BEST PRACTICES
Look for Trouble
by John M. Evans
O
rganizational excellence depends on peo-
ple, who are all inherently vulnerable to
human error. While many continuous
improvement programs succeed in reducing other
quality related costs, human error remains a persis-
tent and intractable problem. Unless an organization
can tackle this problem successfully, organizational
excellence will remain an aspiration rather than an
achievable goal.
More than 30 years ago, W. Edwards Deming
In 50 Words
Or Less
• Risk influencing factors (RIFs) worsen natural
tendencies to make errors.
• Stressors might trigger errors and be difficult to
avoid, but structural RIFs are often more important
yet easier to resolve.
• Gather information systematically to identify RIFs,
and then apply good practices to proactively
reduce each factor.
56 I DECEMBER 2006 I www.asq.org
pointed to the need to seek a fresh approach to
reduce delays, mistakes and defective workman-
ship. Yet, in many organizations human error still
accounts for more than half of these kinds of costs.
Of that proportion, the rule of thumb is that about
85% results from largely automatic errors of execu-
tion, the causes of which remain inadequately under-
stood and addressed within many organizations.
A widespread concern is that even when respons-
es to incidents avoid repetition of specific errors, all
too often the problem doesn’t go away. Something
else goes wrong somewhere else, and there might
seem to be an inexhaustible potential for apparently
unrelated and unforeseen errors to occur in spite of
efforts to avoid them.
Perhaps even more frustrating are errors that
seemingly happen time and time again, no matter
what anyone does. In these circumstances, frustra-
tion easily turns to blaming individuals for perfor-
mance failures beyond their direct control.
As Deming indicated, this can result in a vicious
circle of defensive behaviors including concealment,
denial, delayed reporting, buck passing and worse.
These defenses make it more difficult to gather objec-
tive information needed to understand the problem.
In successful organizations with capable business
processes operated by trained and experienced peo-
ple, the incidence of error on each specific activity is
likely to be low. The trouble is there are lots of peo-
ple doing lots of things, day after day, so error can
be both commonplace and apparently random.
 Consequences are not limited to directly measur-
able costs. Apart from rework, delays, rescheduling
and displacement of other work, people at higher
levels of an organization are drawn into attempts to
explain error, avoid repetition and limit damage.
When consequences of single incidents or cumula-
tive effects of several incidents are significant, credi-
bility might need to be salvaged with customers,
regulatory authorities, colleagues, shareholders,
suppliers and perhaps the general public.
For many activities in which failure costs are not
measured routinely, costs of informal rework and
other consequences might never be known or even
estimated with much accuracy. There is, however,
widespread acknowledgement that human error is
implicated in a major proportion of quality related
costs.
Once people become aware of these few basic
principles, often they are able to apply
experience of their own work to find
practical ways of reducing risk of error.
Recognition that adverse influences
(rather than individual shortcomings) are
the focus reassures employees the organi-
zation is concerned with finding con-
structive ways to avoid error rather than
blaming people.
Intention vs. Execution
The term human error covers a spectrum
of behavior that results in unwanted out-
comes ranging from the formation of conscious inten-
tion through virtually unconscious or automatic exe-
cution.
Meeting an unfamiliar, challenging or unpre-
dictable situation or learning something new
demands plenty of conscious attention. As we
form each new intention to direct our actions, we
must think about what to do and monitor the
results closely. We should use feedback from our
senses to refine or redirect our actions as we work
toward the intended outcome.
Trial and error learning forms a part of this con-
scious approach, as does learning from the accumu-
lated experience of others. When a consciously
formed intention fails to lead to the intended out-
come it can be described as a mistake (see Figure 1).
Organizations try to minimize mistakes by
providing training, encouraging attention to
FIGURE 1 Consciously Formed Action
Conscious formation Conscious selection
Execution Outcome
of intention from repertoire
Conscious close
monitoring
If this outcome is not as
intended, it is a mistake.
QUALITY PROGRESS I DECEMBER 2006 I 57
BEST PRACTICES
detail, reducing uncertainty and undertaking FIGURE 2
a range of other conscious strategies. If well
designed, these interventions might succeed
in reducing the incidence of this type of
human error.
As situations and actions to deal with errors
become increasingly familiar, there is no need
to think much about what to do. Brushing your
teeth is second nature. That experience prompts
recognition of the situation, which leads to
selection of an action from a familiar repertoire.
Execution becomes virtually automatic.
Most of what we do throughout the day follows
this pattern of recognition, selection and action,
with very little conscious thought needed (see
Figure 2). This makes economical use of the limited
resource of consciousness, leaving the mind avail-
able to orchestrate the flow of intentions that give
our lives purpose and meaning.
Unfortunately the price of this economy is a nat-
ural vulnerability that sometimes leads to error of
execution. Ironically, forming an intention to moni-
tor a familiar action more closely might disrupt the
smooth flow of execution and even increase the
risk of error.
The split-second recognition of a situation and
selection of response, coupled with limited moni-
toring of action, is vulnerable to anything that
competes for attention, disturbs recall of memory
or affects operation of the senses.
Often we are hardly aware of adverse influences
on these cognitive processes. Most of the time natur-
al defenses cope with them successfully. However,
the presence of each additional risk influencing fac-
tor (RIF) increases the likelihood error will occur. See
“Two Examples of RIFs” (p. 60) for an idea of situa-
tions in which accumulating RIFs are likely to cause
errors.
Reducing Risk
Risk of error, particularly those of execution, can be
reduced by taking full account of natural memory
attention and perception characteristics when design-
ing tasks to minimize the adverse effects of RIFs.
