Blame human error for the loss of 25 million records

The big news story in the UK at the moment is the loss of 25 million child benefit records which include personal details including bank account information. I’m directly affected:

The government has insisted the security breach followed a junior member of staff breaking the rules.

The loss of the HM Revenue and Customs computer discs may have put members of the public at risk of identity fraud.

The UK Government is firmly blaming an unknown worker for the blunder:

It is understood that one worker, a 23-year-old man, has resigned over the disappearance of the two data CDs.

Perhaps Mr Brown needs to read some Deming? One of the many things that Deming taught us is that its human nature when you come across a problem to look for someone to blame. The system that the person is working within accounts for the majority of the problem … at least 93%! So why is the Government blaming one person here?

Two reasons:

1. The general public does not appreciate the concept of a system
2. The general public likes to see one person blamed, kicked, so they get a warm glow inside … the thought process being, we had a problem now that person who caused it is no longer there so the problem won’t happen again.

Here’s a theoretical 5-Why on what should have occurred:

1. Why did the CDs get sent in the post with bank infomration on them?: Because he didn’t know that he wasn’t supposed to
2. Why didn’t he know that he wasn’t supposed to?: Because the procedures and processes weren’t in place to prevent him from doing so (poke-yoke / jidoka)
3. Why weren’t the procedures and processes in place to prevent him from doing so?: Because the Senior Management had not put them in place
4. Why did Senior Management not put them in place? Because there was no direction or policy set by the Government to ensure they were required
5. Why was there was no direction or policy set by the Government to ensure they were required? Because the growth in the public sector has made management or standardisation of regional working practices impossible (go to Gemba!)

Deming also emphasized the importance of thinking about all management tasks in terms of improving the performance of a whole system. Failures have no meaning outside their context within some wider system. It is the system performance that we need to assess, as it is the whole process that determines the risk of system failure. Failures tend to occur due to failures of management to understand the nature of the systems within which their processes operated. This is especially true in hierarchical organizations found in the public sector. Deming’s systems thinking offers key insights and remedies for these deficiencies, in particular:

• thinking in terms of processes and the psychology of those who work therein
• exploring system boundaries and continually improving their definition
• measuring and improving processes rather than solely monitoring results
• creating a climate of flexibility and responsiveness where dissent is not suppressed through fear, and learning is cultivated
• organizing through cross-functional teams rather than functionally-defined hierarchies
• understanding the process dynamics that arise from variation and from human factors.

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So in summary three quotes sum this up:

1. The old way of dealing with human error was to scold people, retrain them, and tell them to be more careful. My view is that you can’t do much to change human nature, and people are going to make mistakes. If you can’t tolerate them then you should remove the opportunities for error.
2. Training and motivation work best when the physical part of the system is well-designed. If you train people to use poorly designed systems, they’ll be okay for awhile. Eventually, they’ll go back to what they’re used to or what’s easy, instead of what’s safe.
3. You’re not going to become world class through just training, you have to improve the system so that the easy way to do a job is also the safe, right way. The potential for human error can be dramatically reduced.

Are you listening Gordon!