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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HUMAN ERROR PREVENTION
By BW (Ben) Marguglio

We license "human error prevention", including "root cause analysis" training material.

Avoid time lost in travel and out-of-pocket travel cost.  Work at your own pace.

The licensee receives an electronic file consisting of approximately 350 slides, with        exercises and about a dozen case studies - all together about 40 hours of material for live training sessions.  The licensee can adjust the material to suit.  The licensee can re-organize the material into smaller packages for shorter training sessions.  Some of the material applies to all employees at all levels in the enterprise, some is best suited for senior executives, some is best suited for and middle managers, some is best suited for first-line supervisors, technicians, crafts persons and others in the field / on the line / on the factory floor, and some is best suited for investigation and root cause analysts. 

For almost every slide, and for every exercise and case study, there are extensive and comprehensive bulleted notes.  The complete answers to the exercise and case study assignments are provided. 

The licensee's trainer would have to learn the bulleted notes for the slides, exercises and case studies.  Thereafter, in live, in-house training sessions, the trainer could use the slides, exercises and cases studies and make the oral presentation without the need to read the bulleted notes.  With the info in the licensed training material, the trainer can become a subject matter expert.

For additional licensing information, please click here to contact us

You get Marguglio’s “Human Error Prevention” and “Root Cause Analysis” Seminar PowerPoint slides and bulleted, detailed notes – from the thought leader who has been acclaimed by hundreds of satisfied clients.

You get even more information than is presented in the live seminars.

You get specific and unique principles, practices, models, and templates.

You get comprehensive and comprehensible information.

You get “take-aways” that can be directly implemented.

You
get it all at a fraction of the cost of attending the live seminars.

As well as anyone, or better, Marguglio can teach you how to prevent error.
      

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:
     
 ·  Preventing human error that can activate hazards with intolerable or  unacceptable risks;
      
·  Preventing the recurrence of any such error that can and should have been prevented initially;
      
· Mitigating the effects of any such error that can’t be 100% prevented (e.g., skill-based and lapse- based errors).

LEARNING OBJECTIVES
Upon completion of this e-learning experience, 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; 
•
 Techniques by which to make barriers effective;
• The relationship of barriers to adverse effects and to the full scope of the quality, safety and risk management functions;
•
 Error-inducing conditions and error-likely situations
•
 Behaviors by which to counteract these conditions and situations;
•
 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;
• Problem identification, problem reporting, data codification, data grouping, data analysis, extent of condition, causal factor analysis, and corrective action terminology;
• Root cause analysis using any of the techniques listed in the Outline, below;
• Design and implementation of a problem reporting, root cause analysis, and
corrective action system;
• Management and assessment such a system;

• 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 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
   • Objectives
   • Coaching criteria
   • The seven steps
   • The five outcomes
   • Exercises to demonstrate the five outcomes

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

 

 
 
 
 Image credit: experimental / 123RF Stock Photo