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The Precept
Losses
are attributable to human error, not only error in the
implementation of processes but also error in the design of the
processes, including the design of the hardware used in the
processes – except for the following:
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Science and discovery effects that can't be postulated in advance -
thus can't be prevented and mitigated.
·
Unpreventable natural
disasters that can’t be postulated in advance - thus, their effects
can't be mitigated;
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Sabotage that can’t be postulated in advance - thus, can't be
prevented and mitigated;
·
Decisions to accept risk, based on cost-benefit analysis.
Systems,
techniques and tools must be in place by which to:
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Identify and cost-effectively eliminate hazards (e.g., safety,
quality, environmental hazards);
·
Assess the risks of hazards that can’t be eliminated and that can be
activated by human error;
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Control these risks by:
o
Preventing human error that can activate hazards with intolerable or
unacceptable risks;
o
Preventing the recurrence of any such error that can and should have
been prevented initially;
o
Mitigating the effects of any such error that can’t be 100%
prevented (e.g., skill-based and lapse- based errors).
To
learn more about the universally applicable principles and practices
supporting the foregoing precept, attend Ben Marguglio’s “Human
Error Prevention” and “Root Cause Analysis” Seminars.
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The Four Fields of Focus for Human Error Prevention |
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1.
Concern
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Hazards |
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Response
-Implement techniques by which to recognize hazards. Eliminate
hazards. Create administrative process, technical process, equipment and personal barriers
to prevent and detect error and hazards activated by error and
to mitigate the
effects of activated hazards. Implement techniques by which to avoid holes in
barriers. Implement techniques by which to increase the
effectiveness of barriers. |
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2.
Concern
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Error-Inducing Conditions and
Error-Likely Situations |
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Response
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Recognize error-inducing conditions and error-likely
situations. Eliminate these conditions/situations. Use
behavioral tools and techniques (for individual contributors,
supervisors and managers) by which to counteract error- inducing
conditions and error-likely situations. |
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3.
Concern -
Inappropriate Risk-Taking |
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Response
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Recognize the behaviors that lead to inappropriate risk-taking.
Practice behaviors that lead to conservative decision-making. |
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4.
Concern -
Recurrence of Past Errors |
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Response
-
Implement a field observation and coaching system.
Implement a problem reporting, root cause analysis, and
preventive corrective action system. Implement performance
metrics. |
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The Seven
Universally Applicable Human Error Causal Factors |
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1. Knowledge-based Error - Lack of knowledge of the standard, requirement or
need. |
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2. Cognition-based
Error
- Lack of the
appropriate level of cognition; lack of ability to understand,
apply, analyze, synthesize or evaluate such as to be able to
meet the standard, requirement or need.
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3. Value-based Error /
Belief-based Error
- Lack of respect for or lack of acceptance of the
standard, requirement or need. |
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4. Error-Inducing Condition-based
Error / Error-Likely Situation-based Error -
Lack of
recognition of the condition or situation and/or lack of
behavior to counteract the condition or situation. |
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5. Reflexive-based Error -
Lack of conservative behavior
in immediately reacting to a "field stimulus". |
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6. Skill-based
Error - Lack of manual dexterity. |
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7. Lapse-based Error -
Lack of attention. |
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Human Error Prevention
Ben Marguglio |
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Why this seminar? |
In addition to discovery and invention, human error prevention
can be the greatest contributor to improved productivity, safety and
quality. This seminar provides the most current developments in human error prevention.
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Audience |
This seminar is designed for anyone whose objective is to
improve productivity, safety and quality. The principles and practices of
human error prevention are universally applicable regardless of the type
of industrial, commercial or governmental enterprise, and regardless of
the type of function performed within the enterprise. |
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Learning Outcomes |
Upon completion of this seminar, one will understand:
·
Human error prevention terminology;
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The relationships among culture, beliefs, values, attitudes and behavior;
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The seven human error causal factors;
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The five levels of human error;
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The three levels of barriers to human error;
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The four types of barriers within each barrier level;
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Techniques by which to make barriers effective;
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Error-inducing conditions and behaviors by
which to counteract these conditions;
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Non-conservative decision thought processes and behaviors;
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Conservative decision thought processes and behaviors;
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Coaching to reduce the recurrence of human error;
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Human error root causes;
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Human error measurement;
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Design and implementation of a Human Error Prevention Program. |
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Outline |
1. Definitions
of human performance and human error
2. Classifications
of human error
3. Behavior
model
4. The
seven human error causal factors with an example and case study to
demonstrate their applicability
5. Human
error and barrier models describing the five levels of human error and the
three levels of barriers with a case study to demonstrate their
applicability
6. The
relationship of barriers to the total quality / safety function
7. Techniques
by which to strengthen administrative, technical, equipment and human
barriers, with an emphasis on procedure and training barriers, and with a
case study to demonstrate the application of these techniques
8. Poka
yoke
9. Types
of error-inducing conditions and error-likely situations existing in the
task demands, work environment and humans and behaviors to counteract
these conditions and situations, with examples and a case study to
demonstrate their applicability
10. Thought
processes and behaviors leading to non-conservative decisions and those
leading to conservative decisions, with a case study to demonstrate their
applicability
11. Coaching
to reduce the recurrence of human error, with coaching exercises
12. Human
error root causes
13. Human
error measurements
14. Defense
in depth
15. Review
of the universally applicable principles of human error prevention
16. Review
of the elements of a Human Error Prevention Program |
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Handouts |
·
Copy of the visual aids
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Compilation of recommended behaviors to
prevent human error
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Case study and exercise materials
·
Certificate of Completion, with Continuing Education Units
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© - B.W. (Ben)
Marguglio - 2005-2013 |
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