ISO9001, TQM, Lean, Six Sigma, Human Error Reduction, Quality, Environment, Safety, Health… are all ways of seeing (the same) things from a different perspective. Full of energy, we jump on every new hype or wave. Our ultimate goal: to create an ideal organization where nothing goes wrong.

But step by step, we start to realize that “zero fault tolerance” is out of reach, it’s an illusion. If we ever achieve to proactively track and tackle all the thinkable conditions that might influence the risk of error, some new conditions will loom up out of nothingness. We have to face the fact that we live in a very complex and dynamic world. Today’s reality will be completely out of date by tomorrow. Our organization continuously goes through all kinds of (sometimes drastic) changes.

Sidney Dekker, Erik Hollnagel, David Woods and some of their colleague-experts in the field of safety, human error and risk management clearly state that the one and only answer is to create a “resilient organization”. Resilience. By inspecting our organization and processes (e.g. the Swiss cheese model of James Reason) we can map most of the unnecessary conditions and contributors of errors, but it will never be enough. We must make our people and our organization more resilient: to prevent “bad” from becoming “worse”, and to be able to recover from “worse” if it happens anyway.

People are not the weakest link in the chain; on the contrary, they are the strength of every organization. If a software application contains some substantial conceptual errors, the computer system will not be able to recover without the help of developers. Human beings on the contrary are able to recover from errors without any help from outside. It would be the wrong strategy to remove the human factor form our processes. Instead, we should make our people, and thus our organization, more resilient so that they are armed against unforeseen situations, so that they are ready for battle.

People who are interested in this subject are free to contact Protecting Achilles. We will be glad to change some ideas and see how we can be of any help.

It seems everyone is talking about risk management, whether it’s about financial investments, political strategies, or quality management. Like other quality initiatives, it may be regarded as simply another “quality program du jour”, but a well-managed risk management program helps focus improvement effort on the truly important issues, resulting in more effective and efficient means of maintaining and improving quality.

Each industry seems to promote different methods for risk management; FMEA in the automotive industry, HACCP in food and pharmaceuticals, HAZOP in chemicals, and ISO 14971 in medical devices, but each method contains similar methods for analyzing risk. Regardless of the method, potential hazards or risks are identified and evaluated to determine a cause or failure mode, and each hazard or risk is assigned a measure of criticality and a measure of the frequency of occurrence (some methods add a third measurement of failure detection). After considering the combined risk for an uncontrolled or failure state, controls methods are devised to mitigate risk, and the combined risk is re-evaluated. Risks that are above a specified threshold are subjected to further analysis to determine methods to reduce risk to an acceptable level.

Unfortunately, some organizations do not actually practice effective risk management. Instead, they go through an exercise of analyzing risk with and without controls, making impressive risk charts, wiping the sweat off their brows following the work, and simply pulling out the file whenever an auditor asks for it.

But an effective risk management program should be a living process. In programs I have managed, I’ve made it a policy to have each risk management file reviewed on at least an annual basis. Changes to risk analysis should be made using data collected from sources such as customer complaints, audit findings, industry white papers and articles, public reports, and other data sources (perhaps even an idea from a blog!). New control strategies are then developed to address previously unidentified or significantly changed hazards and risks.

Finally, managing risk is not necessarily easy, but it is rewarding. Perhaps the best comment I ever heard following some intensive sessions was from an individual who said, “I thought this would just be another exercise in bureaucracy, but I have to admit I know more about our product and processes than I ever knew before.”

What about you? Have you used risk management and has your experience been favorable? Share your thoughts with us.

On March 27th 1977, the biggest accident in airline history took place (at least if we leave the attack on the Twin Towers out of the equation).

The accident happened due to a concurrence of circumstances and an accumulation of human errors escalating to a disastrous 583 casualties.

A few of those circumstances and/or causes were:

• Stressors: fog and drizzle (limited sight of 1000 to 3000 feet), pilots were stressed out because both Boeing 747’s were (inconveniently) diverted to Tenerife instead of their original destination, Las Palmas. They couldn’t go there because of a bomb alarm, causing serious delays.
• Human error: due to the limited vision, the PanAm reaches the junction too late causing them to remain on the runway (too long).
• Technical problems: part of the lighting (center line) wasn’t ready yet and they were experiencing radio interference.
  Authority: the KLM captain was (internationally) known for being ‘the exemplary pilot’ of KLM. He was a pilot and a flight instructor at the same time and KLM used him in advertising. They referred to him as Mr. KLM. Although his colleagues were uncertain about the position of the PanAm, they wouldn’t question his authority.

This story proves that a lot can go fundamentally wrong due to a couple of “human errors”. In order to reduce the risk on errors, making an overview of all possible “risk factors” and taking precautionary measures where possible (some factors are hard to prevent) is a good start. FMEA is a very know method originating from the automotive industry. On the other hand, FMEA doesn’t really consider human errors.

If you’re interested in some more background information about this accident, you can find a lot of opinions, details and multimedia on http://www.project-tenerife.com/

Research has proven that, when questioned, about 50% of employees of a company or organization are stating that they are spending an average of 1 to 2 hours a week on correcting errors. Theirs and their colleagues’. 17% of the questioned admit to losing more than 4 hours weekly. This not only costs a lot of money (mostly hidden costs) but leads to a lot of frustration with personnel.

Most important cause for this is once again “human error”. If you do some quick math on how many people work in your organization, you can have a general idea of how much (financial) leverage is within reach once you decide to work on these “errors”.

Yesterday, I attended an introduction seminar about the “Goed Gedaan” (transl. “Well Done”) project of the VCK (Flemish Centre for Quality Assessment) in Antwerp (Belgium). It’s a project lasting 18 months that helps the participants to tackle “human errors” that occur in their organization, especially during repetitive tasks. The whole project is driven by Mr. John Evans (UK) who is a real expert in this field. He has more than 20 years of experience and he gave advice to big companies like Merck, Lloyds TSB, GlaxoSmithKline, Coca Cola and Rolls Royce.

Those of you who are familiar with TQM and Six Sigma will agree that “human error” is one of the most frequent root causes of non-conformities. Corrective actions such as additional training, more testing and inspection only take away the side effects and/or block defective products. The knowledge to tackle the real cause of this “human error” is not well spread and thus not used to take real action to solve this problem.

Interested? Take a look at the website of the VCK or at the website of John Evans.