Human Error; Human Error Prevention; Human Error Reduction; Error; Human Performance; Human Performance Improvement; Root Cause Analysis; Corrective Action; Process Improvement, seminars, training license, ebook

Purchase a License to Use the Human Performance Improvement through Human Error Prevention Training Material.

We license “HPI / HEP”, including “root cause analysis” training materials. The licensee receives an electronic file consisting of 724 PowerPoint sheets. In “Normal” view, there are 407 slides, excluding those for exercises and case studies. In “Notes Page” view, below the slides and extending to additional sheets, as necessary, there are itemized notes for the trainer to use with the presentation of the slides. There are 6 exercises and 7 in-depth case studies, each with their assignment completion, comprising 78 sheets. Also, there are other techniques with which to gain trainee participation. There are templates with which to maintain the logic, discipline and rigor for the use of two major root cause analysis techniques. There are 38 appendices consisting of 150 sheets of additional valuable specifics of criteria for incorporation into the enterprise business management system..

For additional licensing information, please contact us.

• You get Marguglio’s “HPI / HEP”, including “Root Cause Analysis” Seminar PowerPoint slides and itemized, detailed notes – from the thought leader 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.

The implementation of the principles and practices in this training material will save lives! In addition, it will save the enterprise $millions, tens of $millions for a mega enterprise. That’s a whopping return on investment!

Almost all enterprise operational loss is attributable to human error in the design of the enterprise administrative and technical processes, including the design of the hardware used in the processes, and in the implementation of the processes. This training material provides the principles and practices by which to prevent or significantly reduce these losses. That’s why this material should be of the greatest interest to enterprises in all business sectors.

The principles and practices in this training material can be implemented cost-effectively. They are universally applicable regardless of the type of industrial, commercial, educational and governmental enterprise and regardless of the function performed within the enterprise.

This training material has extensive breadth of scope and extensive depth of specificity, enabling the trainees to directly implement the principles and practices. It’s all there!

This training material is unique, not only because much of its content is original, adding to the body of knowledge, but also because the training material is in presentation format, usable as is!

The objective of this training material is to provide the enterprise trainer with PowerPoint slides, trainer’s presentation notes (written in the voice of the trainer), and exercises and case studies with which to train workers on the subject of human performance improvement by means of human error prevention.

There are approximately 40 hours of training material. The material is applicable to workers at all levels in the enterprise. The material is organized such that it can be easily grouped into shorter training sessions for executive, middle management levels, first-line management/supervisory and individual contributor levels. All of the training material should be presented to first-line managers / supervisors and their direct reports.

More than 300 sheets of new training material have been added to Marguglio’s earlier book entitled Human Error Prevention, published in 2009. The physical layout of the updated training material is the same as was used in Marguglio’s earlier book. If you peruse the earlier book, you’ll get a good sense of what you’ll get with the purchase of the license for the updated material. Used copies of the earlier book may be available on Amazon.

PRECEPT FOR HPI / HEP TRAINING

Almost all operational 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., hazards to the quality of production, safety, environment);
• 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 OUTCOMES

Upon completion of this e-learning experience, one will understand:

• HPI / HEP 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 1 source of operational loss;
• The 2 essentials;
• The 3 levels of barriers to human error;
• The 4 types of barriers within each barrier level;
• The 5 stages of human error;
• The 6 “M”s;
• The 7 human error causal factors;
• The “Rule of 8” – Marguglio’s 8-step approach to process risk management;
• 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 HPI / HEP Program.

OUTLINE

Introduction

Precepts
• Beliefs, Values and Attitudes
• Behavior, Results and Performance
Marguglio’s Model of Behavior
• Quality – Quality of:
  o Production
  o Safety and Health
  o Environmental Protection
  o Security
  o Emergency Preparedness and Response
  o Etc.
• Culture
• Quality Culture
• Quality-Conscious Work Environment
  o Questioning Attitude – Why? When? How?
  o Leadership Responsibilities for Creating the Quality-Conscious Work Environment
  o Leadership Responsibilities for Transitioning to the Quality-Conscious Work Environment
  o Keys to Success for Transition to the Quality-Conscious Work Environment
  o Avoiding the Blame Spiral
• Classifications of Human Error
  o Based on the Timing of the Adverse Effect
      Active
      Latent
  o Based on the Significance of the Adverse Effect
      Risk
      Risk Assessment 
      Initial Level of Risk
      Risk Treatment
      Residual Level of Risk
  o Based on the Human Error Causal Factor
      Dr. Juran’s Taxonomy
      Reason’s Taxonomy
      Marguglio’s Taxonomy of The Seven Human Error Causal Factors
        * Knowledge-based Error with Examples
        * Cognition-based Error with Examples / Bloom’s Taxonomy
        * Value-based Error with Examples
        * Error Inducing Condition-based / Error-likely Situation-based Error (Error Trap-based Error) with Examples
        * Reflexive-based Error / Reactive-based Error with Examples
        * Skill-based Error with Examples
        * Lapse-based Error with Examples
  o Exercises and case studies – Demonstrations of the Seven Human Error Causal Factors and Human Error Prevention Principles

