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Human Error Solutions : a systemic approach
- 1. MAY-2020 Christophe OUDOT –Human Factors Specialist Christophe.oudot@altran.com Human Error vs Human Performance
- 2. Purpose of thispresentation Human error and performance studies have been growing exponentially over the last few years. It recognizes the importance of human nature in our day-to-day. In this material, we will present you a new and systemic approach to go beyond classic root cause analysis and define a range of concrete solutions. In order to manage human errors you need to understand what is a human, how does his brain works, what are his preferred behaviours in front of an issue. We will answer following questions: • What is a human error and why are we making them? Who or what is to blame? • How to go beyond a simple root cause analysis? • How to (re)find the motivation to seek for a solution? • How does culture play a role in human error avoidance? Human Error Vs Human Performance2
- 3. The author: ChristopheOudot, Altran Human Factors Specialist 3 Human Error Vs Human Performance ERP: MPS-MRP Software Process Improvement Change Mgt IT Governance Functional Analyst Project Manager CMMI expert Process Architect IT Governance advisor Change Mgt trainer & coach Years 1999-2001 3 years 2002-2007 6 years 2008-2012 5 years 2013-2016 4 years 10 100 500 1000 Human Factors Specialist Number of people impacted per year Transformation LeaderKnowledge & Innovation Manager Agile Transformation Sherpa 2017- 2000 Community Builder, Culture Change Manager Team Coach, Technology & Happiness Manager https://www.linkedin.com/in/coudot/ Christophe.oudot@altran.com+32498035324
- 4. 4 Human ErrorVs Human Performance What do they have in common? Low-performing people miss deadlines, are less focused on details or on what is really important, have poor Communication and Collaboration with Colleagues, lack of Enthusiasm and Energy They make a lot of human errors…. ? High-performing people don't have problems citing their goals. They determine what they must accomplish, set goals, and organize themselves to achieve these goals efficiently. They act right first time…
- 5. 5 Human ErrorVs Human Performance They are human beings with energy and needs! ? Need to understand HOW the system works, how to perform tasks Need to feel WHO is involved and with WHOM relationships will be positive Need to be inspired by a clear WHY, the purpose Need to perform WHAT has to be done to achieve concrete value-added results If you want to help them, understand them.
- 6. 6 Human ErrorVs Human Performance Our agenda 1 WHY Human Factors is a Hype Topic? 2 HOW to Understand & Classify Human Errors? 3 WHAT systemic approach can we use to avoid Human Errors and increase Performance?
- 7. 1. WHY “Human Error”is a hype topic?
- 8. 8 Human ErrorVs Human Performance Humans are the cause of 94 percent of all motor vehicle crashes 80 percent of airplane accidents 60 to 80 percent of work accidents in industry
- 9. And consequences canbe huge 9 In 1986, the Chernobyl disaster caused the death of thousands of people, spreading a radioactive cloud over all Europe. The accident occurred during a safety simulation exercise. A faulty equipment caused the explosion of Space Shuttle Columbia on its return on February 2003, killing all seven mission members. Damage sustained during the launch was not analyzed before the return. In 1994, The Piper Bravo Oil Rig exploded, because safety inspectors forgot to replace a single safety valve. Within two hours the 300 foot platform collapsed and 167 workers were dead. In 1989, the California bound tanker Exxon Valdez spilled close to 760,000 barrels of oil. The captain had been drinking heavily the night before the tanker crash.
- 10. Most of thepeople think that humans are stupid Human Error Vs Human Performance10 o Critical judgment "after the fact“ o “Who is wrong ?” takes precedence over “What’s wrong ?” o Makes people get defensive o Problems stay buried for years o Favorise a crisis orientation
- 11. Other think thereis no solution … Human Error Vs Human Performance11 ! Bad Luck ! Can’t be helped… We’ll wait for next time… Errare humanum est…
- 12. “Human Errors” isa hype topic because it generates catastrophes and it is a never ending story. Each error is an improvement opportunity Group together engineers, human specialists and creative people to define solutions Errare humanum est … perseverare diabolicum Human Error Vs Human Performance12
- 13. 2. HOW to understand &classify Human Errors?
