You have said that ERR is about increasing organizational reliability, but can it be implemented on a small scale? The ERR approach can certainly be applied to a single activity; in fact, that’s how the process begins. However, many RIFs cross organizational boundaries, and so ERR becomes increasingly effective as more activities are included.
Can you tell us about times when ERR has not worked well? Yes there have certainly been some. ERR relies on a fine-grained understanding of activities, and this can not be achieved without active participation of those whose work is being addressed. The “core team” are agents of transformation, but they cannot impose it. Where managers have tried to build a “core team” without including some people with recent hands-on experience of the kinds of activities being addressed, they generally struggle to succeed. A diagonal cross section of people from across the organization offers the best prospect for success. Another way to fail is by asking the “core team” to work on the most serious and pressing problems first, before they have built up their skill and experience.
You have said that ERR does not address errors of judgement, but is there a way of avoiding that sort of error? There are many ways of trying to avoid conscious errors and most organizations already use a variety of strategies to combat them. Errors of execution are generally dealt with much less effectively, and that is why we have tended to concentrate on them. However, we do offer advanced training that can offer fresh insights into avoiding conscious errors.
Is ERR an alternative to Six Sigma, or can they work together? Although ERR works well as a stand-alone approach, it is also complementary to Six Sigma, and they work well together. Some of the same people are likely to be involved in both.
How quickly would ERR pay for itself? Add up the cost of time spent on damage limitation when errors occur and you have a sense of how much you might save. If human error is implicated in 50% of your measured quality failure costs, and you reduce that by a few percent in the first year, you will have covered your costs. However, most costs associated with human error are not usually measured, although their effects are felt as efficiency burdens and frustrations.
Is top management’s support of error-proof activities usually from their experience with past and current failures, or are they looking at industry practices? I would really like to say that most people are looking at error proactively because they realize its value. Of course the reality is most people only start to look at human error when it becomes a big problem for them. Perhaps it is because they’ve experienced an error with serious consequences. Often, work on error is kicked off by something that needs immediate attention, but the lessons learned from studying those RIFs can often be applied throughout the organization. This encourages further work to improve human reliability, once its value becomes obvious.
I work in the railroad industry, and often, our locomotive engineers fail to cut out on the initial operating locomotive when changing directions. This, in turn, leads to delays. How would you address this type of issue? The work of a locomotive engineer is systematic. The use of a checklist is useful for avoiding forgetting steps in a process but cannot guarantee compliance, even where this is intended. The reality is that people will tend to rely on their memory and this creates vulnerability. We can look for ways in which we can better direct the attention of the engineers to “risk critical” parts of the task by reducing relevant RIFs. You will need to develop a core team, comprised of people from across the organization with relevant experience. Once these folk understand why human error happens, and have a systematic way of exploring the relevant activities, they will have no difficulty of reducing the probability of the kind of error that you describe. (Not 100% but a definite improvement) If you need help to develop a “core team,” details of a training program can be found on the SAM Group websites: www.statamatrix.com www.orielinc.com
Are there specific work scenarios where ERR is best applied (i.e., call center, data entry, manufacturing, etc.? ERR can be applied to any kind of work in which people are very familiar with the tasks. It has been used across all kinds of sectors and organizations (e.g. pharmaceuticals, aerospace, healthcare, financial services, transportation, food processing, IT providers, etc.) and at all levels. It has also been applied in all sorts of environments ranging from laboratories, to administrative areas, production areas, high security areas, hospital wards, and so on.
How do you handle resistance to cultural change when implementing ERR? To enhance an organization’s reliability, of course, there has to be cultural change. But that cultural change is a result of work on error, as much as it is a driver. When work begins on addressing RIFs, those that are easiest to identify and deal with tend to be those that are relatively tangible and “mechanical.” Many of these will have been an irritant to people and they will be pleased to see them being addressed. This reinforces the message that, “the focus is on activities rather than individuals,” which begins to dissipate a blame culture. This lays a foundation for starting to address more sensitive issues that might need attitudinal shift and a willingness to change deeply rooted ways of operating. Some occupational groups may well be more resistant than others but as those more willing to change demonstrate the benefits, those inclined to resist find their position increasingly untenable and difficult to defend. This is especially true where the consequences of error cause physical harm and/or damage reputations.