1st Field of Focus – Hazards and Barriers

• The 1 Predominant Source of Operation Loss – Human Error
• The 2 Critical Elements – Hazards and Barriers
  o Hazards
      Risk Associated with Hazard
      Risk Assessment
      Initial Level of Risk
      Treatment
      Residual Level of Risk
      Examples of Different Level of Risk or Significance
  o Barriers
  o Hazard and Barrier Models
      Reason’s Swiss cheese model
      Marguglio’s adaptations of Reason’s model
        * Initiation Action
        * Initiating Error
        * Barriers
        * Adverse Effect
• The 3 Types of Barriers
  o Prevention
  o Detection
  o Mitigation
• The 4 Things in which Barriers Exist
  o Administrative Processes
  o Technical Processes
  o Hardware Items
  o Humans
• Marguglio’s 5 Stages of Error
  o Hazard identification and assessment in process design
  o Prevention barrier(s) in process design
  o Detection barrier(s) in process design
  o Mitigation barrier(s) in process design
  o Process implementation
• The 6 “M”s
  o Man
  o Machine
  o Material
  o Method
  o Measurement
  o Mother-nature / man-made environment
• Marguglio’s 7 Human Error Causal Factors
  o Knowledge-based
  o Cognition-based
  o Value-based
  o Error Inducing Condition-based / Error Likely Situation-based (Error trap-based)
  o Reflexive-based / Reaction-based
  o Skill-based
  o Lapse-based
• Process Risk Management During Design
Marguglio’s Rule of 8 for Process Risk Management
• Sources of Administrative and Technical Process Barriers
• Process Performance Criteria
• Process Design Criteria
• Techniques for Strengthening Process Barriers
   o Specificity and Simplicity
   o Specificity and Flexibility – “If and Then” Convention
   o Etc.
• Process Owner Responsibilities
• Process Qualification
• Exercise – Demonstration of Process Barriers
• Exercise – Demonstration of Process Design Criteria
• Training Barriers
• Systematic Approach to Training
  o ADDIE
  o Task Analysis
Marguglio’s Techniques for Concurrently Strengthening Training Barriers and Process Barriers
• Hardware Item Barriers and Process Barriers Needed Create Hardware Item Barriers
• Component Risk Management During Component Design
  o Failure Mode and Effects Analysis During Design
• Facility Risk Management
  o Probabilistic Risk Analysis During Design
     Event Trees   
     Fault Trees
• Human Barriers
• Barrier Functions
• Exercise to Demonstrate Barrier functions
• Spectrum of Barrier Effectiveness and Dependability
• Causes of Barrier Failure
• The Full Scope of the Quality Function
  o Dr. Feigenbaum’s Model
  o Marguglio’s Adaptations of Feigenbaum’s Model
  o Marguglio’s Ultimate Model in Terms of Hazards and Barriers
  o The 8 Types of Corrective Action

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

• Sources of Error-Inducing Conditions and Error-Likely Situations (Error Traps)
• Types of Error-Inducing Conditions and Error-Likely Situations in Processes
• Types of Error-Inducing Conditions and Error-Likely Situations in the Work Environment
• Behaviors to Counteract Error-Inducing Conditions and Error-Likely Situations
  o Poka Yoke Applications
  o Walk-Arounds, the 5 Types of
  o Pre-Job Briefings, Including Reverse Briefings
     Special Considerations for Engineers
  o Post-job assessments
  o Turnovers
  o STAR/STOP
  o Time out
  o Stop Work Order
  o QVV
  o Flagging
  o Fencing
  o Three-Way Communication
  o Four-Way Communication
  o Standardized Acronyms
  o NATO Phonetic Alphabet
  o Marguglio’s Phonetic Alphabet
  o Place Keeping
  o Procedure Usage
     Procedure Usage Ground Rules
     Procedure Categories
     Quick-Pace Procedure Change Process
     Risk-Based Usage of Red-Lined Procedures
     The 6 Reasons for Not Making Value-Based Error
     Elimination of Value-Based Error
  o Verbalization
  o Peer Checking / Peer Review
  o Independent Verification
     Independence
  o Questioning Attitude
  o Reinforcement
  o Other tools
  o Case Study – Demonstration of Error-Traps and Counteracting Behaviors