- 14. What is ahuman error ? 14 A human error is an inappropriate action or a inappropriate response that results or could result in an undesired outcome voluntary or unvoluntary of a person or a group of people with potential consequences for customers, colleagues, the environment or the company's image Human Error Vs Human Performance
- 15. Classification using the6M Method, figures from pharma industry 15 Human Error Vs Human Performance 15-30% 25-40% Doc, training, process variability… Organisation, Communication, Mistaking, Decision making… Root Causes
- 16. Human Factors Analysis andClassification System (HFACS) used by US Navy 16 Human Error Vs Human Performance Four levels of potential failure according to https://www.hfacs. com/hfacs- framework.html : (unintentional behaviours) (willful disregard of the rules)
- 17. Classification by partof the brain involved: reflexes, emotions, decisions 17 Analysis and decisions, Creativity We have 3 kind of brains ! Examples of stress : unknown context, time pressure, environment too complex or saturated with information... At least 2 speeds ! https://www.youtube.co m/watch?v=JiTz2i4VHFw Under stress, the reptilian brain takes over! Reactions, reflexes (flight, fight, freeze) Emotions, Memory & automatisms
- 18. 18 A clear messagefor one will not necessarily be clear for the other, or it will not be understood in the same way... We have Different Perceptions of the same Reality Human Error Vs Human Performance
- 19. What were theroot cause(s) of your human error ? Using your own example of human error in your personal or working environment Share what were its root causes. Human Error Vs Human Performance19 Keep in mind a human error is often multi factorial Ishikawa
- 20. TOP 12 causescollected during post error interviews 1. Time/Deadline pressure 2. Distractions/interruptions 3. Multi-tasking 4. Vague advice or subject to interpretation 5. Excessive confidence, habits, routine 6. Start/ End of a working day
- 21. TOP 12 causescollected during post error interviews 7. Collegues’ pressure 8. Changes & unknown 9. Physical environment 12. Stress / Moral exhaustion 10. Unavailable or inconsistent documentation 11. Inefficient training
- 22. What were theroot causes of your mistake? 22 Human Error Vs Human Performance 23% 20% 14% 13% 6% 6% 4% 4% 3% 3% 1% 1% Distractions/interruptions Multi-tasking Time/Deadline pressure Excessive confidence, habits, routine Collegues’ or others' pressure Unavailable or inconsistent documents Vague advice or subject to interpretation Start/ End of a working day Inefficient training Changes or unknown Physical environment Moral exhaustion, lack of motivation Poll result on a group of 40 consutlants
- 23. What was theconsequence of this mistake? 23 Human Error Vs Human Performance 57% 25% 11% 7% people upset around me None material broken injured people Poll result on a group of 40 consutlants
- 24. 3. WHAT systemic approach canwe use to avoid Human Errors and increase Performance? Elimination Prevention Replacement Facilitation Detecti on Mitig ation
- 25. 5 steps toreduce human errors with a human perspective 1. Change the glasses used to tackle this issue 2. Understand the 4 dimensions of human beings 3. Set-up a multi-barrier system 4. Communicate properly ideas and plans 5. Celebrate successes & focus on resources instead of issues Human Error Vs Human Performance25
- 26. 1- Change glassesused to tackle this issue 26 What is the dominant culture today in your organization ? Human errors progressive approach : Our processes are complex and not perfect. It works thanks to humans who deal with complexity on a daily basis. Let's simplify and improve our processes and working conditions, and problems will decrease. Let's push our processes to adapt it to people. Human Error Vs Human Performance Human errors conventional approach : Our processes are perfect. Human beings are the cause of accidents. Let us get rid of incompetent people and the problems will decrease. Let's push people to adapt themselves to the process.
