I don't know of any department that has used it yet. But an earlier version was used in the Detail # 459 to classify errors in a latent print examination project for the Department of Defense.

-Kasey