It is widely accepted that human error is the major source of problems associated with quality, production and safety in many industries.

SQR Consulting can deliver a range of Human Factors training workshops tailored to an individual client's requirements aimed at eliminating the process causes of human error.

The influence of Human Error in Business and Industry

Global examples such as Three Mile Island, Piper Alpha Oil Platform, Chernobyl, Longford Oil Refinery, HMAS Westralia and the Concorde disaster have all, after thorough investigation, highlighted the influence that human error played in contributing to the eventual disastrous outcome.

For example, an analysis of error incident data has shown :

• 98,000 medical deaths annually (in the USA)
  
• 80% of aviation accidents
  
• 75% of maritime accidents
  
• 70% of nuclear accidents

... ALL due to Human Error!! 

To use a phrase from a popular global television game show –

“... You (humans) Are The Weakest Link!! ...”

With the advent of increased reliance on technology in our day to day activities, it has now reached a point where improved safety, quality and business processes can only be achieved by understanding human error mechanisms.

Although it is unlikely that all human error can be eliminated from every situation, it is possible to understand the root causes of these introduced (human) problems and develop and implement systematic preventive strategies through the use of Human Factors training, tools and techniques. 
Human Factors training, tools and techniques can be utilised to train people on how to avoid making the errors he/she never intended to make.

However training alone will not prevent all human errors.

Organisational “Just Culture”

Businesses need to develop an organisational culture focused on quality, safety and the reduction of human error.

It also requires a paradigm shift from the arch-typical “Blame Culture” mindset to a more constructive “Just Culture” mindset whereby true (accidental) human error introduced into a system is actively reported to the organisation with no fear of blame.

In an organisation established under a “Blame Culture” mindset the tendency is for errors to become visible only as a consequence of the actual effect the introduced error has caused.

e.g. An aircraft’s engine falls off its wing resulting in a crash because of a failure to follow correct maintenance procedures and subsequent inspection procedures.

The opportunity to initiate corrective action to eliminate the effect of the introduced error can never be fully realised since the emergence of the subsequent (often disastrous) effect is the first indication that an error and/or errors had been introduced at some time earlier in the process.

In fact, in many cases, an introduced error may not result in a causal effect until such time as a combination of introduced errors working together create the subsequent effect.

In a “Blame Culture” mindset the majority of these individual “near miss” and/or latent errors will remain undetected until the correct permutation of introduced errors has occurred causing a sequence of events (the domino effect) resulting in a possibly disastrous outcome.

Conversely, organisations that exhibit a totally “No Blame Culture” mindset are not ensuring that people take personal responsibility and accountability for ensuring that human error (that can effect safety and indeed such things as bad quality) is minimised.

Under a “Just Culture” individuals who consistently introduce errors by flaunting the organisation’s systems and processes would be held accountable for their actions with subsequent justified (hence the name “Just Culture”) ramifications such as reprimand, demotion, or even employment termination, however, true (accidental) human error is treated with the appropriate level of “no blame”.

Having identified that human error has occurred, the objective is to determine the root cause of the introduced problem, identify the systemic breakdown and develop revised systems and processes that have a high degree of likelihood of preventing the recurrence of the originally introduced human error.

This can only be effective when human errors being introduced (including the “near miss” and latent errors) are being reported to the organisation rather than being covered up under a “Blame Culture”.

Once this reported data is analysed and the root causes have been determined then an organisation is able to implement effective corrective actions and preventive actions that can eliminate both the recurrence of existing introduced errors and prevent the occurrence of potential errors not yet introduced into the system.

This has the knock on effect of reducing the consequence whereby individual “near miss” and/or latent errors and potential errors are able to combine resulting in a disastrous outcome.

In 1993 Transport Canada hired Gordon Dupont from System Safety Services (SSS) as a special programs coordinator to develop, in close co-operation with the Aircraft industry, a human factors workshop for aviation maintenance personnel.

As part of that assignment the concept of twelve major contributors to human error to be known as “The Dirty Dozen” were identified, namely :-

• Lack of Communication
• Complacency
• Lack of Knowledge
• Distractions
• Lack of Teamwork
• Fatigue
• Lack of Resources
• Pressure
• Lack of Assertiveness
• Stress
• Lack of Awareness
• Norms

Each of the twelve contributors individually has the ability to cause the introduction of human error, however when one or more of the contributors combine together through a series of events then any number of disastrous outcomes may occur.ops were originally targeted at Maintenance Engineers within the aviation industry it soon became apparent that Human Factors training could benefit people with different occupations from any number of diverse industries.

In fact wherever there are humans involved as part of a system or process there is the opportunity for human error to be introduced.

In February 2003, Gary Wilkinson flew to Vancouver, Canada and attended a "Train the Trainer" workshop conducted by Gordon Dupont covering Human Factors training for Aviation Maintenance Engineers.

On his return to Australia, Gary re-modelled Gordon's original material in such a way that it can now be delivered to participants from any particular industry group.

SQR Consulting are able to offer Human Factors Training - Part 1 as a two day workshop either in-house or off-site.