How a knee jerk reaction can waste time, money, and leave the problem unsolved.
Recently I heard a tale of a worker who, after over two years of high quality work and great performance reviews, made a documentation error that cost the company a few days of lost time. The worker’s manager jumped to the conclusion that the employee had not received adequate documentation training during the new hire training program. The employee had attended the program over 2 years in the past and had been producing high quality documentation ever since—just not this time.
The knee jerk reaction to blame training whenever someone makes a mistake is very common across all industries. Re-train and re-read are the usual corrective actions. This approach is problematic because training is not usually the answer when “human error” is the root cause.
Figure 1 – Gilbert’s Behavioral Engineering Model 
According to Thomas Gilbert’s behavioral engineering model, there are six primary influencers on an employee’s performance. When an investigation deems “human error” as the root cause for a non-conformance, it is only a general term that masks the true root cause, which lies in one or more of the six categories.
A thorough examination of the incident, along with interviews with top performers and average performers, will uncover the true root cause. Only then can we implement meaningful corrective actions that will prevent future incidents. Unfortunately, this deep examination takes more time and resources up front. However, if we can avoid sending an entire population of workers through remedial “training” and instead provide a targeted solution, we can save countless hours of time wasted in training that is simply not needed.
How can we apply this approach to the parable above? Upon further investigation, the company determined that the worker was not appropriately supervised or given adequate feedback on his/her work. The corrective action involved working with the manager to establish a plan for the employee to check in with a peer and have work reviewed on a regular basis.
The Human Performance team at Commissioning Agents, Inc. can help you review your non-conformances and CAPAs to determine the true source of the human error. We can suggest changes that impact your organization and move the needle on human performance. Our team of experienced project managers can manage the implementation process. Contact our Human Performance team to see how we can help you reach a higher standard.
 Adapted from Gilbert, T. 1978. Human Competence