Error Management – Q&A

Once an English poet Alexander Pope said “To Err is human, to forgive, divine.” Human beings knew since too long that whatever the precautions taken, humans still susceptible to make errors, but it seems that our modern organizations were very late to realize this fact, so errors were being dealt with a punitive procedures without a clear strategy to manage and learn from these errors, error management is about how we perceive errors in the organization, Do errors resemble stones that block the path of success? Or they resemble multiple stairs that elevate the organization up to excellence and continuous growth?

Error Management is a nascent field of research that focuses on the handling of the inevitable errors after they occur, so they don’t reoccur again, to easily detect them, to mitigate their adverse consequences, and finally to spread the learning of errors in the organization so it becomes less casual that the same error to emerges twice in the organization.

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Where the idea of Error Management did come from?

It all began with the aviation industry, from the 50s till the late 70s the rate of accidents attributed to the human factor was ranked as the top of the causes by almost 70% and the interesting part of this, that those human factors were non-technical in their essence, pilots and co-pilots were very well-experienced, some with a record of more than 25,000 flight hours. The investigations reached that the cause of those fatal accidents was an inevitable error that the cabin crew couldn’t deal with neither could implement a fast and accurate strategy to fix such an error, in some cases co-pilots noticed a near danger or a missing instruction but they didn’t speak up, as in some cases the co-pilot had just 26 years old and the pilot is almost 60 years, the authority of the pilot was overwhelming the cockpit, in other cases the commands directed weren’t assertive enough, so finally the flight safety associations worldwide gathered to overcome this issue and finally they came up with a new approach they called CRM “cockpit resource management” and then it turned to be “crew resource management.”

CRM is a set of training procedures meant to deal with the human factor and to reduce human errors, beginning by managing the leadership structure not to be so steep so the information wouldn’t flow from bottom to top and neither to be so flat otherwise leader decisions aren’t effective, so gradient in leadership hierarchy need to be reasonable. Secondly, applying a non-punitive culture for the inevitable errors, so it leads to the spread of psychological safety that let people speaks up about errors with no fear, so it could be detected and mitigated rapidly. Third, enhancing and encouraging debriefing system which is very effective to continuously reveal what went wrong and what is the opinion of the staff about it, so it also enhance learning and developing skills to confront future errors with more knowledge and preparation.

What is the difference between Error Management and the other traditional ways of management like error prevention?

A natural instinct of human beings is the tendency to avoid losses much more than the tendency for gaining something, people look for hits rather than misses, in the same context, its an organizational strategy to have more sensitivity toward errors and failures, so the entire system is built upon the strategy of error prevention, so when errors take place, managers feel frustrated and their reaction tend to be more punitive, blaming one single person while actually the entire system needs a serious revision.

Prof. Sidney Dekker always used to affirm about this issue, that out of many errors and failures he was investigating, he noticed that the inefficient handling of errors was to blame one or several people, while the wise and efficient way was to blame several parts of the system. For Example when Japan lost the track of their satellite that cost about $365 million dollars Dr. Dr.Saku Tsumeta, the director of the Space Science Research Centre at JAXA said “There was a human error, but in a critical system like this we have to imagine that humans do make errors. So rather than thinking of this as an error of a human, we believe that there’s a problem in the system.”

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On the other hand, perceiving the error as single or multiple human failure surely will lead to a hesitant decisions that would turn the simple error to a big tragedy, but when the organization is ready with a well-trained procedures to deal with the unexpected errors, the process of overcoming those errors, taking corrective actions and learning from errors become more seamless and highly efficient process which sooner reflect upon the overall progress of the organization.

What is the need of Organizations for an error management strategy?

As the famous quote says “Need is the mother of invention.” The indispensable need to save an entire aviation industry from the threat of multiple fatal accidents led them to develop and innovate a successful error management techniques, as well all critical industries that threaten human lives like nuclear power plants and ammunition factories were inspired of such system and they began to apply it. Now business institutions are in a substantial need for an error management strategy to cease the flow of losses happen due to the unmanaged errors in the organizations, some statistics mention that poor hiring decisions for a candidate earning $100,000 yearly could cost, on average, $250,000.

Another study claims that the average yearly errors of one employee in the UK almost cost more than 400 GBP, so in an industry of 10,000 staff we are speaking about more than four million GBP each year as a direct cost of errors. Managers who listen to me right now have a very close perception on how errors are ruining the business, and whatever strategy that will show a glimpse of success to manage better the errors, to reduce their adverse ramification will be much appreciated and embraced by the organization.

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