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 Today’s reality will be completely out of date by tomorrow.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.

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.