If you have a choice between starting with ERR, or say, something like Six Sigma, where would you start? I think it would depend on the organization and what kinds of issues it is trying to address. In areas where there may be a lot of repeat errors going on across the boards, I might start with something like Six Sigma, especially if the causal factors are relatively “mechanical.” For organizations worried about lower probability errors with serious consequences, I might be inclined to start with ERR. Or better yet, run and ERR program in conjunction with Six Sigma initiative, if both approaches can be useful. ERR tends to favor organizations with mature continuous improvement programs, but has worked well as a stand-alone.
If an organization is constantly taking on too many projects and people have too much to do, can the organization ever make good progress? To begin with, let me remind you of differences between stressors and structural Risk Influencing Factors (RIFs). While stressors might make life uncomfortable, they alone (usually) do not cause error. What they do is expose vulnerabilities in the design of processes, information systems, workplace facilities, and specific competence deficits. If your organization often takes too much on, that seems unlikely to change soon. However, that doesn’t mean that you cannot work on all of those other issues, so that everyone can better tolerate the pressures. As I explained during the Webinar, I was focusing on “errors of execution” (everyday slip-ups and lapses), and so my remarks apply in particular to that kind of error (and they are 85% of errors). However, errors of judgement and other more conscious kinds of errors are also affected adversely by stressors. The more conscious activities can also be made more robust, although an additional range of techniques is likely to be needed. In summary I would say, life in lots of organizations is too hectic for comfort, but you can still drive down your vulnerability to error with a systematic and well-informed program.
Does your model also include some form of standard work? I’m not clear about what this question is asking, although there seem to be two possibilities. (A) Does the ERR model address routine activities at work, like repetitious task? Yes very much so. Many errors of execution happen on familiar activities on which it is difficult to focus and sustain undivided attention. (B) Does the ERR model itself have any standard “off the shelf” fixes for common RIFs? Yes it does, although they might need adapting to specific kinds of work.
Where can I find the 60 questions? On the Oriel website: www.orielinc.com , titled the Error Risk Survey.
Where can I find the list of the 400 RIFs? The PIRCOS Knowledge Base (which details the RIFs) is licensed to SAM Group clients who want to train “core teams.” It is not normally supplied on any other basis.
Can/how does the Failure Mode and Effects Analysis (FMEA) methodology support ERR? You might remember that during the Webinar I explained the futility of trying to guess (forecast/predict) where low probability errors might occur. ERR works by identifying as many RIFs as possible in an area or stream of activity, and dealing with them proactively. FMEA works reactively, or speculatively, to understand contributory causes of a specific outcome and as such does not have a place in the ERR model. However, FMEA is a powerful technique and there is no reason why the PIRCOS Knowledge Base (which details the RIFs) cannot be “plugged into” FMEA to extend it’s utility when addressing human failure modes. We have done so many times, to good effect.
Have you seen more errors from the results of routine/repetitive work rather than performing multiple or various tasks for a person? Both kinds of work are vulnerable to errors of execution although the specific failure modes may differ. In the case of routine/repetitive work where people become very familiar and/or skilled at it, it might become almost impossible for them to focus consciously on it for more than a few moments at a time, however hard they try. Indeed if they try to it might disrupt their fluency on the task. They will also suffer decay of vigilance beyond (typically) about 20 minutes or so. It takes detailed and well informed design to maintain attention to detail on this sort of work, although ironically this kind of work is often regarded as “simple,” at least by those who don’t have to do it. In the case of somebody who has to perform multiple tasks, the problem is more so one of division of attention. This is especially difficult where these tasks are carried out concurrently, so that several things have to be “borne in mind” at the same time. Frankly, unless structural support is built into such work, it is just a matter of time before something gets missed, or mixed up.
The presentation was very fast paced. Will handouts be available? It would be useful to spend more time reviewing some of the slides. This material is only available on license to our clients. However, if you have any specific questions, we would be pleased to try to answer them. Many of the concepts mentioned during the Webinar are addressed in our white paper, “The Final Frontier: Improving Reliability by Reducing Human Error,” which is available for download on our website www.orielinc.com.
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