Avoiding Human Error - Creating the Right Environment

Introduction to Avoiding Human Error
While many factors can lead to errors, the human factor is by far the most significant contributor, with 35–70% of all errors attributed directly to human beings. In fact, the transportation industry reports that its human error rate is 80%. The Cost of Quality (COQ) ranges from 15–45% and a large portion of COQ can be directly related to human errors within an organization. As stated by the noted psychologist James Reason, “human factors cannot be ignored.”

The human factor is not limited to individuals. It is actually a complex situation that involves individuals, leadership, process, organizational structure, and culture. Recent publications and key reports also recognize the contribution of these elements to errors. The Shuttle Columbia accident report noted the organization’s impact on human error by stating “people’s actions are influenced by the organizations in which they work, shaping their choices in directions that they many not even recognize.” In its landmark publication “To err is human,” the Institute of Medicine (2000) reported that human error results in up to 98,000 deaths per year The report stated that 80% of error in medicine administration was directly attributed to human error A key report investigating the death of 14 firefighters in the 1994 Storm King Mountain fire outside Glenwood Spring, CO found that the firefighting community places too much emphasis on technology and not enough emphasis on human factors (Putnam 1995). In addition, The National Law Enforcement Officers Memorial Foundation identifies attitude as the number one in the list of ten fatal errors that have killed experienced officers.

Although the industries referenced earlier highlight more severe examples of human error, all organizations have a great need to create the right environment at all levels to detect and avoid human errors. Also, investigating and understanding where breakdowns have or may occur is essential to mitigate and preclude recurrence. When looking at errors, the tendency is to focus more on technical issues than human factors because technical issues are measurable, more easily understood, and more readily changed. When human factors are considered, solutions for nonconformance generally include statements like the root cause was human error; corrective action is to retrain and/or discipline the individual; and anomaly report completed. Unfortunately, this does not address the systemics or total environment related to the error, such as the process, organizational structure, or culture that may have set up or contributed to the situation and allowed the error to occur. Without looking for systemic issues, the true root cause may not have been determined and the adverse environment with the potential for the error may still exist to trap the next unsuspecting individual.

Cicero statement in 200 BC “to err is human,” still applies today. It is essential for an organization to have a proactive approach to avoiding and managing human error and creating the environment necessary to minimize the potential for error at all levels. The aviation industry’s highly successful Crew Resource Management (CRM) program addresses the human factors and interactions in the cockpit, which has significantly reduced the number and severity of accidents/incidents since its implementation (Helmreich, Merritt, Wilhelm, (1999). Similar proactive program are needed in all industries. Recently, an aerospace executive that requested and received specialized error avoidance training after a major incident stated “why does something have to happen for us to do something we should have done before it happened.”

Background on Ongoing Activities
The aviation industry initiated the CRM training program during the 1970s in response to the high accident rate, and it is the first proactive program designed to create the environment necessary to avoid human error. The Federal Aviation Administration (FAA) performed analysis of flight voice recorder data, which revealed that an unacceptable working environment between crew members in the cockpit caused most of the accidents. Very few accidents were due solely to technical conditions. In addition, the analysis showed that two primary factors leading to the accidents existed in the working environment: lack of leadership by the command pilot and lack of assertiveness by the crew members. This analysis was summarized in the Public Broadcasting Service Nova series program entitled “Why Planes Crash.” Combined, these tendencies lead to catastrophic results. Crew members often knew that a problem existed, but they did not feel comfortable demanding the captain’s attention or the captain did not pay adequate attention to the concerns of the crew. A prime example is the crash of United Flight 173 en route to Portland, OR on December 28, 1978. The co-pilot and first officer knew the plane would run out of fuel and asked the captain to check the fuel. When the captain did not respond, the crew did not assertively alert the captain of the fuel status and the plane crashed (National Transportation Safety Board Report, 1979).

