Is a Heart Attack Human Error?

A ridiculous assumption
    Of course not. Baumgartner made no mistake, no more than if he had gotten sick or suffered a stroke. But since the “machine,” the paraglider, was technically sound and found to have no problems, the investigation still had to ascribe a cause to the crash. It couldn’t leave the cause blank. So, it was called a human error.
    Human error gets tossed around too freely, too broadly, especially in workplaces where there is no safety and health professional. The path of least resistance and least study in identifying the cause of an incident — again, in the absence of a professional — is to cite a human failing. There’s plenty to choose from: recklessness, rushing, complacency, the Superman complex, some kind of blinding bias, a slip up, a memory failure, inattention, fatigue, misunderstanding, breaking the rules, taking a shortcut and on and on.
    The human error label can be used to conveniently cover up any number of possible contributing issues. Issues that many employers don’t have the time, resources or interest in taking on: poor training, poor supervision, poor scheduling, short staffing, long hours, lack of maintenance, lack of safety values (culture), lack of employee engagement, in-house competitive contests, pressures to produce, get the job done and satisfy customers.
    Concluding that an incident was due to human error also fails to account for random events, such as Baumgartner’s heart attack. It comes closer to being described as a random error — an “unpredictable variation” caused by uncontrollable factors. But a heart attack is not an error. And to call it an “unpredictable variation” is not what the family wants to hear.

Defying easy explanation
    Categorizing an incident is not a check-the-box exercise. Most incidents are not black and white, having any number of contributing factors. And some of those are uncontrollable. This contradicts today’s thinking that there are no “accidents,”and all incidents are preventable with controls and capacity — an organization’s ability to manage risk and failure and have plans to handle unexpected events. You can’t control and don’t always have time to prepare for a hurricane, a flash flood, a blizzard, or a tornado. Yes, sometimes they can be forecast, and emergency preparedness takes over. But there are instances when these events happen too quickly, too unpredictably.
    Be careful how you use that word “error” in an investigation. And are you sure you want to use the word “investigation.” Numerous safety experts prefer “incident analysis” to broaden the focus beyond individual blame and the behaviors of frontline employees. Serious analysis today veers away from the idea of error to consider organizational and process systemic issues.

False logic
    When something goes very wrong — Baumgartner spiraling to his death — don’t fall for the false logic of “either/or.” As in, well, it was either a machine/equipment failure or it was a human error. That’s what the Italian investigators seemed to do. Safety is not that superficial.