- 27. 2- Understand the4 types of needs of human beings 27 Introversion, Prefers working alone Thinking, focus on the tasks Feeling, focus on the Relationship Extraversion, Prefers interaction with others Insights Discovery® Let’s do it NOW Let’s do it TOGETHER Let’s do it RIGHT Let’s do it IN A CARING WAY Need to be inspired by a clear WHY Need to understand HOW to perform tasks Need to feel WHO is involved Need to target a concrete & feasible WHAT
- 28. 3- Identify yournatural preferred barriers … 28 Introversion Task Relationship I focus on the most important as the most urgent. I seek concrete solutions I like using tools to prevent problems I explain the "why" I encourage sharing I show my enthusiasm and optimism I bring energy being a good story teller I encourage and give feedback in real time I value team work I take care of my health & my colleagues. I reduce unnecessary stress I analyse the facts to determine the best process I do things one step at a time. I like to know the detailed steps to follow Procedural barrier Technical visible barrier Organisational & Learning barrier Extraversion Human & Culture barrier
- 29. What type ofbarrier do you prefer? 29 Human Error Vs Human Performance 30% 29% 21% 20% Technical visible barrier Organisational & Learning barrier Procedural barrier Human & Culture barrier Poll result on a group of 40 consutlants
- 30. … and set-upa multi-barrier system 30 Introversion Task Relationship Procedural barrier Technical visible barrier Organisational & Learning barrier Extraversion Detailed Procedures Clear and standard Roles & Responsibilities, Checklists Co-analysis of problems, Near misses and root causes 5 why, Multi tasking avoided Error proofing system, Visual Capacity Mgt, KPI First Time Right focus Lean Projects Rules with incentives Expert guides Coaching attitudes Gemba (management on shop floor) Process validation involving shop floor Experts accessibility Performance Mgt-lead measures Time for feedback or pre-job info Interactive learning sessions Brainstorming & After Actions Reviews Team building events Positive atmosphere creation Engaging feedback sessions Continuous Improvement ideas Competence Development Human Error Vs Human Performance Human & Culture barrier
- 31. Limited number of «Human Errors » Potential Errors 4- Communicate properly ideas and plans... 31 Reason’s Swiss Cheese Model Human Error Vs Human Performance
- 32. Limited number of «Human Errors » Potential Errors … using concrete examples… 32 Car manual Label on the valve The staff of the station or the car rental company Tank diameter
- 33. …and involving theshop floor! 33 I am concrete, ideally with an object. I check that my colleagues agree there is a problem. For this I ask questions. We agree there is potential for improvement. Together we look for a solution, we evaluate it, test it, challenge it with others (cost versus benefit). Many of us want the situation to change. We take the remarks into account, identify and motivate the sponsor who could support our idea by demonstrating the benefits. We meet with colleagues who will be impacted by repeating steps 1 and 2. 2) Share motivations & solutions 1) Show the issue 3) Launch improvements + + Human Error Vs Human Performance
- 34. 5- Celebrate successes… 34 Introversion Task Relationship Congratulateskey actors involved in improvements Develop Honor, recognition, competition Organize a team building Nourish the culture of the team Develop freedom, letting go, ideation Spend more time to help people to grow Develop Acceptance & relatedness, empathy Make improvement visible : monitor KPI Design positive KPI on Happiness, Trust… Develop Curiosity Extraversion Human Error Vs Human Performance
- 35. 5- … andfocus on resources instead of issues 1. Develop strengths based leadership (strenthsfinder) https://www.gallup.com/cliftonstrengths/en/strengt hsfinder.aspx Human Error Vs Human Performance35 2. Help your clients to identify their intrinsic motivating factors https://management30.com/practice/moving-motivators/ 3. Replace problem solving by appreciative inquiry https://en.wikipedia.org/wiki/Appreciative_inquiry 4. Look at the video “4 best tips to be happy (at work)” and subscribe to this Youtube chain https://youtu.be/J_kxCNq5Gq8
- 36. 36 Thank you for your atention tHumanError Vs Human Performance