You are facing a lot of human errors in your organization and you want to improve the performance of your team. Use this new and systemic approach to define a successful action plan.
Imagine - Creating Healthy Workplaces - Anthony Montgomery.pdf
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 this presentation
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: Christophe Oudot, 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 Error Vs 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 Error Vs 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 Error Vs 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?
8. 8 Human Error Vs 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 can be 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 the people 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 there is 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” is a 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
14. What is a human 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 the 6M 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
and Classification 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 part of 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 message for 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 the root 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 causes collected 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 causes collected 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 the root 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 the consequence 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
can we use to avoid
Human Errors
and increase Performance?
Elimination
Prevention
Replacement
Facilitation
Detecti
on
Mitig
ation
25. 5 steps to reduce 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 glasses used 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 the 4 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 your natural 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 of barrier 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-up a 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 the shop 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
Congratulates key 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- … and focus 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