Unfortunately many organizations fail to recog-
nize conscious strategies that can work well enough
to reduce incidence of mistakes are largely ineffec-
tive when applied to errors of execution.
Approaches to reduce incidences of mistakes,
58 I DECEMBER 2006 I www.asq.org
Automatic Selection of Action
Recognition Selection Execution Outcome
Automatically
triggers
Minimal
monitoring
If this outcome is not as intended,
it is a slip or lapse of execution.
such as providing additional training, encourag-
ing extra care and offering incentives, will have lit-
tle effect. Ironically, individuals sometimes are
blamed for failure when these well-intentioned
but naive attempts to avoid error fall short.
Stressors and Structural RIFs
When asked why humans make mistakes, often
people say it results from some sort of pressure or
overload. “I was trying to do too many things at a
time,” or “It was very noisy and people kept inter-
rupting me.” These kinds of influences are known
as stressors.
However, issues such as visually confusing doc-
uments, working practices that rely too much on
remembering or passive monitoring can be impli-
cated in an error. They differ from stressors by
being relatively permanent and objectively mea-
surable influences. They are often not the first fac-
tor to come to mind when thinking about causes.
Perhaps these structural RIFs are overlooked
because they become regarded as intrinsic proper-
ties of the process or task and too trivial to give rise
to error. However, when errors do occur they usu-
ally result from coincidental or cumulative effects
of several structural RIFs—perhaps in the presence
of one or more stressors.
Often a stressor acts as a trigger and might even
be mistaken as the cause. This can result in a naive
analysis of the error, leading to ineffective correc-
tive action because another stressor might serve as
the trigger on the next occasion.
Information Gathering
Recognizing how inherent vulnerabilities might
reduce the reliability of a process is key to understand-
ing why error occurs. But in practice, it is the RIFs that
need to be identified if error is to be avoided. An possible to achieve worthwhile risk reduction.
informed awareness can make a useful contribution For example, when there is a risk that labels on a
by identifying obvious RIFs, but only systematic package might be misread, their poor design might
examination of activities will be likely to find the rest. be beyond the influence of their reader, who might
Usually this will need to begin by making explicit have no choice about reading them in a noisy, busy
many important aspects of an activity, such as the environment that is far from ideal.
process itself, the physical and informational envi- Perhaps by using a magnifying glass, and ensuring
ronment and the organization of work. the labels are adequately illuminated and viewed
Several observational, measuring and recording against an uncluttered background, people can
tools, such as video analysis of movement around clearly read the label.
the work area and logs of interruptions might be Add to that an improved and more systematic
used to develop insight about how people perform process for looking at each item of information, and
and experience their work. Much of this informa- the risks are further reduced. Maybe later it will be
tion becomes easier to fully appreciate when it is possible to tackle additional RIFs, but for the time
represented graphically, for example, as a flow- being those that have been addressed might repre-
chart, Gantt chart or communications diagram. sent the best risk reduction that can be achieved in
Sufficient detail needs to be gathered to identify the current circumstances.
points at which error might occur and the failure Although RIFs are usually identified specifically
characteristics. At this time, it is usually necessary on one activity, their presence on others then might
to consider possible consequences and probability be recognized. When generic RIFs are addressed, a
of occurrence and give further consideration only single intervention might reduce risk on several
to risks that give significant cause for concern. The more activities across the organization.
presence of RIFs attendant to selected risks then For many RIFs, the kinds of good practices need-
needs to be identified. ed to address them are readily available off the
Although several studies have identified as many shelf or can be developed easily once the nature of
as 1,500 RIFs, most commonplace errors result from the adverse influence is understood. The many
variations of 200 to 300 RIFs. Even so, there are too sources of reference and examples on issues such as
many to simply remember, so an empirical checklist ergonomics and information design address plenty
of summary descriptions facilitates their recogni- of common RIFs. 1, 2
It is surprising easily accessible
tion (see Table 1).
This checklist groups the most common RIFs
into six main categories to make them more TABLE 1 Extract from Information
manageable. The list is a valuable component Section of Checklist
of an organization’s knowledge base about
Item Look for: Concern:
error and needs continual refinement and Number Documentation:
updating to maximize relevance to the chal- 01 Contains redundant information Redundant information confuses
lenges encountered. for intended purpose or is understanding of required items
Consequences of error are usually used to unnecessarily visually complex. or causes them to be overlooked.
describe risks—for example, spilt milk, train 02 Contains inappropriate level There is too much detail, and
crash or missed appointment. They might be of detail. document is scanned or ignored.
Guesses or assumptions are
addressed directly by containment and achieved used to fill gaps.
by prompt detection and effective contingency 03 Structure of document not well Document might not be used or not
action. suited to how it is used (for exam- used in the way intended, tempting
But containment activities are also vulnera- ple, no logical information flow or people to rely on memory or use
ble to human error, so reliance on checking and not divided into task related topics. informal alternative documents.
correction is risky. The risk that errors actually 04 Document used to serve several Poor structure and redundancy of
will occur can be addressed by tackling RIFs. purposes with differing or incom- information make document diffi-
patible requirements (for example, cult to use for some purposes,
For a given risk, every RIF might not be acces- regulation, training or job aid). encouraging reliance on memory.
sible or even identified, but it could still be

