Quality News » Human Error

Human Error: Tenerife runway collision (1977): concurrence of errors…

QU-King — Sun, 07 Jun 2009 18:51:16 +0000

n March 27th 1977, the biggest accident in airline history took place (at least if we leave the attack on the Twin Towers out of the equation).

The accident happened due to a concurrence of circumstances and an accumulation of human errors escalating to a disastrous 583 casualties.

A few of those circumstances and/or causes were:

* Stressors: fog and drizzle (limited sight of 1000 to 3000 feet), pilots were stressed out because both Boeing 747’s were (inconveniently) diverted to Tenerife instead of their original destination, Las Palmas. They couldn’t go there because of a bomb alarm, causing serious delays.
* Human error: due to the limited vision, the PanAm reaches the junction too late causing them to remain on the runway (too long).
* Technical problems: part of the lighting (center line) wasn’t ready yet and they were experiencing radio interference.
Authority: the KLM captain was (internationally) known for being ‘the exemplary pilot’ of KLM. He was a pilot and a flight instructor at the same time and KLM used him in advertising.

How many hours are you working on correcting errors?

QU-King — Wed, 03 Jun 2009 08:46:31 +0000

Research has proven that, when questioned, about 50% of employees of a company or organization are stating that they are spending an average of 1 to 2 hours a week on correcting errors. Theirs and their colleagues’. 17% of the questioned admit to losing more than 4 hours weekly. This not only costs a lot of money (mostly hidden costs) but leads to a lot of frustration with personnel. Read more here

Resilient organizations

DrZoom — Mon, 01 Jun 2009 12:09:51 +0000

resilience

ISO9001, TQM, Lean, Six Sigma, Human Error Reduction, Quality, Environment, Safety, Health… are all ways of seeing (the same) things from a different perspective. Full of energy, we jump on every new hype or wave. Our ultimate goal: to create an ideal organization where nothing goes wrong.

But step by step, we start to realize that “zero fault tolerance” is out of reach, it’s an illusion. If we ever achieve to proactively track and tackle all the thinkable conditions that might influence the risk of error, some new conditions will loom up out of nothingness. We have to face the fact that we live in a very complex and dynamic world. Today’s reality will be completely out of date by tomorrow. Our organization … Read more on source