Human Error Management -
Quality Drives Economic Value

Introduction
Current research shows that the Cost of Quality (COQ) can range anywhere from 15 to 40% of sales. Even with the varying COQ ranges, there is no disagreement that the cost of quality is very large and has significant impacts to the bottom line profitability of an organization. Edward Deming believed that the cost of non-conformance (and the resulting loss of good will) was so high that evaluating the cost of quality was unnecessary. Phillip B. Crosby is frequently identified as the individual who popularized the use of COQ in his book Quality is Free. He referred to COQ as “the price of conformance.” To meet basic objectives, an organization must focus on increasing profits by reducing the costs of quality through a variety of methods, including the reduction of errors and the elimination of non-value-added activities and waste. In addition to the monetary costs of quality, an organization must also consider the major impact that poor quality can have on its current and future customers and its market share.

Human error is a major contributor to non-conformances and therefore COQ. Research shows that human error is responsible for 35 to70% of accidents, incidents, and non-conformances. This range generally holds true in all industries. Error is generally defined as a deviation from accuracy or completeness. More specifically, the medical community defines an error of execution as “the failure of a planned action to be completed as intended” (Institute of Medicine 2000). Crosby also acknowledged the significance of human error when he stated, “Most human error is caused by a lack of attention rather than a lack of knowledge.”

In the mid-1970s, the National Aeronautics and Space Administration (NASA), and subsequently the Federal Aviation Administration (FAA), became significantly involved in human error because of concern over the increasing number of accidents. (Helmreich, Merrit, Wilhelm 1999). They sponsored a study that examined voice and data recorder information (black boxes) obtained from aircraft accident scenes. The study determined that cockpit crews were not performing in the professional manner that their aircrew training was expected to provide. The study concluded that the human element in the cockpit was the initiating factor in many of the accidents. Inappropriate decisions and reactions to common flight conditions by pilots in command actually created tragic accidents. In addition to lack of effective leadership, another major factor contributing to accidents was the lack of assertiveness on the part of crew members who knew that something was not right but did not feel free to speak up. A reenactment of the crash of Eastern’s Flight 401 into the Florida Everglades, presented on the Public Broadcasting Service Nova series program entitled “Why Planes Crash”, paints a vivid picture of the disastrous affects of lack of leadership and lack of assertiveness on the part of the aircrew.

In response to the lack of performance by cockpit teams, special training referred to as Cockpit Resource Management was created. The cockpit training was so successful in reducing accidents that the aviation industry broadened the training to include flight crew members and maintenance personnel, renaming it Crew Resource Management (CRM). Since its initiation in the 1970s, CRM training has become a part of standard training for U.S. commercial, military, and private aviation. It has been expanded to aviation training throughout the world.

CRM focuses on training individuals and teams in a number of error management areas. The training provides techniques designed to identify the Mind Traps affecting individuals and teams during daily operations that can set them up for error. It also provides them with Tools including communication approaches to improve their combined knowledge and interaction of the entire crew to detect and avoid error opportunities. With assistance from the University of Texas Department of Psychology, Aerospace Crew Research Project, the research agency for the Federal Aviation Administration, CRM has evolved into an acceptance and recognition of human limitations that can result in errors. The basic starting point for managing human error is to understand and accept Cicero’s statement in 200 BC that “To err is human.” Although this statement suggests that there is nothing we can do about errors, the Pulitzer Prize winning author Pearl Buck said, “Every great mistake has a half-way moment, a split second when it can be recalled and perhaps remedied.” Error management is based on the premises that we can take advantage of this half-way moment. We can learn to recognize when we are about to make a mistake and we can be trained to manage human error by learning to detect, avoid, mitigate, and preclude the recurrence of errors. Due to the successes in aviation and the recognition that human elements are the initiating factor in almost every organizational accident, incident, and error, a number of industries are adapting the CRM training approach to their specific needs.

Synergy of COQ and Human Error Management
Based on the established high percentage of COQ related to sales and the high percentage of errors attributed to humans (35-70%), COQ and human error are both areas of opportunity for the significant improvement to an organization’s bottom line. Developing a solution to reduce these percentages requires examination of key elements of COQ and human error management and how they can work together to improve economic value.

