Press "Enter" to skip to content

Month: December 2016

‘Just Culture’: an introduction

As I noted in last week’s blog post, the phrase “human error” covers a lot of ground, and fails to distinguish the causes of errors from each other; thus not being terribly helpful in incident analysis, being a generic statement of “something happened that wasn’t supposed to”.

The “something” may cover a number of scenarios, behaviours and motivations but to unpick an incident and protect against further occurrences, the conditions and actions do need to be examined, because it is those which determine the appropriate response. This is where a “Just Culture” comes in.

For those of you not familiar with the phrase, the term “Just Culture” arose from the work on aviation safety by Professor James Reason in the late 90s and early 00s. Professor Reason recognised that fear of a punitive reaction to human error is likely to discourage reporting of incidents, whereas it would be more advantageous to foster  “an atmosphere of trust in which those who provide essential safety-related information are encouraged and even rewarded, but in which people are clear about where the line is drawn between acceptable and unacceptable behaviour.”

There is much written about the principles and practices of a Just Culture, which has been adopted in many safety-conscious industries, including transport, construction and healthcare which I will refrain from regurgitating (if you’re interested, see the links at the end). My putpose here is to generally have a bit of a moan about how far the information security industry has lagged behind in adopting a similar position, and how personally, I think it’s time we caught up.  

When individuals are afraid to report information security risks and incidents for fear of ‘getting into trouble’, apathetic resignation to broken systems and processes or simply because they don’t recognise a problem when it arises, those risks and incidents will not be managed – increasing the likelihood that they will accumulate to the point of causing serious damage or disruption.

Security policies and procedures are routinely breached for various reasons – they fail to reflect the needs and risk appetite of an organisation, they are difficult to find or to understand, or they demand a higher level of technological capacity than the organisation can muster. If the only time that these breaches are identified is when the consequences are adverse -and the outcome of such occurrences is that individuals are punished for being ‘caught out’ by doing what they see everyone else doing – then human nature being what it is; more effort will go into concealing the instances of policy breach than the rectification of the core problems that cause the policy to be breached, and breaches will continue to occur. 

However, simply enforcing reporting of breaches and incidents won’t, on its own, result in any meaningful change if the root causes of incidents aren’t analysed and treated. In my next blog post I will look a bit deeper into the analysis of incident causes and the behaviours that contribute to their occurrence.

References:

“Just Culture: A Debrief” https://www.tc.gc.ca/eng/civilaviation/publications/tp185-3-2012-6286.htm

“Just Culture” http://www.eurocontrol.int/articles/just-culture

“Patient Safety and the  Just Culture” https://psnet.ahrq.gov/resources/resource/1582

“Just Culture” Sidney Dekker: http://sidneydekker.com/just-culture/

Human Error

To err is human…..to forgive, divine..

…(but to really screw things up, you need a computer….!)

One can’t help noticing a recurring theme in the spate of data breach news reports these days. The phrase “human error” is coming up an awful lot. I’d like to take a closer look at just what that phrase means, and whether it is at all a helpful description at all.

What do you think when you hear that something happened due to a “human error”? Do you think “aww, the poor person that made a mistake; how awful for them, I hope someone gives them a hug, a cup of tea and consolation that humans are fallible frail creatures who can’t be expected to get stuff right all the time” or do you – like me – think to yourself “h’mm, what this means is that something went wrong and that humans were involved. I wonder whether systems, processes and training were designed to robustly identify and mitigate risks, whether management support and provision of resources were adequate and whether this is just a case of someone getting unlucky while dodging around policies in a commonly-accepted and laxly-monitored way”

Premise; I fully believe that the statement “the breach was down to human error” is a total copout.

Why?

Let’s start with “error”. The dictionary definition says:

  1. A mistake
  2. The state or condition of being wrong in conduct or judgement
  3. A measure of the estimated difference between the observed or calculated value of a quantity and its true value

The first definition is probably the one that is called to mind most often when an occurrence is described as an “error”. Mistakes are common and unavoidable, everyone knows that. I believe that the phrase “human error” is used consciously and cynically to create the perception that information incidents are freak occurrences of nature (rather like hiccups or lightning) about which it would be churlish and unkind to take umbrage; and unreasonable to demand better.

But in my humble and personal opinion, (based on nothing more than anecdote and observation) the perception thus created is a false one – in fact, breaches that occur solely as a result of genuine mistakes are rare. Even if a “oops” moment was the tipping-point; the circumstances that allowed the breach to take place are just as significant – and usually indicate a wider systemic failure of risk management which could – and should – have been done better.

Risky behaviour that leads to a breach though, is not usually a sincere mistake – it is either a calculated decision of the odds, a failure to understand the risk or ignorance of the possibility that a risk exists. Risky behaviour is *not* an unavoidable whim of Mother Universe (setting aside the philosophical implications, otherwise we’ll be here all day), but the output of a deliberate act or decision. We should not regard ‘risky behaviour which led to a realisation of the risk and unwanted consequences’ in the same way that we do ‘inadvertent screwup due to human frailty’ and to lump them together under the same heading of “human error” does a disservice to us all, by blurring the lines between what is forgivable and what we should be demanding improvements to.

The human bit

Since we’re not yet at the stage of having autonomous, conscious Artificial Intelligence; it must follow therefore that errors arising from any human endeavour must therefore always be “human errors”. Humans design systems, they deploy them, they use (and misuse) them. Humans are firmly in the driving seat (discounting for the moment that based on the evidence so far, the driver is reckless, probably intoxicated, has no concept of risk management and is probably trying to run over an ex-spouse without making it look obviously like a crime). So; whether an information security or privacy breach is intentional, inadvertent or a state in which someone got caught out doing something dodgy, describing the cause as “human error” is rather tautological and – as I’ve noted above – potentially misleading.

I believe that the phrase “human error” is a technically-accurate but wholly uninformative description of what is much more likely to be better described as human recklessness, human negligence, human short-sightedness, human malice or simple human incompetence. Of course; no organisation is going to hold their hands up in public to any of that, so they deploy meaningless platitudes (such as “we take data protection very seriously – that’s a diatribe for another day!), of which “the breach occurred due to human error” is one.

Take for example, the common ‘puts all addresses in the To: field of an email instead of BCC’ screwup which was the cause of an NHS Trust being issued with a Civil Monetary Penalty after the Dean Street clinic incident in 2015. Maybe the insertion of the email addresses into the wrong field was down to the human operator being distracted, working at breakneck speed to get stuff done, being under stress or simply being blissfully unaware of the requirements of data protection law and email etiquette. But they should not carry all of the culpability for this incident – where was the training? Where were the adequate resources to do all the work that needs to be done in the time available? Most of all, where the hell was the professional bulk-emailing platform which would have obfuscated all recipient emails by default and therefore be a much more suitable mechanism to send out a patient newsletter? (provided of course, that the supplier was carefully chosen, UK-based, tied to appropriate Data Processor contract clauses and monitored for compliance…etc etc). The management would seem to have a lot more to answer for than the individual who sent the email out.

So the next time you read of a data breach, privacy abuse or in fact, any other type of incident at all, and see the phrase “human error”, stop and ask yourself: “What was the error”? Was it lack of appropriate training for staff? Cutting corners to cut costs? Failure to provide the appropriate tools for the job? Mismatch between the outputs demanded and the resources provided to deliver them? None of these are inevitable Acts of Nature, the way that occasional “Oops” moments would be.

And as long as organisations are allowed hide behind the illusion of unavoidability; the less likely they are to tackle the real problems.