In 2003, the perfectly named James Reason (with his co-author Alan Hobbs) published a 12 factor error management system called the “12 Principles of Error Management”. By isolating and examining these sources of error and what to do about them, Reason reasoned that fatal and damaging errors could be anticipated, prepared for, and eliminated.
1. Human Error is both Universal and Inevitable
You cannot avoid human error – humans are fallible by nature. It can be factored into equations but never eliminated entirely.
2. Errors are not Intrinsically Bad
Errors guide those who are paying attention to success. Learning is impossible without making errors, which you need to make to acquire skills. There is nothing “bad” about an error if you respond to it by changing what caused it and avoiding it in the future.
3. You cannot Change the Human Condition, but you can Change the Conditions in which Humans Work
Humans are reactive creatures: our environment plays a big role in what we think and do. We can identify the characteristics of conditions that are likely to produce errors and compensate for them in error management settings.
4. The Best People can make the Worst Mistakes
Everyone makes mistakes. Anticipate even the best workers' mistakes and further anticipate the larger impacts of the mistakes of important workers. Because the best people have the most responsibility, their mistakes can be the biggest.
5. People cannot easily avoid those Actions they did not intend to commit
People do not deliberately make errors, do not punish them for them. Just because someone did not intend to make the error, they are still accountable for them – error management requires acknowledgement and revision to work.
6. Errors are Consequences, not Causes
Errors happen for a reason. When you have found an error, you can work back from the error to the cause and eliminated it. Otherwise, you are fighting the wrong battles.
7. Many Errors Fall into Recurrent Patterns
The most common errors are usually a part of a pattern of interactions. Understand the pattern and why it recurs and you can effectively eliminate errors.
8. Safety Significant Errors can occur at all Levels of the Spectrum
The more power a person has in an organisation, the more impact their error can have. Everyone makes mistakes, the Error Management techniques must be applied uniformly in an organisation to work.
9. Error Management is About Managing the Manageable
Most error solutions target technical aspects, procedures, or organisation. Human nature is hard to manage, so work with it, not against it.
10. Error Management is About Making Good People Excellent
Improving error detection through improving error detection skills is as important as identifying the causes of errors.
11. There is no One Best Way
Organisations are not rigid and one solution cannot be applied to everyone. Mix and match techniques to achieve optimum error management.
12. Effective Error Management aims at Continuous Reform, not Local Fixes
Singling out errors and fixing them does not work as well as identifying errors and reforming the system to eliminate their possibility of return. This is a continuous process and must be constantly reviewed and improved.