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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.

5 Comments

  1. Bruce Hallas Bruce Hallas 2016-12-07

    Nice one Rowenna. To summarise. Where does the human error lie? Naturally people focus on the person at the tipping point where the breach occurred? However, if you did a thorough root cause analysis, I think you will find evidence of “human error” on a broad scale.

    • wp_sb7hyk wp_sb7hyk 2016-12-09

      Ex-ACT-ly!

  2. Helen Helen 2016-12-07

    Reminds me of a patient I was speaking to recently who received another woman’s medical details in the post. Hers had gone out to that other woman. When I said she needed to make a formal complaint, she said “no, I don’t want to get someone in trouble, they were probably very busy, just a mistake…”. I wonder how many IG breaches actually go under the radar? I think of all the times it is a struggle to get people to complete IG training, to properly resource controls. As you highlight, mistakes are still breaches and lessons can be learnt. IG is everyone’s responsibility, including patients/consumers to apply pressure for change.

    • wp_sb7hyk wp_sb7hyk 2016-12-09

      Probably thousands – that’s why the principle of a Just Culture are so important. More about that coming this weekend……!

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