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Resources for
"Seven Practical Steps"

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Fewer Errors


Safer Operations


More Trust

If you find these resources helpful and use any of them in your slide decks, handouts, etc., please include From Jake Mazulewicz at Thanks.

SS1) 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.”


SS2) 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."



SS3) 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."


SS4) 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.


SS5) 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.



SS6) 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).


SS7) Creating Psychological Safety in the Workplace (interview with Dr. Amy Edmondson)

  • "One thing that really surprised me was the Google study – Project Aristotle, which was written up in the New York Times a couple of years ago. The goal of this study was to find out what distinguishes high performing teams from low performing teams.... And nothing worked until they stumbled into the concept of psychological safety and found that it was... the most powerful predictor of team performance at Google."


SS8) Amy Edmondson in "The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth" (2019)

"When people have Psychological safety at work, they feel comfortable sharing concerns and mistakes without fear of embarrassment or retribution. They are confident they can speak up and won't be humiliated, ignored or blamed...


They know they can ask questions when they are unsure about something... mistakes are reported quickly so that prompt corrective actions can be taken... and potentially game-changing ideas for innovation are shared...


In short, psychological safety is a crucial source of value creation in organizations operating in a complex, changing environment.” (p.xvi).


SS9) Creating Psychological Safety in a Knowledge Economy (3-minute video)

  • "The research and the data are overwhelming in that many people feel they can't speak up at work. In many companies, it might be as many as half the employees are reporting that it really doesn't feel safe to speak up. That means we're losing enormous value."


SS10) Strategies for Learning from Failure by Amy C. Edmondson (article)

  • "When I ask executives... to estimate how many of the failures in their organizations are truly blameworthy, their answers are usually in single digits — perhaps 2% to 5%. But when I ask how many [faulures] are treated as blameworthy, they say (after a pause or a laugh) 70% to 90%. The unfortunate consequence is that many failures go unreported and their lessons are lost."


SS11) See resources for After Action Reviews here


SS12) How Dr. Peter Pronovost saved 1,500+ lives... with a checklist



SS12) 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."


SS13) 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.



SS14) Why Teams Don't Learn from Their Mistakes (and How to Change That)

"In 2002, Dr. Gary S. Kaplan, the recently appointed chief executive of the Virginia Mason Health System in Seattle, visited Japan with some fellow executives. He wanted to see how organizations outside the health care sector did things. At a Toyota plant, Kaplan had a revelation... If a culture is open and honest about mistakes, the entire system can learn from them.”

Since the new approach was taken, the hospital has seen a 74% reduction in liability insurance premiums."

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