Human error expertise · SENTINELLE method
Errors that come back deviation after deviation, retraining as the only response, checks added for reassurance: human error isn’t inevitable. We identify its real causes and put in place on the shop floor the rituals and practices that prevent it.
−47 %human-error deviations, in one year
−46 %human errors across two production units
−27 %deviations, all causes combined
−76 %human-error deviations in packagingResults measured on several production sites.
Raising awareness isn’t enough to eliminate human error.An error isn’t the fault of the person who makes it: it’s the symptom of causes that can be addressed.
85% of errors come back after 6 months following awareness training, a document change or an added check. Adding checks doesn’t strengthen control: the double signature creates an illusion of safety.
A human error always has an explanation. Our DTMIC tool looks for it in five broad families of causes.
Having the activity described isn’t enough: the information must be accessible, understandable and correct.
Passing on knowledge isn’t enough: the information must remain available at the moment of action.
Nobody can concentrate on two tasks at once: multitasking breeds error.
A reactive quality culture waits for errors instead of anticipating them.
Changing an ingrained habit requires genuine human change management.
They are what makes the difference. Depending on the task and the person, the same causes carry very different weight: the 3 factors adjust the weight of each and target the real leads, instead of reviewing everything.
A simple, low-stakes task doesn’t call for the same analysis as a complex operation or one critical for the patient.
A task done every day exposes people to routine and autopilot; a task done twice a year exposes them to forgetting.
An operator who has been here for ten years and a newcomer don’t make mistakes for the same reasons.
An operator who arrived in the sterile area two weeks ago isn’t exposed to the same risks as an experienced operator who works every day in a non-sterile area. Same apparent error, different analysis.
No single tool eliminates human error. It’s the accumulation of the right tools, at the right time, that reduces it drastically.
The DTMIC Tool analyses each error against 5 causes and 3 influencing factors. No more retraining by default: CAPAs finally address what produced the error.
DTMIC Toolroot cause
Teams spot risky situations before they become deviations. A quick huddle in the workshop, a weekly meeting to decide collectively on simple actions that can be done within the month.
weak signalsshort-term actions
Quick, regular, informal observations, anything but an audit. Managers see the gap between what is written and what is done, and correct it with the teams.
task observationshop floor
15 minutes for Quality: every two weeks or every month, the manager and their team discuss a quality topic, using ready-to-use sheets.
15 minutes for Qualityquality culture
The V.A.K. check: you look, you say it out loud, you point at it. 75% of packaging errors are attention errors: fewer checks, but real ones.
V.A.K. checkcritical checksstart-up
The pre-job briefing: 5 minutes before a batch start-up or a shift change to go over the day’s 2 or 3 critical points out loud. Instructions that say everything don’t make what matters stand out.
pre-job briefingshift change
408 deviations in 2022, a quarter of them due to human error, and retraining with no lasting effect. A human error expert per area, 4 shop-floor rituals and 6 months of coaching.
Recurring errors in production and strong growth. Weak signals, task observations, 15 minutes for Quality and action management, run by the teams.
It’s a deviation that results directly from a person’s action: a wrong setting, a forgotten step, a poorly performed check. But human error isn’t the fault of the person who makes it: it’s the symptom of causes that can be identified and acted upon.
Because it doesn’t address the cause. In our benchmark, 85% of errors come back after 6 months following awareness training, a document change or an added check. As long as the documentation, training, mental load, behaviours or changes involved aren’t addressed, the error comes back.
With the DTMIC Tool, which screens the error against 5 major causes: documentation, training, mental load, behaviour and change. It cross-references them with 3 influencing factors: task complexity, its frequency and the person’s experience.
It’s a way of performing critical checks using three senses: you look at the actual item (visual), you say out loud what you read (auditory) and you point at or touch the item (kinaesthetic). Inspired by aviation and Japanese railways, it takes the operator out of autopilot: the check becomes conscious again.
A short moment, about 5 minutes, taken by the line lead before a batch start-up, a shift change or a restart after an interruption. It goes over out loud the objective, who does what, the day’s 2 or 3 critical points, what has changed and what to do in case of doubt. It doesn’t replace the documentation: it brings out what the documentation buries among everything else.
The first weak signals come up within the first few weeks. On our assignments, the drop in human-error deviations can be measured over a few months of coaching, with up to −47% in one year.
Tell us about your situation in thirty minutes. We’ll tell you where to start.
