Avoid The Dirty Dozen: 12 Common Causes Of Human Factor Errors

An IT Company’s Perspective on Preventable IT Failures

‍The Federal Aviation Association is well acquainted with human error. In fact, according to them, 80 percent of all maintenance mistakes are a result of human error, and, if these mistakes go undetected, they will likely lead to accidents. In aviation, an accident means catastrophe, and though IT systems usually don’t have the same life and death consequences of proper propeller maintenance or altimeter calibration, IT failure can indeed be catastrophic for an organization. The FAA has detailed the 12 most common factors of human error and though they are intended to keep pilots and passengers safe, we have found that they are also a very practical guide to preventing the human error from crippling your IT systems.

Here are the FAA’s “dirty dozen”

1. Lack of Communication
2. Complacency
3. Lack of Knowledge
4. Distractions
5. Lack of Teamwork
6. Fatigue
7. Lack of Resources
8. Pressure
9. Lack of Assertiveness
10. Stress
11. Lack of Awareness
12. Norms

We would recommend checking out the full list in detail, however, we will cover 3 that we have seen most commonly cause IT issues and failures along with potential countermeasures to avoid mistakes.

1. Lack of Resources

Richard Komarniski of Aviation says this about a lack of resources:  

“If all the parts are not available to complete a maintenance task, then there may be pressure on a technician to complete the task using old, or inappropriate parts. Regardless of the task, resources also include personnel, time, data, tools, skill, experience and knowledge etc. A lack of any of these resources can interfere with one’s ability to complete a task. It may also be the case that the resources available, including support, are of a low quality or inadequate for the task.”

It is quickly evident how a lack of resources can lead to human error and equipment failure.

One such example comes from the crew and maintenance personnel of a Piper Navajo, a small 5-7 passenger aircraft. The crew began to notice a “Door Not Closed” warning light appearing intermittently during their flight. When the maintenance crew checked it out, they were unable to resolve the issue when the aircraft was grounded. Despite that, they still ordered a new door latch to be installed in the next maintenance window. However, the next maintenance window arrived, and the part never showed up due to the manufacturer going through a bankruptcy. Though they lacked the resources to fix the problem, the plane returned to service as it was not a critical issue. On a flight some weeks later, a passenger complained of a draft in the cabin. The co-pilot got up to check out the issue and as he neared the cabin door, it flew open and he fell out. Luckily, his feet had become tangled in the strap that held the door in place, but he was left dangling from the aircraft 3,000 feet in the air. They made an emergency landing and miraculously he walked away with no physical injuries. Despite the lucky outcome, one backordered part meant the difference between a very precarious situation and a smooth flight.

Much like aviation, the lack of resources in an IT environment can lead to failure of critical systems. This can look like cheap consumer grade servers supporting a large office, not having enough manpower to maintain equipment, or old employee workstations that take a long time to even check emails. These issues don’t always lead to catastrophic failures but often can mean slow-burn problems. Hundreds of hours of efficiency lost per year, frustrated team members, and much more.  

Ensuring your IT environment has adequate resources allotted to it removes a big component of human error and allows your systems to run smoothly with less likelihood of failure.  

To combat this, we recommend planning ahead to acquire and maintain the resources you may need. Understanding the people and processes needed can save a lot of work down the road. In addition, make sure the resources you are using are up to the task.

2. Norms

Norms are habits that become adapted into larger workplace processes but exist outside of the documented processes of an organization.

Rich Komarniski of Aviation Pros defines norms as follows:  

“Workplace practices develop over time, through experience, and often under the influence of a specific workplace culture. These practices can be both, good and bad, safe and unsafe; they are referred to as “the way we do things round here” and become Norms. Unfortunately, such practices follow unwritten rules or behaviors, which deviate from the required rules, procedures and instructions. These Norms can then be enforced through peer pressure and force of habit. It is important to understand that most Norms have not been designed to meet all circumstances, and therefore are not adequately tested against potential threats.”

If you didn’t know we were talking about aviation, you might think that quote was pulled directly from a cybersecurity website! In today’s technological landscape, “the way we do things” or “that’s how we’ve always done it” translate directly to potential security risks.  

In the 1970s, it became the norm for American Airlines to change the engines on DC10s with a forklift. Changing the engines in that manner was not proper protocol, however it became the norm because it saved 12 hours per engine.  There was no ill-intent; it simply made a big difference on efficiency and time. Tragically, the time-saving norm led to catastrophic results. On May 25, 1979 an engine separated from the wing on Flight 191 as the plane took off leading to a crash and the deaths of all 273 people on board.  

IT norms are often born from the same types of reasons; something saves time, it’s easier, or it simply becomes reinforced through habit. This can look like storing important passwords in unsecure locations (a post-it note on your monitor) using a co-workers login credentials to access certain documents or ignoring IT issues because you’ve gotten used to it (complacency is another “dirty dozen” item).

Creating strategic IT processes, rules, and documentation are vital countermeasures that can rectify risky norms and keep your organization safe from cyber-attacks or downtime.

3. Lack of Communication

The dirty dozen list is not technically in order of importance, however, the consensus #1 human error component is lack of communication; 37% of human error occurrences involve a breakdown of communication. Communication is comprised of three elements: the transmitter, the receiver, and the method of communication. Verbal communication is especially susceptible to errors; especially if ambiguous words are used or incorrect assumptions are made.  

Proper communication between different departments and people is vital in aviation. Pilots and crew must communicate issues to the maintenance crew, Air Traffic Control must communicate to pilots and vice versa. Communication breakdown can lead to delays, neglected maintenance, and tense relationships between different departments.

Likewise, communication is vital for IT departments. Documentation, communication training, and detailed written communication can help fight against issues arising from bad or incomplete communication. When verbal communication is necessary, air-traffic control style protocol is a useful process to follow. A pilot files a flight plan and submits it to ATC, ATC approves the plan and calls the pilot to read the information, the pilot then reads back the information to ATC and only at that point is the pilot cleared for takeoff.  

Communication becomes especially important when there is a change to the IT environment. Imagine the confusion of coming back into your office and it is announced with no warning that you have switched phone and email systems over the weekend and no instructions are provided. Conversely, it would be a much better experience if the change was communicated to you beforehand, tutorials or instructions were provided, and follow-up communication takes place to make sure everything is working smoothly.

Conclusion

IT systems and cybersecurity are becoming more and more integral to businesses in all industries. As organizations more heavily rely on technology, cyber threats and IT issues present much larger risks. Stolen data, downtime, and ransomware are all very real problems that can cripple a business. Much like in aviation, human error plays a big role in the severity and likelihood of IT problems.  

Minimizing human error can help minimize IT problems.

References:

https://www.faasafety.gov/files/gslac/library/documents/2012/Nov/71574/DirtyDozenWeb3.pdf
‍https://www.aviationpros.com/home/article/10389111/lack-of-resources
‍https://www.aviationpros.com/home/article/10389084/norms
‍https://www.aviationpros.com/aircraft/commercial-airline/article/12402208/its-a-matter-of-communication
‍https://www.skybrary.aero/index.php/The_Human_Factors_%22Dirty_Dozen%22#Lack_of_resources