Most quality cost models are based on a PAF classification (Punkett and Dale 1987). The basic categories of the PAF Model were identified by Armand Feigenbaum (1956) and are described as: 1) Prevention—Refers to those actions taken to ensure that a process provides quality products and services, 2) Appraisal—Actions that are designed to measure the levels of achieved quality, 3) Failure—Actions taken to correct quality in products or services that are both internal (within the organization) and external (after delivery to the customer).

The ultimate goal in reducing COQ is to eliminate failure and to sustain a quality system through continuous prevention efforts with minimal appraisal activities. Human error management techniques use the data from appraisal and failure activities to assist in establishing and sustaining a preventive culture. Again, since human error has been cited as causing up to 70% of non-conformances, reducing human error can have a major impact on reducing failures that result in decreased COQ and major improvements to the bottom line.

An example of Crew Resource Management training being successfully applied in other industries is the benchmark study by the Institute of Medicine (2000) which showed between 44,000 to 98,000 deaths occurred each year due to human error. The study recommended that the medical industry adapt the proven techniques of Crew Resource Management. Since that time, fire departments have also recognized the value of CRM and have created a major effort to adapt these same techniques to the Fire Service. Gary Briese, Executive Director of International Association of Fire Chiefs, put the importance of their efforts in perspective when he stated, “ In the 10 years it will take CRM to be introduced nationally, we will attend 1,000 firefighter funerals…I can’t get that out of my mind.”
Ongoing research at the Aerospace Research Project continues to expand CRM through process improvement efforts. They define error management as “using all available data to understand the causes of errors and taking appropriate actions, including changing policy, procedures, and special training to reduce their incidence of error and minimize the consequences of those that do occur.” Clearly, the activities associated with error management support organizational efforts of prevention, appraisal, and reduction in failures as a means to reduce COQ.

Methods and Approaches
As shown by the date of Cicero’s statement, human error has been around for a long time. However, proven results of the application of error management techniques show that with awareness of human Mind Traps that cause errors and through the application of error management Tools, human error can be detected, avoided, mitigated, and precluded from recurrence. In his book, Human Error, James Reason noted that human psychology cannot be ignored. Error management adaptations of CRM include addressing a number of error management areas as shown in figure 1.

The number of management areas and training emphasis in each area depends on the specific industry or occupation being trained. For example, in law enforcement the number one fatal error by police officers is the Mind Trap of a risky attitude, (e.g. trying to be a hero rather than understanding reality, impulsivity). In training of police officers, emphasis is placed on understanding Attitude Mind Traps and the error management Risky Attitude Antidote Tools (e.g. “It could happen to me”, “Taking a chance is foolish”).

In his book Managing the Risks of Organizational Accidents, James Reason created what he referred to as the Swiss Cheese model which graphically displays lines of defenses that an organization creates in an attempt to engineer out the possibility of human error. The Swiss Cheese Model has been adapted in figure 2 to illustrate how the barriers of technical, cultural, organizational, and the individual are defenses against error. Identifying the individual as “the last line of defense” has been attributed to Dr. Edward Deming. Unfortunately, as Reason points out, many of these barriers can have holes like that of Swiss cheese allowing an error opportunity to penetrate all the defenses resulting in a loss. In addition, these defenses are not static. Depending on specific circumstances for each error opportunity they are changing all the time. Error management provides Tools whereby individuals and organizations can detect human Mind Traps and fill the holes that lead to human error.

An explanation of the application of error management techniques from the perspective of an individual or last line of defense helps illustrate the error management process. Phillip Crosby also stated that “Most human error is caused by a lack of attention rather than a lack of knowledge.” In the terminology of CRM and error management, lack of attention is identified as the Mind Trap “Loss of Situational Awareness.” “Loss of Situational Awareness” has been identified as the number one cause of human error. This poses an interesting question. How do individuals recognize that they have lost Situational Awareness and how can they regain it? There are a number of error management signs that can help an individual identify that situational awareness (e.g. distraction, fixation) has been lost as well as error management Tools to help regain situational awareness. One of the most powerful error management Tools that humans have is the gut feeling that something is not right which Malcolm Gladwell refers to as an “adaptive unconscious” (Gladwell, 2005). This gut feeling has been shown to be very effective in regaining situational awareness.

