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Resources for the "Business Case for a Learning-Based Approach to Errors"

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From Jake Mazulewicz at Thanks.

BC1) The Northeast blackout of 2003

"All told, 50 million people lost power for up to two days in the biggest blackout in North American history. The event contributed to at least 11 deaths and cost an estimated $6 billion."


BC2) The NOAA satellite that fell over

"While the turn-over cart used during the procedure was in storage, a technician removed twenty-four bolts securing an adapter plate to it without documenting the action. The team subsequently using the cart to turn the satellite failed to check the bolts, as specified in the procedure, before attempting to move the satellite.[23] Repairs to the satellite cost US$135 million. Lockheed Martin agreed to forfeit all profit from the project to help pay for repair costs.”


BC3) The nuclear kitty litter incident

"It exposed 22 people to radiation, shut down the underground facility for 35 months and cost the United States over a billion dollars. Heat and pressure had built up in the drum due to chemical reactions with an organic kitty litter, Swheat Scoop, which had been mistakenly added to it at Los Alamos National Laboratory, the birthplace of the atomic bomb."



BC4) How one error cost Citibank $800 million

"Citi (C)bank, which was acting as Revlon’s loan agent, meant to send about $8 million in interest payments to the cosmetic company’s lenders. Instead, Citi (C)bank accidentally wired almost 100 times that amount, including $175 million to a hedge fund. In all, Citi (C) accidentally sent $900 million to Revlon’s lenders."



BC5) To Err is Human -- medical errors lead to 44,000 - 98,000 deaths each year

".Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDS--three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems.

  • Some have challenged this study’s methodology and focus.

  • A similar 2014 study found that medical errors lead to over 250,000 deaths each year, making medical error the 3rd leading cause of death in the US.


BC6) The $37 billion problem

"The global analyst firm IDC, in a 2008 white paper, examined human error in the form of “employee misunderstanding” and its financial impact on 400 U.K. and U.S. businesses...


It defined employee misunderstanding as actions by employees who have misunderstood or misinterpreted company policies, business processes, job functions—or a combination of the three.

The average cost of this misunderstanding, at a company with 100,000 employees, is $62.4 million per year. Combined, U.K. and U.S. enterprises are losing an estimated $37 billion every year. The cost of intangibles—like reputation or customer trust—could have even greater consequences.



BC7) USS Benfold -- from the worst ship in the Navy to the best, in 20 months

  • When Mike Abrashoff became Captain of the USS Benfold, he replaced traditional “command & control” leadership with human engagement & trust.

  • Within 20 months: retention rose from 28% to 100%, safety incidents dropped from 31 to 2, costs dropped to 25% below budget (p.28), and the crew won the award for “most combat-ready ship in the Pacific fleet.” (p.30).

  • “I found that the more control I gave up, the more command I got.” (p.6).


BC8) How Dr. Peter Pronovost saved 1,500+ lives... with a checklist



BC9) How UPS dramatically reduced serious crashes... and saves $300 million per year

"...turning left is one of the leading “critical pre-crash events” (an event that made a collision inevitable), occurring in 22.2 percent of crashes, as opposed to 1.2 percent for right turns. About 61 percent of crashes that occur while turning or crossing an intersection involve left turns, as opposed to just 3.1 percent involving right turns."

"UPS, which makes 18 million deliveries a day in the US, says that Orion analyzes 250 million address points a day and performs 30,000 route optimizations per minute. This saves the company $300 to $400 million annually in fuel, wages and vehicle running costs."


BC10) Black Box Thinking: Why Most People Never Learn from their Mistakes, but Some Do

by Matthew Syed

A great introduction to the applied psychology of human error. No jargon. No unnecessary academic terminology. Just powerful stories of real world errors and evidence-based ideas for how to manage them better.


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