A National Aeronautics and Space Administration workshop in 1979 on aircraft accidents is usually referred to the initiating event in the effort to improve air safety. Using research performed by the Department of Psychology at the University of Texas, the FAA established specialized cockpit member training in six error management areas: Situational Awareness, Communication, Attitude, Risk, Workload, and Group Dynamics. The training evolved over time with various names and is now referred to as Crew Resource Management

In 2001, the University of Texas, Department of Psychology suggested that the basic principles of CRM could be applied in other domains, specifically identifying the medical and maritime industries as prime candidates, (Helmreich, Wilhelm, Klinect, and Merritt, 2001). The Institute of Medicine recognized this need in 2000 and recommended “incorporating proven methods of managing work teams as exemplified in aviation industry.” The Fire Service also recognized the value of CRM and is adapting these same techniques. Gary Briese, Executive Director of International Association of Fire Chiefs, put the importance of their efforts in perspective when he said “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.”

Other industries have initiated adaptations of CRM, including Nuclear Power, Aerospace, Coast Guard, and Military Aviation industries. In fact, an Air Force Regulation establishes a CRM program for the Air Force. In its publication, the Air Force stated that although this type of training was “historically geared toward the operational flight environment, the potential exists to adapt the fundamental program principles to any tasks or functional areas requiring cooperation or time critical efforts.”

Pioneering efforts by Nancy Leveson at MIT analyzing major aerospace accidents showed that leaders and organizations can also create adverse environments leading to human error (Leveson, 2001). She referred to this adverse environment as “systemic conditions because the system which includes the individual as well as the organization broke down and allowed the error to occur” (Leveson, 2001). She recommended that accident investigations include the examination of the technical, human, organizational, management, and societal systemic conditions. Dr. Leveson’s approach included the usual accident/incident description of events and conditions and expands to include the review of systemic factors as the indicators for true root cause. This basic approach was used in the Shuttle Columbia accident investigation to assess the conditions, events, and systemic factors that caused the accident to occur. The approach pioneered by Dr. Leveson is being considered by other industries to determine the true root cause of an accident or incident.

Other tools to improve organization efficiency and effectiveness are Lean Thinking and Cycle Time Reduction. The application of these tools, which is often used in conjunction with Six Sigma to reduce steps in a process, includes reducing waste and close examination of the methods used to reduce human error (e.g., reducing workmanship errors is a major element of waste).

The aviation industry forged the path by creating a comprehensive human error program. Comparatively, very little has been done in other industries to establish a total system approach to avoiding human errors. Some industries are just starting robust activities, and they are beginning to understand the difficulty in creating the necessary environment in avoiding errors and obtaining acceptance on the importance of human factors to avoid errors. The medical and fire service communities have cultural similarities to that of the aviation industry in the 1970s and are finding difficulties with implementation. The aviation industry again provides valuable insight for those who research and adapt the lessons learned to their specific culture.

Although there are limited examples of a comprehensive, total system approach to human error outside of aviation, there are some exceptional examples on the consideration of human factors as a key component in avoiding errors. One example is the pioneering work in the Doctor Quality Incident Reporting System developed and implemented for employees at the Baylor Medical Center at Grapevine Texas (Atherton, 2002). The most significant aspect of this incident reporting system is the development of a new organizational culture regarding errors and error reporting that includes both employees and hospital leadership. Another example is found in the Fire Service’s landmark study on the Storm King fire where it recognized that continuing a primary focus on the technical aspects of fire fighting without considering human factors would not reduce the number of firefighter deaths in similar situations (Putnam, 1995).

When establishing robust error avoidance activities, industries and organizations must recognize and accept human fallibility and the potential for error and expand beyond industry adaptations to include the unique cultures within their organizations. One type of training does not fit the needs of every organization. The book Crew Resource Management for the Fire Service states that training must be tailored for every individual fire station (Okray and Lubnau, 2004-2011). Based on the author’s seven years of experience analyzing organizations and conducting training, an error avoidance culture can only develop by considering the existing leadership and workforce culture, adapting training appropriately, planning for strategic and tactical implementation, and developing a follow-up strategy to incorporate changes.

