Exploring and preventing human error

Teamwork, self-management and cognitive training all lend a hand

By Michael TopfExploring and preventing human error 

There is an ongoing concern among business leaders today to identify methods to prevent errors in all aspects of their operations. From healthcare to manufacturing to research and development to transportation, errors can and do adversely affect diverse aspects of what we do each day at home or at work. The results can be costly and even tragic.

Errors are caused by a multitude of factors and can result in untold human suffering, as well as material and financial loss. Safety, health and environmental incidents and the resulting injuries, illnesses or fatalities offer a worst-case scenario.

Ships running aground, explosions, spills and releases, incorrect shipments, patients receiving the wrong medication and treatment and damaged equipment that hampers production and profits are only some of the possible results. The short- and long-range effects can be unfathomable. Memories of the Exxon Valdez running aground and spilling hundreds of thousands of gallons of crude oil, the partial nuclear meltdown at Three Mile Island and the Bhopal gas leak that killed thousands still haunt us today.

Since 1983, we have studied and addressed the various human factors that cause the errors that can result in incidents and breakdowns related to overall productivity, including defects, injuries and health/environmental incidents. This article addresses research and findings related to the cultural influences and human factors that cause errors and examines the awareness, skills and strategies needed to achieve operating excellence.

It also describes the awareness and skills essential to error reduction and elimination. The result is potential improvement in the quality of the systems, products and services, as well as the safety, health and well-being of employees, customers and public citizens. Regardless of their position or level of experience, everyone operating in the marketplace needs to work optimally with the least chance for error. In this way, organizations become more successful and better able to carry out their missions, minimizing negative consequences in a multitude of areas.

A demanding marketplace

Preventing errors is a challenge in today's demanding and fast-paced business climate. Our competitive markets and the need to deliver in all circumstances require that personnel be highly trained, capable and aware. Across the board, employees must be able to recognize the importance of taking personal responsibility for their own performance and the performance of others. They must be able to think in a multidimensional manner, focus and respond to changing situations, make good decisions and perform under pressure.

One of the most important hedges against errors is teamwork. Because of the complex roles and responsibilities that personnel have taken on (or have been handed) the importance of teamwork cannot be underestimated. Working independently in most situations is an illusion and typically does not contribute to maximum effectiveness. Functioning as a team requires that employees have the skills to communicate, cooperate and support each other in both routine and emergency situations. They need the peace of mind that the system in which they operate supports them as individuals and as team members.

Error reduction through self-management

An important strategy for error reduction is to increase employee proficiency in self-management, interpersonal, leadership and management skills. Honing these basic workplace skills can help prevent operational errors and the possibility of accidents, injuries and incidents. The strategy involves focusing on the underlying "human mechanisms" that cause errors in personal and team performance.

Communication is critical. Personnel must be clear and consistent in the expression of their commitment to excellence. They must know how to elicit commitments from each other and their co-workers for what is required, and they must know how to coach and counsel each other to achieve their results. They also must be able and willing to communicate (speak and listen) with each other laterally and vertically and to operate as a team in which the risks and rewards are shared.

Simple methods to double-check what was heard against what was said can avoid misinterpretations that can lead to errors occurring. We discovered while training control room operators for a major utility that a common cause of errors occurred when people in the field automatically repeated back without full understanding what moves the operator instructed them to take. Training in how to detect this simple "parroting" of their instructions detected and prevented errors that could have led to a number of potential incidents.

Organization-based confusion

Thus far, the 21st century has been characterized by near-constant organizational change and uncertainty. Flux in the form of mergers, reorganizations, re-engineering, downsizing, upsizing and "right-sizing," not to mention "dot-coming" and "Enronizing," are the norm. Reductions in staff and efforts to economize have become top priorities.

Exploring and preventing human error

Few industries are immune from this trend, with companies working nonstop to guarantee their futures by eliminating redundancies, waste and unnecessary costs. In their efforts to trim, too many companies ignore the cost of errors in this equation. For many organizations, the frenzy to rush to ensure their viability has compromised the effort to reduce error.

Levels of distraction and errors in judgment are compounded when employees are worried about their own and their company's future and their employment status. Stress, which we found to be a contributing factor in incident causation when first researching the causes of incidents for a major chemical company, is at record levels in many workplaces. Emotional distress related to personal and organizational concerns can cause people to lose confidence and can feed into distrust of management. And stress can erode employee relations, communications, cooperation and teamwork, ultimately affecting the quality of work, the likelihood of error and safety, health and environmental performance.

Deteriorating fundamentals in a variety of industries, weak order books attributable to slowing economies in the U.S., Canada, Latin America and Europe, along with rising and tough competition from other countries have increased stress and distractions for employees.

But it's not only negative changes that distract employees. Increased production demands, new equipment, increased responsibilities, cross-training and new management initiatives also play a part.