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

• Thought Processes and Behaviors Leading to Non-Conservative Decision-Making
  o Biases, 25 Types
  o Satisficing, Good and Bad
  o Operational Loafing, 6 Types
  o Group Think
  o Case Study
• Thought Processes and Behaviors for Conservative Decision-Making
  o Precautionary Principle
  o Designated Challenger
  o Situational Awareness
  o Focus Versus Fixation
  o Clues to the Loss of Situational Awareness
Questions to Ask Before Making a Decision
• Case Studies – Demonstrations of Non-Conservative Decisions

4th Field of Focus – Prevention of Error Recurrence

• Observation and Coaching System to Reduce Human Error Recurrence
  o Coaching Objectives
  o Coaching Skills
  o Coaching Preparations
  o The 7-Step Coaching Method
  o Exercises
  o Special Considerations for Engineers
• Condition Reporting and Corrective Action System
  o Condition Reporting and Corrective Action System Objectives
  o Types of Conditions
  o System Participants and Their Responsibilities
     Condition Report Originator
     Supervisor
     Controller
     Actionee
     Sub-Actionee
  o Capabilities of the Condition Report and Corrective Action Tracking Tool
  o Sequence of Activities for the Design of the Condition Report and Corrective Action Tracking Tool
  o Data Collection Criteria
  o Data Attributes, 15 Types of
  o Standard Data Tables, 12 Different
  o Problem Definition
     Actions for Good Problem Definition
     4 “W”s and How, Combined with IS / IS NOT
     What’s Happened
     3 Things in which a Problem Can Exist
     Data Elements for Problem Definition
  o Fact Versus Conclusion
  o Operating Experience
  o Risk-Based initial Screening of Problem Reports
  o Risk, Priority and Significance
  o Risk / Significance Matrices
  o Criteria for Action
  o Extent of Problem Analysis
  o Direct, Contributing and Root Causes
  o Root Cause Analysis
     Root Cause Analysis Logic
     Root Cause Analysis Team Qualifications
     Administration of Root Cause Analysis
      * Charter
      * Plan
      * Etc.
     Data Collection / 5 Sources of Data
• Interviewing
  o Actions Immediately Following the Adverse Effect
  o Interviewing Preparedness
  o Criteria for Interview Questions
  o Interview Questions, Template for
  o Success Factors
  o Criteria for Effective Root Cause Analysis Techniques
  o Root Cause Analysis Techniques
     5 WHYs Analysis
       * Criteria for Use
       * Analytical Process
       * “Therefore” Convention with an Example
       * Scenario of a Hardware Item Failure
     Reasons for Component Failure, Acceptable and Unacceptable
     Failure Mode & Effects Analysis
       * Criteria for Use
       * Analytical Process
       * Example
     Change Analysis
       * Criteria for Use
       * Analytical Process
     Marguglio’s Process Design & Implementation Analysis
       * Criteria for Use
       * Analytical Process
       * Case Study Using Templates
     Time-Line Analysis
       * Criteria for Use
       * Analytical Process
       * Case Study, Using Templates
     Cause & Effects Analysis / Fishbone Diagrams for Root Cause Analysis
       * Criteria for Use
       * Analytical Process
       * Examples
       Prioritizing Data Collection
     Cause & Effects Analysis / Fishbone Diagrams for Improvement Projects
       * Criteria for Use
       * Analytical Process
       * Examples
     Probabilistic Risk/Safety Analysis
       * Event Tree
       * Fault Trees
       * Examples
     Process Flow Diagrams
       * Examples
     Value Stream Diagrams
       * Examples
     Spaghetti Diagram
       * Examples
     Gap Analysis
       * Example
 o Hardware Failure Modes
 o Hardware Failure Causes
 o Human Performance Root Causes
 o Extent of Cause Analysis
 o Corrective Action
     Objectives
     Decision Rules
     Prioritizing
     Corrective Actions, 8 Types that Comprise 5 Different Categories
       * Broken Thing Corrective Action
       * Ameliorative Corrective Action
       * Preventive Corrective Action
       * Compensatory Corrective Action
       * Assurance Process Corrective Action
     Corrective Action Commitment, 7 Elements of
     Verification and Validation
     Conditions Yielding Ineffective Corrective Actions
 o Root Cause Analysis Report. Contents of
 o Corrective Action Verification and Validation Techniques
 o The “D”s