Figure 1 Error Management Areas - Traps and Tools

New Activities to Create the Right Environment
The starting point for implementing new error avoidance activities or methods is accepting that although the basic principles inherited from the successes of CRM activities must be considered, training must be specifically adapted and tailored for each unique organizational culture. Standardized training courses cannot fit every industry or every organization within an industry. Because errors are powerful and insidious, training and other activities must be developed and adapted for each organization to help individuals and groups raise their level of awareness of the potential for an error and the impact on activities. James Reason summarized it very well when he stated that we need to “create an environment of chronic unease…”

Pearl Buck, the Pulitzer Prize author, gave us hope in avoiding errors when she stated “Every great mistake has a half-way moment, a split second when it can be recalled and perhaps remedied.” As part of our efforts to create the right environment and avoid errors, we can learn to recognize when we are about to make a mistake and can be trained to take advantage of the split second before we make an error.

Training of individuals and teams to avoid errors in each error management area (e.g., Situational Awareness) focuses on understanding the Mind Traps that can prevent us from seeing that an error may occur. Through this understanding we are better able to recognize when we are about to make a mistake by sensing that something isn’t right. Training in error avoidance Tools assists us in avoiding the potential for error. Figure 1 gives examples of Traps and Tools associated with the six error management areas described earlier. One of the most powerful tools is intuition or the gut feeling that senses something is not right and by verbalizing it to ourselves or others it becomes real. In his book Blink, Gladwell, 2005 vividly describes this powerful tool, referring to it as “adaptive unconscious.” Evidence suggests that this powerful tool can be traced back to our primitive human nature when survival required its use and the integration of all our senses to determine and assess danger. Ideally, an organization and its leadership create an environment where it is expected for individuals to feel free to speak up without the fear of retribution.

Error avoidance training can use an adaptation of the Swiss Cheese Model, Figure 2, developed by James Reason to remind the individual, the last line of defense, to look at the adequacy of technical, organization, and culture defenses (Reason, 1997). To fill holes in these defenses, every person in the organization should be looking upstream to determine what could go wrong in any of the defenses they use or create. Therefore, individuals and team members need to be trained to look for what could go wrong.

Figure 2 Adapted Swiss Cheese Model

AIn an error avoidance culture, effective leaders are learning how they can adversely influence the behavior of members of their organization (Banda, Associated Press). Under certain circumstances, encouraging a “can do” attitude can be interpreted by team members as permission to take unnecessary risks. Leaders also understand that they must create and accept assertive followers (Abeyta, 1997) in order to receive the information needed to fully understand risks in making informed decisions. They need to instill a culture of encouraging bad news to travel at least six times faster than good news if they want their employees to really keep them informed on current situations and the risks associated with various actions. Additionally, they find it better to determine what happened rather than following the usual pattern of blame, discipline, and/or retrain.

Studies also show that leaders are working to improve their interpersonal skills, since leadership failures stem more from a lack of these skills than a lack of technical or business knowledge. From an error avoidance perspective, leaders are trained that sharing about errors made during their own careers demonstrates their humanity and proves beneficial to both the team members and the organization. It illustrates the leader’s expectation that errors are to be avoided but also recognizes human fallibility and the importance that everyone in the organization understands where the system broke down to cause an error, thereby avoiding future recurrence.

Both individuals and teams are using error avoidance techniques to carefully examine established processes and determine what could go wrong. Error avoidance Tools are used to examine the specifics of the task, equipment to be used, barriers to completing the task, and the ability of individuals and the team to perform the activity. Too often individuals and teams think they cannot make a mistake because of an approved or established process. They are forgetting that processes cannot evaluate themselves. It is people who care about processes and who can make errors by following a faulty process. As James Reason suggested, those organizations are considered to be high reliability organizations, such as Navy aircraft carriers or the nuclear power industry, which have created an environment of “chronic unease” about what could go wrong.

Due to the inherent diversity in individual personalities and the possibility of an adverse environment in their own organization, many individuals are reluctant to bring attention to errors and near misses or analyze errors within their organization. To overcome this situation, some organizations find it useful to start by analyzing incidents from other organizations as case studies and discussing how the incidents could occur in their own environment and how they can prevent it from happening.