When an employee is worried about being laid off, sidetracked by challenging new duties or concerned about problems at home, he or she does not bring a clear mind to the job. This diminished ability to focus can lead to an error and decreases one's ability to manage his or her performance and that of others.

The error-free workplace

Managers must approach the process in a manner that leaves no one out and involves all levels of employees to assure that the organization is more likely to break free of the bonds of the old culture and the old way of doing things. Management must approach the process of performance improvement by creating a common vision for excellence.

Creating and communicating a vision for excellence are the keys to producing breakthroughs in performance. Vision is defined as an ideal state, something seen in a dream. And creating breakthroughs in performance not only requires establishing and communicating a vision, but reiterating and recommunicating this vision at every possible occasion.

Approach the process of creating an "error-free" environment and performance improvement from a number of levels:

  • The self-management level: All employees must have skills to observe and take personal responsibility to manage their level of attention and focus as well as their attitudes and behaviors on and off the job.
  • The peer/team support level: People need to develop an attitude of mutual support and caring for what we do individually and collectively and a willingness to intervene at any time to encourage their co-workers to be excellent. Skills are needed to do this constructively.
  • The leadership-management, supervisory and labor level: All levels of leadership need to be able to put aside political and business issues to create and maintain an environment in which everyone can work in an excellent and quality manner regardless of external or internal organizational circumstances.
  • The organizational level: This level includes the culture, norms, values, beliefs, attitudes and commitments of the company and its employees. A commitment to excellence, including safety, health and the environment, must be a core value. The attitudes and behaviors that reflect these values must be encouraged, supported and acknowledged.

Employing a holistic, integrated approach can help prevent errors and subsequent incidents. This way uses a variety of awareness, attitudinal and behavioral change methods that stress strategies for thinking, problem-solving and influencing perception and attention. Cognitive learning approaches that are employed involve restructuring knowledge to fit new circumstances. People learn strategies for paying attention to any task and the potential dangers of loss of focus.

Rather than being manipulated by the environment, the learner must be taught to interact with the environment so that mental structures continue to develop over time and experience. Both memory and attention develop with cognitive training. In simple terms, people learn to "think excellence," and develop related skills to prevent errors that can be transferred from one environment or task to another.

In one chemical plant operation, in a follow-up review session for training, a chemist noted that he initially planned to make an adjustment to a process without shutting it down in order to save precious time in a competitive environment. Though this was a task he had done many times before in his years of experience with this process, he observed his thinking process and the belief or internal message that he could do this and pull it off without a problem. Recognizing that something could happen, even though the likelihood of an incident was small, he stopped himself, followed protocol, shut down the process and made the adjustment safely and without error. He reported that he believed the extra time spent was worth it.



For the second time in less than two years, Microsoft pinpointed human error as the culprit for outages in its Azure cloud storage service.

The service was down in February 2013 and again in November 2014, Techworld reported. Recent updates that automate formerly manual processes should prevent such problems in the future, according to Techworld.

Cloud providers generally run pilot tests before rolling out changes to a large number of customers. But in November, an engineer thought an update had been tested sufficiently when it had not. After applying the change across the entire system, a bug caused the storage service software to go into an infinite loop, preventing communications with other system components.

Techworld's Joab Jackson reported that although the storage system was back online the next morning, restoring all of the system's virtual machines took two days. The company has updated its deployment system to enforce its testing policies before applying a change across the entire system.

In 2013, part of the system went offline due to lapsed security certificates, according to Techworld. Engineers were not aware that new certificates would not be delivered until the old ones expired and scheduled a larger routine update simultaneous to applying the updated certificates to Azure machines.

"Both cases show how even small errors can have a huge impact in a service as large as Azure," Jackson wrote, "and seem to have reinforced for Microsoft the importance of automating manual processes as thoroughly as possible."

The cognitive approach has been part of our strategy for organizational effectiveness training and consulting since 1980. In 1983 at a large research and development facility and pilot plant operation for a major chemical company, we found errors and incidents happening despite the fact that employees clearly knew what to do and what not to do.

We concluded that the most effective way to bring about lasting behavioral change was to start by raising people's awareness. The next step was to examine the core beliefs and attitudes that shape decisions in individuals and groups. These beliefs can directly influence and affect the results we produce in any domain, including quality, safety, health, the environment, production, R&D, sales, service, etc.

Our experience led us to explore a number of cognitive issues that can cause an employee to produce quality work or commit errors. One is an understanding of how complacency sets in, placing employees, customers and the public at risk of serious errors. The culprits are behaviors that include losing focus, not paying attention, taking shortcuts and bypassing protocols. The result is an open door to errors, defects, injuries or incidents, even when people are apparently complying with requirements such as wearing personal protective equipment. Self-observation skills are a valuable tool in overcoming complacency and avoiding errors.

