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

Words and Terms Used in the Licensed Training Material

The following words and terms are used in this training material and have specific management or technical meanings.  The explanation following each word or term is intended only to provide only an indication of the meaning of the word or term.  These pages do NOT constitute a glossary; these pages are NOT intended to provide definitions of the words or terms.  The words and terms are defined upon first use in the training material, itself.

80/20 rule – a generalization of the Pareto principle

Accelerated life testing – a technique for design assessment and corrective action verification

Active error – as a category of error based on the timing of its undesired effect

Adequacy – no more and no less than is necessary to do the job

Administrative process barrier – the 1st type of barrier

Alert – a type of Level 1 Barrier

Ameliorate / amelioration – the Level 3 Barrier

Ameliorative corrective action – the 2nd type of corrective action

AND gate – in a fault tree, all conditions needed for the next higher condition

Apparent cause analysis – a technique for root cause analysis

As is / as found – the configuration of a hardware item or the existing condition of a document

Attitude – an influence on behavior

Attribute – a defining element of a hardware item, process or human

Audit – an independent assessment of an item or process

Availability – a function of reliability and maintainability

Bar chart – a tool for data analysis

Barrier – the three levels of barriers to prevent, detect and mitigate / ameliorate error

Barrier Level 1 – for the prevention of error

Barrier Level 2 – for the detection of error or of the hazard activated by error

Barrier Level 3 – for the mitigation / amelioration of the undesired effect of error or the hazard

Behavior – an action that yields a result

Belief – a contributor to one’s value(s)

Binning – combining end states in an event tree

Blame spiral – resulting in an ever worsening loss of communication and trust

Boolean logic – used in the construction of fault trees

Causal factor – the three types of causal factors

Cause & effects analysis – a technique for root cause analysis

Caution – a type of Level 1 Barrier

Certification – an independent attestation of qualification

Change analysis – a technique for root cause analysis

Characteristic– a defining element of an item, process or human

Classification of defects – a method of indicating the level of significance of a defect

Classification of design characteristics – to indicate the level of significance of an attribute

Close-in-time bias – a type of bias leading to non-conservative decisions

Coaching – a method of preventing error recurrence

Cognition-based error – the 2nd human error causal factor

Common mode failure – a failure resulting in the total loss of the benefit of redundancy

Compensatory corrective action – the 4th type of corrective action

Condition reporting and corrective action tracking – a method of preventing error recurrence

Confirmation bias – a type of bias leading to non-conservative decisions

Conservative decision-making – the 3rd field of focus

Constructability – a consideration for the design of a hardware item

Containment – a type of Level 3 Barrier

Contributing cause – the 2nd causal factor

Co-piloting – a type of operational loafing leading to non-conservative decisions

Corrective action – the four types of corrective action

Corrective maintenance – a type of maintenance

Counteracting behavior – a behavior to overcome error-inducing conditions

Critical – a classification of significance of a defect, design characteristic or undesired effect

Culture – a pattern of thought and behavior

Data element – a category of data

Defect – a non-conformance to a requirement for a hardware or process design characteristic

Defective – an item of hardware or a process that contains a defect

Defense in depth – the six levels of defense in depth or the six levels of opportunity

Degradation influence – a contributor to a failure mechanism

Design attribute or characteristic – a defining element of a hardware item or process

Design margin – a spread between a characteristic’s requirement and its maximum load

Designated challenge(r) – a behavior by which to counteract an error-inducing condition

Detect / detection – Barrier Level 2

Detection barrier failure – Error Level 3

Direct cause – the 1st causal factor

Disposability – a consideration for the design of a hardware item

Document corrective action – the 1st type of corrective action

Dropping guard – a type of operational loafing leading to non-conservative decisions

Effectiveness – adequacy and efficiency

Efficiency – adequacy at the least cost

EHS&Q – environmental (protection), (employee and public) health and safety, and quality

EHS&Q culture – a type of culture appropriately considerate of EHS&Q

EHS&Q-conscious work environment – an element of an EHS&Q culture

Employee empowerment – a counter to risky-shifting; a non-participative management style

End state – in an event tree

Environmental (protection), (employee and public) health and safety, and quality – EHS&Q

Environmental qualification – a consideration for the design of a hardware item

Equipment barrier – the 3rd type of barrier

Error – a behavior with an undesired result or effect

Error categorization – by type of behavior, timing of effect, significance, and causal factor

Error – the four levels of error

Error Level 1 – when necessary, the failure to prevent error

Error Level 2 – an initiating error

Error Level 3 – the failure to detect error or the hazard activated by error

Error Level 4 – when necessary, failure to mitigate the undesired effect of an error or hazard