One of the most promising practices for avoiding future errors is the report, analysis, and distribution of information about near misses. The aviation industry pioneered the creation of an anonymous reporting system called the Aviation Safety Reporting System (ASRS) used by both flight crew members and maintenance personnel. Errors are submitted anonymously to an outside organization, the information is analyzed, names and identifying flight information is removed, and the analysis of the event and suggestions for preventing the incident in the future are distributed throughout the aviation industry. The individual submitting the information is provided an acknowledgement of its receipt and is protected from retribution. It is more important to understand all aspects of the problem than to find someone to blame. The system does, however, include methods to deal with individuals abusing the system. As it should be, unsatisfactory behavior and abuse of using the system is not tolerated. Public access to samples and resulting analysis from the ASRS can be found at asrs.arc.nasa.gov/main_nf.htm.

In 2004-2011 an aerospace company created a propriety system to receive and thoroughly analyze near misses and distribute the results. The organization recognizes that near misses are a source of valuable information to avoid future errors. Information about the near misses is distributed throughout the enterprise, and individuals submit feedback on how the information helped them avoid the same or similar errors. The net result of these activities was a 26% increase in reporting of near misses and a 78% reduction of incidents. In 1999 Westrum identified the importance of “looking for and listening to faint signals” that may indicate the potential for a problem or error. Another approach looking for what could go wrong by a high reliability organization is described in Managing the Unexpected (Weick and Sutcliffe, 2001).

To encourage error reporting, some organizations have created a program where individuals identifying areas where they have or may have made an error are recognized with an award. By identifying these possible errors, an organization can review whether an error actually occurred and determine whether or not it can be corrected. Additionally, it may highlight the necessity of requiring additional training for the individual or teams in the specific area where the error occurred. This approach is widely accepted by the organizational members and provides another example where creating the right environment to determine cause is more important than individual blame. It also makes individuals more willing to accept responsibility for actions in their work activities.

Arguments for the Proposed Activities
The biggest argument for the implementation of error avoidance activities is the acceptance by numerous industries and organizations that human factors must be considered. This was specifically emphasized in the report on the Storm King Mountain fire. In addition, and based on the diversity of industries trained by The Center for Error Management, many industries are adapting broad-based error management techniques to avoid human error. For example, law enforcement agencies are being trained using basic CRM principles with special emphasis on recognizing the Mind Trap of a “risky attitude” and how to counter this Trap by the use error avoidance Tools.

Organizations are beginning to realize that they have a tendency to blame an individual rather than taking time to thoroughly analyze the situation to determine a systemic breakdown in the organization that allowed the incident to happen. To demonstrate a resolution to a non-conformance, it is easy to identify the individual who committed the error and define corrective action as discipline and/or retrain the individual. After seeing the repetition of the same or similar incident, customers ask more questions about true root cause and the corrective action plans to prevent future occurrence. As a result, more organizations take time to find the true root cause and established techniques to more easily identify it in future incidents. A good example of this is the NASA root cause analysis approach (Bradley, O’Connor, 2003) that follows many of the concepts advocated by Nancy Leveson.

Error avoidance must be considered a series of techniques and methodologies that can be incorporated throughout an organization rather than a new stand-alone program. In addition to flowing down these techniques to various programs, one aerospace company embracing error management recognizes the importance of creating an atmosphere for individuals to speak up and instituted a proactive two-way communication program encouraging leaders to understand the error and all its causes versus placing blame.
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Error and near miss reporting is the next logical evolution of CRM-based programs. As discussed earlier, Baylor University Hospital has reported extraordinary results after establishing an anonymous reporting system for errors and near misses (Atherton, 2002). The reporting system achieved up to a 500% increase in responses and because of the data being readily available, the time required to track and make improvements was reduced up to 50%. The concentrated efforts and commitments of the leadership team created a culture that accepts and encourages reporting of errors and near misses. Many features of this reporting system were modeled after the highly successful FAA Aviation Safety Reporting System (ASRS).

An aerospace organization with specialized and detailed tasks by machinists, tracked a specific area they called “mental lapse”, or loss of situational awareness. After training team leadership and individuals by The Center for Error Management, this mental lapse category was improved by 30%, from a “red” level of concern to a level of “green” (CEM training 2004-2011). The primary focus of the training was to help facilitate open discussions with the machinists, leaders, and internal customers to bring up potential problems on received work orders and in process concerns. In addition, training was provided to facilitate smooth transitions during shift changes and to encouraging joint discussions on assignment of cause and corrective action when an anomaly occurred.

