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

HUMAN ERROR PREVENTION / HUMAN PERFORMANCE IMPROVEMENT / HUMAN FACTORS / HUMAN ELEMENT – 2 DAYS or 3-DAYS*
Ben Marguglio


* This seminar can be presented in either two or three days. The two-day version does not include the learning outcomes and outline topics that are given in italic font. For the public, only the two-day version is offered. For clients, in-house, both the two-day and three-day versions are offered.

Why This Seminar?

Regardless of the terms used (“human error prevention”, “human performance improvement”, “human factors”, “human element”), the objective of this seminar is to impart knowledge as to how to improve performance by reducing human error in the design and implementation of processes.

Organizational operating losses are caused by human error in process design (including process hardware design) and process implementation. The only exceptions are for losses from risks that:

  • Cannot be identified and/or assessed in advance, such as some risks from discovery and invention;
  • Are accepted based on probabilistic cost-benefit analysis.

This training provides up-to-date, complete and sufficiently specific material, enabling trainees to directly implement the universally applicable principles and practices.

When this training is presented for clients in-house, the material content and material presentation evaluation categories consistently receive average grades greater than 4.5 on a scale of 1 to 5, with “5” being “excellent”.

Audience

This highly acclaimed training addresses the prevention of human error in process design and implementation, the mitigation of its effects and the prevention of its recurrence and, therefore, should be of great interest to those who are responsible for improving productivity, safety, quality and environmental protection, among other functions, in a safety- and quality-conscious work environment focused on learning without blame.

Learning Outcomes

Upon completion of this seminar, one will understand:

  • Human error prevention terminology;
  • The relationships among culture, beliefs, values, attitudes and behavior;
  • Safety and quality culture;
  • The safety-conscious and quality-conscious work environment;
  • Leadership responsibilities for creating and sustaining the safety-/quality-conscious work environment;
  • Models describing how adverse effects occur;
  • The seven human error causal factors;
  • The five stages 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 safety and quality functions;
  • Techniques by which to make barriers effective;
  • Error traps (error-inducing conditions and error-likely situations)
  • Operational performance tools / Behaviors by which to counteract error traps;
  • Non-conservative decision thought processes and behaviors;
  • Conservative decision thought processes and behaviors;
  • Coaching to reduce the recurrence of human error;
  • Problem / condition identification, problem / condition reporting, data codification, data grouping, data analysis, Extent of Problem / Condition Analysis, Extent of Cause Analysis, and correction action good practices;
  • How to perform or facilitate root cause analysis using any of the techniques listed in the Outline, below;
  • The eight types of corrective action;
  • How to design, implement and maintain a problem / condition reporting, root cause analysis, and corrective action system;
  • Human error measurement;
  • Principles and practices of teamwork;
  • Principles and practices of human error prevention.

Outline

Introduction

• Terminology and definitions
— Human error and not human error
— Behavior, results and performance
— Beliefs, values and attitudes
— Culture
• Behavior model
• Safety and quality culture
• The safety-conscious and quality-conscious work environment
• Leadership responsibilities – creating / maintaining the safety-/quality-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 universally applicable human error causal factors
—— Exercise – Demonstration of the error-induced-based causal factor
—— Exercise – Demonstration of all seven human error causal factors
—— Case study – Demonstration of all seven human error causal factors and human error principles

1st Field of Focus – Hazards and Barriers

• Models of adverse effects
— Reason’s Swiss cheese model
— Marguglio’s adaptations of Reason’s model
— Marguglio’s barrier model
• The five stages 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 safety and quality functions
• Process barriers
• Process design criteria
• Specificity and flexibility, using the “If / Then” convention
• Techniques for strengthening process barriers
• Poka yoke
• Exercise – demonstration of process barriers
• Exercise – demonstration of process design criteria
• Training barriers
• Systematic approach to training
— ADDIE
— Task analysis
• Techniques for strengthening training barriers
• Equipment barriers
• Barrier functions
• Exercise – barrier functions
• Spectrum of barrier effectiveness and dependability

2nd Field of Focus – Error Traps and Counteracting Behaviors

• Sources of error traps (error-inducing conditions and error-likely situations)
• Types of error traps
• Case study
• Operational performance tools / Behaviors to counteract error traps
— Walk-arounds
— Pre-job briefings
— Post-job assessments
— Turnovers
— STAR/STOP
— Two-minute rule
— Time out
— Verbalization
— Do not disturb
— Flagging
— Three-way communication
— Four-way communication
— Standardized acronyms
— Phonetic alphabet
— Place keeping
— Procedure compliance
— Quick-step procedure change process
— Peer checking
— Independent verification
— QVV
— Questioning attitude
— Reinforcement
• The blame spiral
• Other tools
• 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
• 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
• Case study

4th Field of Focus – Prevention of Error Recurrence

• Observation and coaching system to reduce human error recurrence*
— System objective
— Coaching skills
— The seven-step method of coaching
— Coaching exercises
• Problem / condition reporting, root cause analysis, and corrective action system to reduce human error recurrence
— 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 / Condition 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
—— Preparations
—— At the scene
—— Interviewing template
— Root cause analysis techniques
—— The 5 WHYs
—— Change Analysis
—— Failure Mode & Effects Analysis with an example
—— Hazard-Barrier-Effects analysis / Process Design & Implementation Analysis with template and case study
——Time-line analysis with a template and case study
—— Cause & effects analysis / Fishbone diagrams with examples
—— Process flow diagrams with an example
—— Value stream diagrams with an example
—— Other
• Hardware failure modes
• Hardware failure causes
• Human performance root causes
• Extent of Cause Analysis
• The eight types of action
• Elements of a corrective action commitment
• Correction action verification and validation 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

Handouts

• Copy of approximately 250 PPT slides (2-days) or 325 PPT slides (3-days) used in the seminar
• Copy of case studies and exercises used in the seminarCertificate of Completion showing 7 ½ education hours per day, with 0.75 Continuing Education Units per day that may be used toward university course credits or professional re-certifications, signed by Ben Marguglio.
• Certificate of Completion showing 7 ½ education hours per day, with 0.75 Continuing Education Units per day that may be used toward university course credits or professional re-certifications, signed by Ben Marguglio.

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