Error of commission – an error category by type of behavior

Error of omission – an error category by type of behavior

Error recurrence prevention – the 4th field of focus

Error-inducing condition – anything  that increases the probability of error

Error-inducing condition-based error – the 4th human error causal factor

Error-inducing conditions & counteracting behaviors – the 2nd field of focus

Error-likely situation – anything that increases the probability of error

Escape – a type of 3rd level barrier

Event – a classification of significance of an undesired effect

Event tree – a tool for design quality assessment and root cause analysis

Extent of cause analysis – a technique to find all locations of a given or similar cause

Extent of problem analysis – a technique to find all locations of a given or similar problem

Fail-safe – the most undesired kind of failure

Failure mechanism – a contributor to failure mode

Failure mode – the way by which a design characteristic or attribute fails

Failure mode & effects analysis – a technique for design assessment and root cause analysis

Failure rate – a measure of reliability

Fault tree – a tool for design quality assessment and root cause analysis

Field of focus – the four fields of focus for human error prevention

Fitness for duty – a human responsibility

Fitness for use – a term indicating quality

Five Ds – deterrents to preventive corrective action

Five-part communication – a behavior by which to counteract an error-inducing condition

Flinch – the inspection acceptance of a marginal defect

Focus – an element of situational awareness

Free-riding – a type of operational loafing leading to non-conservative decisions

Frequency and similarity bias – a type of bias leading to non-conservative decisions

Functionability – a consideration for the design of a hardware item

Good practice – a method providing an exceptional technical or economic benefit

Groupthink – behavior of individuals in a group leading to a non-conservative decision

Hazard – anything that can impart an undesired effect

Hazard-barrier-effects analysis – a technique for design assessment and root cause analysis

Hazards & barriers – the 1st field of focus

Human barrier – the 4th type of barrier

Human corrective action – preventive corrective action for non-conforming behavior

Human error – behavior leading to an undesired result or effect

Human error causal factor – the seven universally applicable reasons for error

Human error clock – a tool to provide a training opportunity

Human error prevention – the subject of this BookinarTM

Human factors – an element of human error prevention

Human performance – behavior yielding results

Independence – a contributor to objectivity

Initiating action – a direct cause of an occurrence yielding an undesired effect

Initiating error – Error Level 2

Initiating occurrence / initiating event – in an event tree

In-service inspection – a method of maintaining the quality and safety of a hardware item

Inspectability – a consideration for the design of a hardware item

Inspection – a method of determining the acceptability of a item or process characteristic

Inspection hold point – a step in a process at which an inspection is required

Institutionalizing corrective action – a means of precluding the return to an undesired state

Interpretation – different understandings from the language in a procedure

Intervention – taking the opportunity to correct an undesired effect

Investigation – data collection as a prerequisite to root cause analysis

Job analysis – a means for identifying gaps between needed and available training

Knowledge-based error – the 1st human error causal factor

Lagging PI – a performance measure that does not enable timely intervention

Lapse-based error – the 7th human error causal factor

Latent defect – a defect that cannot be identified upon initial inspection or test

Latent error – a category of error based on the timing of its undesired effect

Leading PI – a performance measure that provides the opportunity for timely intervention

Level of opportunity / level of defense – the six levels of opportunity or defense

Level of cognition – the six levels of cognition

Life – a measure of reliability

M – the six Ms

Maintainability – a consideration for the design of a hardware item

Major – classification of significance for a defect, design characteristic, or undesired effect

Malicious behavior – sabotage in contrast to error

Malicious compliance – conformance knowing that an undesired effect will result

Management oversight and risk tree analysis – a technique for root cause analysis

Manufacturability – a consideration for the design of a hardware item

Mean time to restore – a measure of maintainability

Minor – a classification of significance of a defect, design characteristic or undesired effect

Mitigate / mitigation – Barrier Level 3

Mitigation barrier failure – Error Level 4

Near miss – a classification of significance of an undesired effect

Node – in an event tree

Non-conformance – a departure from a requirement

Operability – a consideration for the design of a hardware item

Operating experience program – a means of learning from conditions existing elsewhere

OR gate – in a fault tree, any one condition needed for the next higher condition

Order bias – a type of bias leading to non-conservative decisions

Outward neutralizing – a type of operational loafing leading to non-conservative decisions

Overload bias – a type of bias leading to non-conservative decisions

Over-simplification bias – a type of bias leading to non-conservative decisions

Pareto principle – of the distribution of wealth as described by Professor Wilfredo Pareto

Pareto chart / Pareto diagram – a tool for data analysis

Part corrective action – the 1st type of corrective action

Peer inspection – a type of inspection

Peer review – a type of document review

Performance indicator / performance measure – a presentation of quantitative grouped data