Justification of Why Proposed Activities Can Create the Right Environment
Implementing error avoidance methods and techniques as part of the organizational culture yields outstanding results. The suggested activities are proactive and are designed to detect the potential for and the avoidance of errors. Organizations must recognize that some errors will occur despite all efforts and when an error does occur, they must have a solid reactive effort to identify the error; mitigate it, if possible; and perform error analysis to determine systemics to prevent recurrence. Additionally, the activities must be specifically tailored and adapted for the industry and individual organizations. The bottom line is that a single approach cannot fit every organization.

Creating an environment where individuals and team members are owners of organizational success has proven to be very successful. A foreign object elimination (FOE) program demonstrated that when the operators/technicians/laborers were the suspected cause of a foreign object induced failure, the team took undirected action and cleaned up a shop beyond expectations, demonstrating a significant pride of ownership. An assembly shop that had been an eye-sore became an organizational showpiece for customers and provided a great sense of pride for employees.

When leaders are trained in error management techniques, they become sensitive to the many ways that what they say and how they say it, including the subtleties of body language, can influence their teams to cut corners, take chances, bypass procedures and not feel free to speak up about concerns. If the leader understand these sensitivities, they can become a better leader by encouraging Assertive Followership and creating expectations that team members need to speak up to identify things that could go wrong.

Thorough systemic analysis of major anomalies has demonstrated the need for more human error awareness, proactive understanding, and sensitivity for maintaining situational awareness. In addition, it confirmed the need for a “no blame” organizational environment that rewards near miss and active error reporting. The FAA’s success with ASRS verifies that a reporting culture reduces the cost of quality and establishes a more productive work force through fewer missed days of work by employees. As an example of effectiveness of error reporting by the another organization, the FAA has data showing that after implementing near miss reporting and analysis, the organization achieved a 40% reduction in accidents and a 37% decrease in lost time (Chris Hart, undated). Another organization was recognized within an incentive fee for their incorporation of error reporting
Because some errors can result in injury or even death, efforts to avoid errors must be a prime objective for every organization. In addition, having a solid and proven error avoidance program in place sends a strong message about the organization’s commitment to current and future customers. Successful reduction in errors, accidents, and injuries combined with a decrease in workmanship may be used to assist in negotiations with insurance organizations when determining rates.

Considering the high percentages of human error and the significant influence these errors have on the cost of quality, creating the right environment to avoiding error has a remarkable positive impact on the organization. Creating the right environment for avoiding human errors reduces the cost of quality and injuries and improves the bottom line, and customers like it. The development of an organizational understanding of human fallibility results in involvement by leadership, improved team communication, and team building.

Anticipated Directions of Future Activities
Envisioning the ideal environment provides a roadmap of the activities needed to avoid human error. Many activities, although fragmented throughout many industries and organizations, are starting the process of creating the desired end result. For those industries with a fairly robust program, future activities will focus on extensive specialized training to introduce and sustain greater error avoidance awareness. This emphasis will assist all members of the organization to develop an environment of “chronic unease” and better able to effectively maintain situational awareness. The overall concept of error management and lessons learned from CRM will expand into other industries, and industries that have already started implementation will continue to increase their activities and scope. As CRM concepts become more widely understood, other industries will seek out training based on the CRM principles, and include methods for adapting the principles to their particular organization. Many organizations will learn and apply the experiences from other successful organizations and intensify their activities to focus on what could go wrong with ongoing/planned activities and processes. In addition, increased individual and team awareness will expand the well recognized medical Hippocratic Oath “Do No Harm” to include an assertive dedication of “Allow No Harm” by actions of others.