QUALITY PROGRESS I DECEMBER 2006 I 59

BEST PRACTICES

Two Examples of RIFs

An office setting is the first example of a series of risk influencing factors (RIFs) increasing the likelilhood
of error. Most of the time we might cope well enough with a badly structured and overcrowded document,
but the risk increases in poor lighting. Add some background noise, several visual distractions and an
uncomfortably hot and humid day.
Then somebody has to go home early and leaves you with several things to cope with at the same time.
You start to get tired, and your vigilance decreases more quickly. A succession of phone calls and interrup-
tions are the straws that break the camel’s back. None of these RIFs alone might have resulted in an error,
but their cumulative effort leads you to miss something obvious in the document that results in an error.
A second example is in an industrial setting. Imagine working on a production line, injecting tiny spots
of grease into 17 points on a precision assembly. You work methodically from top-left to bottom-right, but
you have to remember how far in the sequence you are because it isn’t easy to see whether the grease has
been applied.
People standing behind you are talking about pay negotiations in progress, and you are interested.
Occasionally an alarm sounds at a nearby workstation because a fault still hasn’t been fixed. Close to you,
somebody is soldering, and sometimes you smell the acrid smoke. Now and again, a trolley is wheeled
along behind you and makes a noise as it passes over a bump.
With your concentration overloaded, your eyes make an involuntary flick in the direction of the sound
and then return to the wrong grease point. You have missed one. It probably will not be detected on
inspection. The unit will fail prematurely.

solutions are underused in many organizations.
Examples of good practices for work processes
and organizational arrangements can be found by
networking and benchmarking within and be-
tween industries. When good practices need to be
developed, advice from specialists about human
characteristics and constraints might be helpful.
In practice, however, experienced and knowl-
edgeable people who have been made aware of the
causes of error and principles of risk reduction
usually devise effective and workable solutions.
Reducing risk of human error usually does not
require major expenditure, although people might
need time to work on identifying, developing or
introducing good practices. When people are
required to change the way they perform familiar
tasks (for example, by relying less on remembering
or by changing the order in which actions are
taken), gaining full and reliable compliance can be
challenging. Adequate resources must support
implementation.
Implementing and Sustaining
Error Risk Reduction
Continuous improvement to reduce both current
and potential incidence of error is not difficult, but
it requires commitment. Experience suggests five
components to sustain risk reduction:
1. Select a core team and train its members in the
theory and practice of risk identification and reduc-
tion. About a week of classroom and practical work
has been shown to provide a sufficiently robust
foundation on which to build a risk reduction capa-
bility. Further cycles of audits to identify and analyze
risk provide plenty of useful opportunities for risk
reduction, which in turn generate worked examples

