Error Management Conference

Second conference on Error Management in Berlin

January 14 and 15, 2016
European School of Management and Technology, Schlossplatz 1, 10178 Berlin


Two years ago, we held our first conference on Error Management. It resulted in the insight that learning from mistakes is an organizational gap that needs to be filled. This time we will focus on the reporting of mistakes and the necessity to do so, regularly and openly.

Vertical Tabs



January 14

6:00 p.m.Registration
7:00 p.m.Welcome, Jan Hagen
Dinner speech by Brigadier General Peter Klement, Director of Aviation Safety of the German Federal Armed Forces
9:00 p.m.Networking with conference members and speakers


January 15

8:00 a.m.Registration
8:30Program introduction, Jan Hagen
8:45―9:30Keynote: Terry von Thaden, PhD, Illinois Fire Service Institute, University of Illinois Urbana-Champaign

Panel I: Generating an error-reporting system – the requirements
Panel members: Wolf Brandes, Captain and Chief Flight Instructor, Cargolux Airlines; Brigadier General Peter Klement, Director of Aviation Safety of the German Federal Armed Forces; Helmut Kunz, Captain, Air Berlin, Corporate Director of Training; Robert Schröder, Captain and Flight Safety Officer, Deutsche Lufthansa; Magnus Sundstrøm, Captain and CFI Crew Resource Management, SAS Scandinavian Airlines

11:00―11:30Coffee break
11:30―12:45 p.m.Panel II: Error reporting – the obstacles
Panel members: Jan Brommundt, University Medical Center Groningen; Barbara Hoffmann, Berlin Chamber of Physicians; Stephan Marsch, Head of Intensive Care Unit, University Hospital Basel; Matthias Münzberg, Trauma Surgeon, BG Trauma Clinic Ludwigshafen




Keynote: Robert Schröder, Captain and Flight Safety Officer, Deutsche Lufthansa


Panel III: Internal reporting – moving beyond quality management
Panel members: Gal Goren, COO Roboteam - Tel Aviv; Andreas Hummel, Total Vehicle Architecture and Integration Department Manager Quality Magement, BMW; Geert Letens, Lieutenant Colonel, Royal Military Academy, Belgian Army; Klaus-Dieter Pannes, Vice President Operational Excellence, B.Braun Melsungen; Jörg Ulrich, CEO, Linde Hydraulics

3:30―4:00Coffee break
4:00―5:15Panel IV: External reporting – the extent of transparency
Panel members: John S. Carroll, Gordon Kaufman Professor of Management, MIT Sloan School of Management; Nicholas Dechy, Organizational and Human Factors Specialist, Institut de Radioprotection et de Sûreté Nucléaire; Christoph Heil, Technical Managing Director, Nuclear Power Plants, EnBW; Lennart Wahlberg, Competence Development, Forsmarks Kraftgrupp AB
5:15―5:30Conference wrap-up and next steps, Jan Hagen




Captain Wolf Brandes is chief flight instructor on Boeing 747-8 and 747-400 aircrafts and the alternative training and qualification program (ATQP) manager at Cargolux Airlines. For 18 years he has been flying jumbo jets and for 8 years he has been involved in training and examining pilots.

Jan Brommundt is a medical doctor and a health economist and leads the cardiac anesthesia team at University Medical Center Groningen. He serves as the medical director of MELONET, an international repatriation organization. Jan teaches Medicine at the Rijksuniversiteit Groningen, and Public Health in Humanitarian Action for the international Erasmus Mundus Network on Humanitarian Action. He has worked with Doctors Without Borders (MSF) and Doctors of the World (MdM) as an anesthesiologist in conflict zones and as a board member for MdM Germany. Brommundt is interested in crew resource management, human factors, safety, and error culture in high-performing teams.

John Carroll is the Gordon Kaufman Professor of Management, a professor of organization studies and engineering systems, and the co-director of the Lean Advancement Initiative at the MIT Sloan School of Management. His recent work focuses on industries that manage significant hazards such as nuclear power, petrochemicals, and healthcare. Carroll holds a BS in physics from MIT, as well as an MA and a PhD in social psychology from Harvard University.

Nicolas Dechy works at the French National Institute of Nuclear Safety and Radiation Protection (IRSN), which provides expertise to the regulator. He conducted the organizational and human factors assessment of safety and radiation protection management of maintenance activities, subcontracting, and emergency response in the aftermath of the meltdown at the Fukushima Nuclear Power Plant in Japan. As an engineer, he has expert experience in the fields of accident investigations (chemical factory explosion in Toulouse, France), risk assessment, emergency response, and crisis management in process safety (chemical accident in Seveso, Italy).

Gal Goren is the CEO of the commercial division at Roboteam, which manufactures robotic vehicle systems for the defense sector. Prior to his current role, Goren acted as VP of R&D and engineering at Roboteam and was responsible for all R&D and delivery activities. He has extensive experience in transferring complex NPI systems into high-volume manufacturing products as well as creating new production lines. Goren is a deputy company commander (reserve) in the paratroopers brigade of the Israel Defense Forces. He holds a BSc in biomedical engineering and an MSc in mechanical engineering. During his MA studies, Goren became an expert in search theory while developing algorithms for autonomous mobile vehicles.

Jan Hagen is an associate professor at ESMT European School of Management and Technology. His research and teaching focus is on leadership and organizational behavior – error management, in particular. In addition to his academic work, he has more than 15 years of management experience in the European financial services industry. He is the author of Confronting Mistakes: Lessons from the Aviation Industry when Dealing with Error; published in 2013.

Christoph Heil is executive director of the operating nuclear power plants of EnBW. He is a member of the German Reactor Safety Commission subcommittee Pressurized Components and Materials as well as several KTA and VGB committees. He studied mechanical engineering at the University of the Federal Armed Forces of Germany in Hamburg.