Because of the differences in organizational structure, culture, and technical processes, and the reality that one training approach does not meet every organization need, human error management must be adapted to the unique characteristics and needs of each organization. When discussing the application of CRM related training to the Fire Service in the book Crew Resource Management for the Fire Service (2004-2011), Randy Okray and Thomas Lubnau II stated that, “It is up to each department to decide what best fits their local culture.” To be effective and credible, the facilitator trainers should be thoroughly familiar with all aspects of error management for the specific industry they are training. This background knowledge is necessary as they work with the organization in the development of a case for intervention, conduct of the initial training and implementation, sustaining implementation, and evaluation of the effectiveness of the error management program. Initial and sustaining implementation activities should be supported through the training of senior management and middle management. In addition training is needed at the individual, program, and team levels. Success in implementation is assisted by
identification and training of program-unique error management coaches. All these activities result in an improved capability to break the chain of events that can result in individual and group errors and sustain the training as it becomes a part of the organization culture and structure.

Expectations for reduction in errors, decrease in cost of quality, and improvements to the bottom line
After training, the implementation of basic techniques and an organizational commitment to vigorously pursue the reduction of errors, an error management culture has been shown to mature into individual and group activities, significantly decreasing COQ and improving the bottom line. These activities include: 1) Focus on detection of latent errors, 2) Conducting thorough analysis of anomalies to determine systemic factors leading to errors, and 3) Open sharing of resulting information. Implementation has also resulted in important by-products including: improved communication, team building, and creation of an open atmosphere to speak up when things do not seem right.
One error management technique being successfully adapted in aviation, medicine, and aerospace is that of anonymous reporting of near misses. The application of error management techniques in an aerospace company resulted in 43% reduction of accidents in a two-year period. By instituting reporting and detailed analysis of events and near misses, the Norwegian Railroad (Chris Hart, undated) achieved 37% reduction in lost time and 40% reduction in accidents. Another organization was recognized in their incentive fee for their incorporation of error reporting.

Error management should not be considered as a new program but rather as an enhancement to existing activities. One senior manager said, “I am not giving you a new task you have plenty to do already; but I am giving you techniques that will help you be a better employee and leader.” These techniques compliment and support ongoing activities in a variety of activities including risk management, environmental safety and health, quality management, safety, CMMI, Lean Thinking and Six-Sigma.

Error management related training and its implementation has resulted in many positive comments and improvements in organizational performance and effectiveness. One program manager commented that “All the team members now have a common knowledge core to work with during a high stress time to detect the possibility of an error.” After error management training of a machine shop team, their anomaly reporting system status was raised from “Yellow-Red” to “Green. Another organization noted an increase in reporting of near misses that might not have been previously reported. They found that the information obtained from reporting of near misses has led to the identification and analysis of systemic conditions that could lead to future accidents and incidents.

Conclusion
Because of the established high percentages of COQ related to sales and the significant percentages of errors attributed to human error, the application of error management concepts and techniques can make significant contributions to reducing the cost of quality and improving an organization’s bottom line. In their survey of models and best practices, Schiffauerova, and Thomson confirm that quality improvement and cost measurement processes bring about a huge reduction in an organization’s COQ. Error management activities can be correlated to the three elements of COQ and the PAF model: prevention, appraisal, and failures. Error management training fits solidly into the prevention element. Since error management uses data from all sources, inputs from both appraisal and failure elements of the PAF model provide key information for adapting, implementing, and sustaining error management methodologies throughout an organization.

Lack of leadership and assertiveness on the part of individuals are the most common contributors to human error. It is essential that organizations understand the role leadership has on creating the right culture where individuals feel free to speak up when things do not seem right. In addition to creating cultures for effective leadership and assertive team members, high reliability organizations recognize that they must have both proactive and reactive processes (Weick and Sutcliffe, 2001) in place to detect, avoid, preclude, mitigate, and preclude recurrence of errors. James Reason’s Swiss-Cheese model graphically illustrates how a chain of events leading up to a hazardous event can be broken by recognizing and filling any one of the holes in the defenses. Everyone in the organization must consider themselves the last line of defense. Regardless of their position or role, everyone must be constantly looking at how to fill the holes in technical, culture, organization, and their own individual areas

Helen Keller said “you can’t change the whole word; but you can change the world where you are.” The challenge is that everyone, regardless of their position and rank in the organization has a responsibility to use all the information available to be proactive in detecting, avoiding, mitigating, and precluding recurrence of errors. Organizations should consider the application of error management concepts and techniques not as a new program but as a valuable tool to compliment and supplement their ongoing activities.

References
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