When looking at the desired end result, the individual feels free to speak up when things seem wrong and shares information with others on errors they made or techniques used to avoid an error. In this ideal environment, the leader encourages high productivity and error-free performance as the expectation, but the leader creates an environment where individuals feel free to talk about anything that doesn’t seem right without the fear of retribution. The leader creates a team environment where anyone feels free to be a courageous follower and stop an operation they feel may cause an accident or injury. The leader rewards individuals for avoiding human error, and the leader’s actions are fully supported by a senior organization leadership structure. The organization openly shares information about accidents, incidents, and near misses so individuals can use the information to avoid future errors. Insurance rates decrease as reports show that incorporating a near miss reporting and analysis system with proactive error avoidance activities significantly decreases the number of injuries, lost time, and payments of workman’s compensation. The organization recognizes and takes preventive actions so organizational culture, structure, and communications do not inadvertently encourage individuals to take unnecessary risks.

In addition, processes are written by individuals who understand the working level and who are implementing the process. This person works proactively with the individuals performing the job to thoroughly review the process and assess what can go wrong. A part of this examination includes how to use error avoidance tools to detect the potential for an error and avoid the error when implementing the process.

At the organizational and culture level, the management and leadership teams are trained in their roles in creating the right environment for error avoidance. They understand that the environment created by their actions, words, and deeds influence the behavior of the members of their organization. They are committed to understand what happened in an incident rather than looking for someone to blame. They support identifying what broke down in the system and what created the environment for the error and recognizes the value of the expertise in their own organization to avoid future errors. Leadership follows the proven practice of creating peer review teams. These teams operate independently and make periodic visits to functional areas similar to their own, evaluate the effectiveness of their error avoidance methods and techniques, and provide personal feedback to the individual team being evaluated. Management is not involved in these self assessments and is only informed on recommendations that need their attention for avoiding human error. To support internal activities on a routine basis, key individuals in the organization from various disciplines are trained as Error Avoidance Coaches. These coaches are called upon in special situations to conduct refresher training, e.g., a team that is about to perform a specialized task. They can also be called upon to be present during critical activities, and provide on the spot assistance for implementing error avoidance methods and techniques. This is an expansion of another option the organization can consider by establishing an in-house training team who receives specialized training in a Train the Trainer program for error avoidance.

In conjunction with creating and sustaining an error reporting and analysis system for near misses, the organization leadership encourages discussion about mistakes and sharing this information with other members. These activities result in the establishment of a Learning Organization where knowledge is openly shared for the benefit of everyone.

Implementation of the techniques and methods discussed above reduce human error and the overall cost of quality, while increasing the organization’s bottom line. The quality organization is able to focus more on prevention/avoidance activities and less on internal rework before shipment or correction of failures that occur after the product is delivered to the customer. Furthermore, the quality organization takes the lead to ensure that error avoidance techniques and methods are implemented throughout the organization.

Conclusion
When considering the high percentages of human error and the significant influence of error on the cost of quality, creating the right environment to avoid error offers a tremendous potential for a positive impact on the organization. Creating the right environment for avoiding human errors at the individual, leadership, and organizational levels, can reduce the cost of quality, avoid injuries, improve the bottom line, and is viewed by customers as proactive corrective action. To create the right environment for avoiding errors, there is a need for development of an organizational acceptance of the phenomena of human fallibility with an understanding of human mind traps that can lead to errors and tools to avoid those errors. These activities can result in a more effective and responsible workforce, a proactive leadership team, and an organization culture dedicated to avoiding errors. These activities send a strong message to current and future customers of an organizational commitment to proactive rather than reactive behavior.

In thinking of the end in mind, implementation of the techniques and methods discussed above will result in a reduction in human error, decrease of overall cost of quality and an increase in organizational bottom line. As shown in Figure 3, error reduction achieved from contributions from Error Avoidance Activities coupled with improvements in Appraisal Contributions, and Failure Contributions result in reductions in total Cost of Quality By incorporating these contributions the quality organization will be able to focus more on prevention/avoidance activities and few appraisal and corrective actions, e.g., internal rework before shipment and correction of failures that occur after the product is delivered to the customer.

Figure 3 Contributions to Reducing the Cost of Quality

In planning for changing to these new ways of doing things, everyone in the organization needs to be reminded of what Helen Keller said, “You cannot change the whole world, but you can change the world where you are”. Gandhi also put this in the proper perspective when he said, “You must be the change you want to see in the world.”

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