Barbara Hoffmann has been working for more than a decade at the Berlin Chamber of Physicians (ÄKB), whose main focus is on patient safety. Her work is centered on patient safety as well as incident reporting and training issues regarding professional medical development. She leads the ÄKB project Netzwerk CIRS-Berlin, a regional incident-reporting platform.

Andreas Hummel is responsible for quality management in the Total Vehicle Architecture and Integration section of the BMW Group in Munich, where he has worked for more than 14 years. Past positions include posts in the BMW in-house consulting division and the corporate quality department.

Peter Klement is the director of Aviation Safety of the German Federal Armed Forces in the rank of Brigadier General. During his career, he flew 3,000 hours in fighter aircraft and has held numerous leadership and staff positions in which he actively promoted aviation safety and flight training programs. In his current position, he is responsible for Accident and Incident Investigation, Accident Prevention, and Aviation Safety Training programs of the German Federal Armed Forces. Building on his master’s degree in Aeronautical Science and professional background, his current research focuses on Crew Resource Management in High Reliability Organizations.

Helmut J. Kunz is the corporate director of training at airberlin. He oversees all crew training for the airberlin group. His doctoral research focused on the application of chaos theory and the learning-organization approach in complex organizations such as long-haul airlines in a deregulated environment. As an active check- and trainings pilot, he is employing threat and error management techniques in two initiatives at airberlin: the development of an Alternative Training and Qualification Program and the introduction of Evidence-based Training.

Geert Letens is a lieutenant colonel of the Department of Economics, Management, and Leadership at the Royal Military Academy in Belgium, a research fellow of the Vlerick Business School, and a visiting research professor at Virginia Tech. His research focuses on leadership, organizational development, and change. Letens currently serves as the president of the American Society for Engineering Management.

Stephan Marsch is professor of intensive care and chairman of the medical intensive care unit at the University Hospital of Basel, Switzerland. The focus of his academic work is on human factors relevant for the settings of acute medicine.

Matthias Muenzberg is a consultant for trauma surgery at one of Germany’s largest trauma centers. In addition to being an emergency physician, he is also the head of staff for the air rescue center and an assistant professor of trauma surgery at the University of Heidelberg. He teaches how to manage severely injured patients before their arrival at the hospital as well as at the clinic in addition to trauma education and human factors.
As an executive committee member of the German Society of Orthopedic and Trauma Surgery (DGOU), Muenzberg was part of the task force to implement a “safety culture in medicine” and was responsible for developing the new course concept of IC (Interpersonal Competence).
He is the national director of the Pre-hospital Trauma Life Support (PHTLS) program as well as the director of several other international trauma programs. He has authored a number of publications about standardization in trauma and burn care.

Klaus-Dieter Pannes is vice president of operational excellence at the B. Braun Melsungen AG. In addition to this function, his main areas of responsibility are B. Braun’s corporate strategy as well as the corporate project management office. Before joining B. Braun, he was responsible for the healthcare, medtech, and pharma practices at the management consultancy Porsche Consulting.

Robert Schröder has been a pilot with the German airline Lufthansa since 1987. He is now a Check and Training captain on the A330/340 fleet. He has been with the Lufthansa Flight Safety Department since 1996, participated in major accident investigations, and was editor in chief of the Lufthansa’s flight safety information circular (CF-Info) for 10 years, among other functions. His specialty is human factors, especially crew debriefings after incidents or accidents.

Magnus Sundstrøm has been working for Scandinavian Airlines since 1986. He became captain in 1998 and is now flying the long-haul operation on the Airbus 330 and 340. Sundstrøm has been working with human factors and Crew Resource Management (CRM) since 2000. He started out as an instructor at SAS Flight Academy and has instructed – and developed training programs for – flight crew and cabin crew at Scandinavian Airlines. Presently, he is the chief flight instructor for CRM at SAS Crew Training.

Terry L. von Thaden is the CEO of Illumia Corporation, a safety culture consultancy company, and home of the SCISMS, the safety culture assessment tool she developed with funding from multi-year research grants from the Federal Aviation Administration and the Air Force Office of Scientific Research. She is also a Human Factors Research Scientist at the Fire Service Institute of the University of Illinois, with affiliate faculty appointments in industrial engineering, psychology, and the Graduate School of Library and Information Science. Her socio-technical systems work focuses on safety culture, crisis response, distributed collective practice, and standardization.

Jörg Ulrich is the President and CEO/CFO of Linde Hydraulics, a mid-sized German manufacturer of high-pressure hydraulics components and systems for global mobile applications in construction, agriculture and material handling industries. Linde Hydraulics was carved out from KION Group/Linde Material Handling in 2012 and sold with 70% to Weichai Power, China´s largest diesel engine manufacturer. This transaction is so far the largest single investment of Chinese investors in Germany. Jörg has joined Linde Hydraulics in 2010 as CFO and has steered the company through this transaction as well as through the recent restructuring process as global OEM markets have significantly cooled down. Jörg holds a doctor degree from European Business School. He has worked in consulting for 8 years before joining Linde AG in 2004 prior to various spin-offs within the group.

Lennart H. Wahlberg is a senior competence developer for operational staff (shift supervisor, reactor operators, turbine operators, plant operators) and a senior advisor for matters concerning human performance, operational fundamentals, and safety culture at Forsmarks Kraftgrupp AB, Vattenfall, Sweden.

Photo gallery

Photo gallery

See the pictures of the second conference on Error Management in Berlin.

The photo gallery is now available on Flickr!

Second conference on Error Management in Berlin


A video showing impressions of the day is now available.

Watch the video here.

Second conference on Error Management in Berlin
Conference summary

Conference summary

The conference summary is now available.

Download it here.