Phonetic alphabet – a behavior by which to counteract an error-inducing condition

Place-keeping – a behavior by which to counteract an error-inducing condition

Poka yoke – a technique for error prevention and detection

Post-job assessment – a behavior by which to counteract an error-inducing condition

Precautionary principle – a fundamental approach to employee and public safety

Precursor – a classification of significance of an undesired effect

Pre-job briefing – a behavior by which to counteract an error-inducing condition

Pre-production item – a thing used to assess design and manufacturing process quality

Prevention – Barrier Level 1

Prevention barrier failure – Error Level 1

Preventive corrective action – the 3rd type of corrective action

Preventive maintenance – a type of maintenance

Probabilistic risk analysis – a technique for design assessment or root cause analysis

Probabilistic risk assessment – same as probabilistic risk analysis

Probabilistic safety analysis – same as probabilistic risk analysis

Probabilistic safety assessments – same as probabilistic risk analysis

Problem – an error, anomaly or departure from logic

Problem thing – the three things in which a problem may exist

Problem statement – the various data elements necessary to adequately describe the problem

Process flow diagram / process flow chart – a tool for design analysis and root cause analysis

Process qualification – an action to help to assure the quality of a process

Protection – a type of 3rd level barrier

Prototype item – a thing used to assess design quality

Qualification – the ability to perform a specific task

Quality of design – an element of the scope of the total quality and safety function

Questioning attitude – an element of a EHS&Q-conscious work environment

QVV – question, verify and validate

Recovery – a type of  3rd level barrier

Reflexive-based or reactive-based error – the 5th human error causal factor

Reliability – a consideration for the design of a hardware item

Reliability centered maintenance – a type of preventive maintenance

Risk – an element of significance; effect times probability of recurrence of effect

Risky-shifting – a type of operational loafing leading to non-conservative decisions

Root cause – the 3rd type of causal factor

Root cause analysis – techniques to ID things to be corrected to prevent problem recurrence

Run to failure – a decision to not replace a hardware item prior to its failure

Sampling plan – an economically and technically beneficial scheme for inspection and test

Satisficing – a type of non-conservative decision-making

Self-assessment – an evaluation of one’s own hardware, processes and performance

Self-revealing problem – a problem for which the undesired effect has been experienced

Sentinel event – an occurrence with a physical adverse effect on a patient in a hospital

Significance – of a design characteristic, of a defect, of an undesired effect

Significance classification – for a defect, design characteristic or undesired effect

Significance level – same as significance classification

Single failure analysis – a technique to avoid a single item’s failure from causing an event

Situational awareness – a behavior by which to counteract an error-inducing condition

Six levels of opportunity / six levels of defense – to avoid error from escaping the enterprise

Skill-based error – the 6th human error causal factor

Spatial diagram – a tool for data analysis

Specificity – the level of detail needed to retain technical and economic benefits of a method

Standard data table – to enable the grouping of data for performance and status measurement

STAR – a behavior by which to counteract an error-inducing condition

Statistical process control chart – a tool for data analysis

Statistical “t” test – to determine if there is a significant difference between sets of data

Statistically significant difference – for verifying the effectiveness of corrective action

Stop work order – an external behavior by which to counteract an error-inducing condition

Surveillance – a process assessment technique

Systematic approach to training – an approach to improve the effectiveness of training

Task analysis – a means for identifying gaps between needed and available training

Taxonomy of human error causal factors – the universally applicable reasons for human error

Technical process barrier – the 2nd type of barrier

Testability – a consideration for the design of a hardware item

Three-part communication – a behavior by which to counteract an error-inducing condition

Time-line analysis – a techniques for root cause analysis

Time-out – a behavior by which to counteract an error-inducing condition

Top response / top event – in an event tree, a system responding to a undesired challenge

Track and trend – for problems of lesser significance

Truncation – of an analysis

Turn-over meeting – a behavior by which to counteract an error-inducing condition

Ultimate event – in an event tree

Undesired effect – a result of an error or hazard activated by an error

Unsharing – a type of operational loafing leading to non-conservative decisions

Urgency – an element of significance

Value chain diagram / value chain table / value stream – a tool for analysis of a process

Value-based error – the 3rd human error causal factor

Values – contributors to attitude

Verbalization – a behavior by which to counteract an error-inducing condition

Vital few – the causes for which preventive corrective action resources should be applied

Walk-down – a behavior by which to counteract an error-inducing condition

Warning – as a 1st level barrier

Workability – a consideration for the design of a hardware item

Working instrument – a measurement device at the lowest level in the hierarchy of accuracy

Working calibration standard – a measurement device used to calibrate a working instrument

The reader is referred to the Glossary of Terms published by the American Society for Quality.

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