Other factors

A primary cause of communication errors and misinterpretations is losing focus, or inattention. Although no one wants errors, employees sometimes behave in a deliberate or nondeliberate manner that causes mistakes to occur. Awareness wanes due to a number of factors that include daydreaming, inattention, repetitive tasks, stress and distraction. As mentioned, preoccupation with both positive and negative organizational changes also can lead to lack of focus and resulting errors.

The other culprit is conscious or pre-meditated behaviors. In these instances, an individual talks herself or himself into taking shortcuts, such as not reading through a job safety analysis before beginning a task or defeating machine guards. These premeditated risk behaviors tend to be supported by rationalizations and justifications and are often ascribed to factors such as time, comfort and convenience. In companies where downsizing or fear of downsizing exists, employees report taking shortcuts to get their jobs done faster because they do not want to be perceived as slow. The prevailing belief is that the slow ones will be the next to be laid off.

In other circumstances, errors occur because insufficiently trained personnel are placed in positions that require levels of experience and expertise beyond what they possess. And we all know that systems don't work unless people do. Ingrained attitudes, such as "We can't afford to spend the money or time on training people completely because we need to focus on production and profits," contribute to error making.

Measurement is another potential culprit. Traditional means of statistical tracking of errors and incidents do not measure levels of awareness or behaviors. Nor do these means ensure that all levels of employees are carrying out activities that help prevent errors and incidents. Low incident rates can cause people to become complacent and place their attention and energies elsewhere. To ensure continual improvement, attention and energy must be applied consistently to quality and safety, health and environmental performance.

Changing attitudes and beliefs

Raising awareness and addressing attitudes, beliefs and counterproductive circumstances are proven means of reducing errors. Leaders set the stage by identifying and addressing the negative influences that shape the attitudes and behaviors of employees.

The attitudes and behaviors of leadership also must reflect the awareness and understanding that attention to quality needs to be heightened, not diminished, in these times.

Essential resources necessary for proper education, training, equipment and resolution of performance issues must be allocated. To diminish resources from this area to "save money" can be far costlier in the long run. This cost can be in dollars or in human suffering, which you just can't put a price tag on.

Defining and communicating desired values and commitments and then backing them up with human, financial and material resources helps convey quality and excellence in performance as esteemed values. The attitudes of employees at all levels must be examined and measured against the vision for the organization. The desired result is that each person exhibit responsibility for his or her performance and the performance of others. When responsibility is perceived as a corporate and individual value, employees at all levels are less likely to take or overlook shortcuts and make the compromises that result in error.

When a person is internally motivated by the value and benefit of excellence in performance for themselves and their company, improvement tends to be more permanent. External motivational strategies are most effective when combined with internal motivation. Leaders must be skilled in coaching and counseling techniques to lead and interact with employees constructively regarding performance issues, attitudes and behaviors. This is especially true during times of organizational change, whether positive or negative. Error-related costs can seriously impair a company's viability or even push it over the edge.

Optimum opportunities for breakthroughs in performance occur when employees as well as shareholders reflect the values and beliefs in quality and performance excellence.

Accomplishing this shift requires consistent and sustained effort. A genuine value for excellence will endure despite changing circumstances. Improving attitudes and behaviors around quality and performance can yield improvements in attitudes and behaviors that impact all areas, including production, safety, health and the environment, costs, morale, creativity and innovation. Return on investment in these areas can be tremendous.

The role of employee involvement

Employee involvement is another key feature in error prevention. With trimmer staffs, all team members must see themselves as leaders proactively seeking ways to identify and solve performance problems. Sometimes employees assume the posture of a "victim" around errors and performance issues. They may blame the company for being too lax, other individuals for being careless or the equipment for being inadequate.

Some employees are like spectators at a game: They passively observe, may comment on how the game should be played, but seldom take effective action to help others prevent errors and incidents. This often occurs because they may have had negative interactions in the past with co-workers or with leadership. Employees need to be encouraged to participate and should be trained in improving interpersonal interactions.

Organizational systems and structures should encourage involvement, including identifying and solving problems, and receive feedback on progress. This is essential for continuous improvement. When employees at all levels are involved in organizational decision-making, they tend to care more about the environment, the product and the image they project. That often translates into working more carefully and with fewer errors.

Michael Topf is owner, president and CEO of Topf Initiatives. Topf has worked as a medical researcher, a hospital administrator, a mental health counselor and as an instructor in the graduate program in health and safety administration at St. Joseph's University. He has designed and conducted training courses in executive leadership, management and line employee development and other areas of organizational effectiveness. He has a bachelor's degree in biology and chemistry from Upsala College and master's degrees in applied psychology and theology from the University of Santa Monica.