Human Error; Human Error Prevention; Human Error Reduction: Error; Human Performance;
Human Performance Improvement; Root Cause Analysis; Corrective Action; Process Improvement

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The Precept

Losses in an organization are attributable to human error in the design of processes (including the design of hardware used in the processes) and in the implementation of processes The only exceptions are for losses from risks that are:
·   Not identifiable and/or assessable in advance, such as some risks from discovery, invention, natural disaster and sabotage;
·   Accepted based on probabilistic cost-benefit analysis. 

Systems, techniques and tools must be in place by which to:
·  
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;
·  
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.

The Four Fields of Focus for Human Error Prevention

1. Concern - Hazards

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.

2. Concern - Error-Inducing Conditions and Error-Likely Situations  
Response - 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.
3. Concern - Inappropriate Risk-Taking  
Response - Recognize the behaviors that lead to inappropriate risk-taking.  Practice behaviors that lead to conservative decision-making.
4. Concern - Recurrence of Past Errors
Response - Implement a field observation and coaching system.  Implement a problem reporting, root cause analysis, and preventive corrective action system.  Implement performance metrics.

The Seven Universally Applicable Human Error Causal Factors

1. Knowledge-based Error - Lack of knowledge of the standard, requirement or need.

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. 

3. Value-based Error / Belief-based Error - Lack of respect for or lack of acceptance of the standard, requirement or need.

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.

5. Reflexive-based Error - Lack of conservative behavior in immediately reacting to a "field stimulus".

6. Skill-based Error - Lack of manual dexterity.

7. Lapse-based Error - Lack of attention.

Human Error Prevention
Ben Marguglio

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.

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.

Learning Outcomes

Upon completion of this seminar, one will understand:

· Human error prevention terminology;  

· The relationships among culture, beliefs, values, attitudes and behavior;
· Quality and safety culture;
· The quality-conscious and safety-conscious work environment;
· Leadership responsibilities for creating and sustaining the quality-  conscious and safety-conscious work environment;

· Models describing how adverse effects occur;

· The seven human error causal factors;  

· The five levels of human error;

· The three levels of barriers to human error;

· The four types of barriers within each barrier level;
· The relationship of barriers to adverse effects and to the full scope of the quality and safety functions;

· Techniques by which to make barriers effective;

· Error-inducing conditions and behaviors by which to counteract these conditions;

· Non-conservative decision thought processes and behaviors;

· Conservative decision thought processes and behaviors;

· Coaching to reduce the recurrence of human error;

· Human error root causes;

· Human error measurement;

· Design and implementation of a Human Error Prevention Program.

Outline

Introduction

• Terminology and definitions
   • Human error and not human error
   • Behavior, results and performance
   • Beliefs, values and attitudes
  
• Culture
• Behavior model
• Quality and safety culture
• The quality-conscious and safety-conscious work environment
• Leadership responsibilities for creating and maintaining the quality- and safety-conscious work environment
• Classifications of human error
   • Based on the timing of the adverse effect
   • Based on the significance of the adverse effect
   • Based on the human error causal factors
      • The seven human error causal factors
      • Exercise – Demonstration - error-induced based causal factor
      • Exercise – Demonstration - seven human error causal factors
      • Case study – Therac-25 –
        Demonstration of the seven causal factors and principles

1st Field of Focus – Hazards and Barriers

• Models of adverse effects
   • Reason’s Swiss cheese model
   • Marguglio’s adaptation of Reason’s model
   • Marguglio’s barrier model
• The five levels of error
• The three levels of barriers to error
• The four types of things into which barriers can be incorporated
• The relationship of barriers to the total quality and safety function
• Process barriers
• Process design criteria
• Specificity and flexibility / If and then
• Techniques for strengthening process barriers
• Poka yoke
• Exercise – Pressure gauges – Demonstration of process barriers
• Exercise – Hose cleaning procedure – Demonstration of process design criteria
• Training barriers
• Systematic approach to training (SAP)
   • ADDIE
   • Task analysis
• Techniques for strengthening training barriers
• Equipment barriers
• Barrier functions
• Exercise – Barrier functions
• Spectrum of barrier effectiveness and dependability
• Case study – Stator bar removal

2nd Field of Focus – Error-Inducing Conditions and Counteracting Behaviors

• Sources of error-inducing conditions and error-likely situations
• Types of error-inducing conditions and error-likely situations
• Union Pacific case study
• Behaviors to counteract error-inducing conditions and error-likely situations
   • Walk-arounds
   • Pre-job briefings
   • Post-job assessments
   • Turnovers
   • STAR/STOP
   • Time out
   • QVV
   • Flagging
   • Three-way communication
   • Four-way communication
   • Standardized acronyms
   • Phonetic alphabet
   • Place keeping
   • Procedure compliance
   • Quick-step procedure change process
   • Verbalization
   • Peer checking
   • Independent verification
   • Questioning attitude
   • Reinforcement
• The blame spiral
• Other tools
• Piper Alpha case study

3rd Field of Focus – Non-Conservative Decisions and Counteracting Thought Processes/Behaviors

• Thought processes and behaviors leading to non-conservative decision-making
   • Biases
   • Satisficing
   • Operational loafing
   • Group think
   • Challenger
• Alaska Flight 261 case study
• Thought processes and behaviors for conservative decision-making
   • Precautionary principle
   • Designated challenger
   • Situational awareness       
   • Focus versus fixation
   • Clues to the loss of situational awareness
• Greenville and Ehime Maru case study

4th Field of Focus – Prevention of Error Recurrence

• Observation and coaching system to reduce human error recurrence
• Problem reporting, root cause analysis, and corrective action system objectives
• System participant responsibilities
• System capabilities
• Problem data collection criteria
• Standard data tables / Data to be collected, and why
• Fact versus conclusion
• Extent of problem analysis
• Operating experience
• Risk-based initial screening of problem reports
• Risk, urgency and significance
• Root, contributing and direct causes
• Criteria for action
• Administration of root cause analysis  
• Data collection
• Interviewing
• Root cause analysis techniques
   • The 5 whys
   • Change analysis
   • Failure mode & effects analysis
      • Example
   • Hazard-barrier-effects analysis
      • Case studies - Various
   • Time-line analysis
      • Case study – Rotor into generator housing
  
• Cause & effects analysis / Fishbone diagrams
       • Examples
   • Probabilistic risk/safety analysis, with event & fault trees
      • Examples
   • Management & oversight risk tree analysis
  
• Process flow diagrams
       • Example
   • Value stream diagrams
      • Example
   • Other
• Hardware failure modes
• Hardware failure causes
• Human performance root causes
• Extent of cause analysis
• The nine types of corrective action that fall into the following five categories
   • Broken thing corrective action
   • Ameliorative corrective action
   • Preventive corrective action
   • Compensatory corrective action
   • Assurance process corrective action
• Elements of a corrective action commitment
• Corrective action verification techniques
• Leading and lagging performance indicators
•
Performance and status indicator reports

Strategy

• Measurement and reporting
• Defense in depth
• Review of human error prevention / mitigation principles and practices

NOTE: Line items that are highlighted in grey are not covered in the 2-day tutorial.

Handouts

·  Copy of the visual aids
·
 Compilation of recommended behaviors to prevent human error
·
  Case study and exercise materials
·
 Certificate of Completion, with Continuing Education Units
Click here to register for the seminar.
Click here for our presenter's credentials.
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 © - B.W. (Ben) Marguglio - 2005-2013