60 I DECEMBER 2006 I www.asq.org

SCORING MATRICES: These are examples of the forms that make it easy to get an impression of how performance
compares with good practice.
and evidence of the utility of the approach.
2. Build an awareness process throughout the
organization or some defined division of it. Run
short sessions to provide basic conceptual ground-
ing and illustrate the issues with case examples
gathered during audits. Don’t be too ambitious at
first, and emphasize that the focus is on adverse
influences—RIFs—rather than individuals.
3. Develop a risk reporting system accessible to
everyone. This can enable anyone to bring a risk to
the attention of those most likely to be affected and
provide them an opportunity to tackle it. The core
team might supply support directly or, more likely,
provide a link to someone who can.
4. Measure what can be measured. It can be diffi-
cult to find metrics that adequately and continuously
measure risk reduction—it’s not easy to count events
that didn’t happen. But you can record the decrease
in time taken on interventions and in administrative
control of jobs from beginning to end.
5. Actively manage and proactively deploy the
growing knowledge base about sources of error
and ways of avoiding them as widely as possible.
To sustain of risk reduction, remember the risk of
human error can become incorporated as a matter of
routine into a wide range of organizational activities.
Identifying potential RIFs and removing them at the
earliest opportunity thus becomes a way of life.
Go Looking for Trouble
An error risk assessment (ERA) process devel-
oped in the United Kingdom provides a straightfor-
QUALITY PROGRESS I DECEMBER 2006 I 61
BEST PRACTICES
ward way of gauging the extent of an organization’s
vulnerability to error, whether actions being taken
are likely to succeed and how realistic the organiza-
tion’s current understanding of risk is.
A short questionnaire is used to gather informa-
tion from a representative sample of people across
an organization or within selected parts.
Scores are generated across six dimensions of
vulnerability to error (process, context, information,
organization, competence and stressors), together
with five dimensions of organizational responses
(visibility, awareness, investment, development and
measurement). Each cell of the scoring matrices is
characterized by a brief statement. The photo (p. 61)
shows some of these forms.
These matrices make it easy for those concerned to
form an impression of how their own performance
on each dimension compares with good practice.
When scores from different parts of an organiza-
tion are compared, who needs help and who might
be able to offer it becomes evident. Similarly, when
comparisons are made between organizations, it
becomes clear who can provide a benchmark on
each issue.
Near Misses
Errors do not need to actually occur to provide
opportunities for risk reduction. For every incident
that occurs, there are usually many more near miss-
es. This means either the error is avoided by a timely
intervention or it does happen but its consequences
are contained before they have any practical effect.
Either way, it might still be possible to under-
stand the causes, but only if the person who makes
or nearly makes the error has been encouraged to
reveal rather than ignore or conceal the event.
In many organizations there is little or no incen-
tive to draw attention to near misses and no mech-
anism for capturing the information. Survey data
reveal that in most organizations senior managers
are given little insight into the incidence of near
misses and therefore—understandably—fail to rec-
ognize either the threat they represent or the op-
portunities they offer.
Organizational Excellence
Senior managers in many organizations remain
unaware of many threats to, and opportunities for,
improving competitiveness because of serious omis-
62 I DECEMBER 2006 I www.asq.org
sions in their reporting systems and metrics.
A well-informed and systematic approach to
gather information about the risk of human error is
necessary to avoid naive and ineffective attempts
to mitigate it. Many organizations already possess
the know-how to reduce risk of error once the con-
tributory causes have been established.
Beyond that technical understanding of error,
the way an organization uses its resources to build
and employ the practical application of that knowl-
edge is vitally important. An excellent organization
could be said to be as good as it can be, given the
realities within which it exists.
One important constraint is that nobody’s per-
fect, yet ordinary, vulnerable individuals can come
close to working without error if the many adverse
influences that undermine their performance can
be avoided.
An excellent organization will empower its work-
force from bottom to top to identify risk wherever it
can be found and support every justifiable effort to
tackle it. Expensive and sometimes painful trial and
error learning needs to be kept to a practical mini-
mum. An excellent organization does not just wait
for error to occur and avoid recurrence; it goes look-
ing for trouble.
REFERENCES
1. Karl H.E. Kroemer and E. Grandjean, Fitting the Task to
the Human: A Textbook of Occupational Ergonomics, CRC, 1997.
2. Karen A. Schriver, Dynamics in Document Design, Wiley,
1996.
JOHN M. EVANS is a principal with HEB, a Healthfield,
United Kingdom, consultancy specializing in reducing the
incidence and impact of human error from a quality improve-
ment perspective. Previously he was with the European
quality function of ITT and British Telecom. Evans earned a
master’s degree in organizational psychology from the
University of London.
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