Strategies

• Performance and Status Reporting
  o Leading and Lagging indicators
  o Indicators of Cultural Performance, with Examples
  o Indicators of Process Performance, with Examples
 30 Human Error Prevention Major Principles, Collectively Comprising Strategy
• Defense in Depth
  o Levels of Defense / Levels of Opportunity, 6
  o Descriptions of the 6 Levels
  o Problem Identification and Correction at Each Level
  o Frequency and Independence of Each Level
• Risk Management
  o Process Risk Management – Marguglio’s Rule of 8
  o Component Risk Management
  o Hardware System / Facility Risk Management
• Four Fields of Focus / Concerns
  o Hazards and Responses
  o Error Traps and Responses
  o Non-Conservative Thought Processes and Responses
  o Recurring Problems and Responses

Appendices

  1. List of Appendices
  2. Training Outline
  3. Words and Terms Used
  4. Criteria for Designing Processes / Procedures, Including Standard Types of Contents of a Process Description Document / Written Procedure and Standard Types of Conventions for Writing a Process Description Document / Written Procedures
  5. Criteria for Designing Processes / Procedures for Process Risk Management
  6. Criteria for Designing Processes / Procedures for Process Design Review
  7. Criteria for Designing Processes / Procedures for Process Verification and Validation
  8. Criteria for Designing Processes / Procedures for Roles, Responsibilities and Training
  9. Criteria for Designing Processes / Procedures for Design Engineering, Including Standard Types of Design Requirements for Hardware Items and Facilities
  10. Criteria for Designing Processes / Procedures for Calculations, Including Calculation Change
  11. Criteria for Designing Processes / Procedures for Software and Firmware, Including Standard Data Attributes
  12. Criteria for Designing Processes / Procedures for Hardware Item and Facility Risk Management
  13. Criteria for Designing Processes / Procedures for Hardware Item and Facility Design Review
  14. Criteria for Designing Processes / Procedures for Procurement, Including Selected Standard Procurement Requirements
  15. Criteria for Designing Processes / Procedures for Measurement
  16. Criteria for Designing Processes / Procedures for Risk-based Production, Maintenance or Operations
  17. Criteria for Designing Processes / Procedures for Pre-job Walkdown and Pre-job Brief
  18. Criteria for Designing Processes / Procedures for Acceptance Check, Inspection, Test, Nondestructive Examination, Pre-service Inspection and In-service Inspection, Including Standard Criteria for Placement of Checks, Inspections and Tests and Standard Techniques for Improving Checks and Inspections
  19. Criteria for Designing Processes / Procedures for Place-keeping
  20. Criteria for Designing Processes / Procedures for Quality Status
  21. Criteria for Designing Processes / Procedures for Post-job Assessment
  22. Criteria for Designing Processes / Procedures for Operational Jurisdictional Control and Turnover for Operations
  23. Criteria for Designing Processes / Procedures for Turnover and Start-up
  24. Criteria for Designing Processes / Procedures for Out-of-service Hardware and Return to Service
  25. Criteria for Designing Processes / Procedures for Records, Including Standard Types of Records
  26. Criteria for Designing Processes / Procedures for Document Change, Including Standard Cross-references for Management of Document Change
  27. Criteria for Designing Processes / Procedures for Security, Including Cyber Security
  28. Criteria for Designing Processes / Procedures for Fire Safety
  29. Criteria for Designing Processes / Procedures for Chemical Control
  30. Criteria for Designing Processes / Procedures for Drum Control
  31. Criteria for Designing Processes / Procedures for Foreign Material Exclusion
  32. Criteria for Designing Processes / Procedures for Haul Path
  33. Criteria for Designing Processes / Procedures for Waste Minimization and Control
  34. Criteria for Designing Processes / Procedures for Emergency Preparedness and Response
  35. Criteria for Designing Processes / Procedures for Site Interfaces, Compatibility of Site Requirements and Communication of Site Hazards
  36. Criteria for Designing Processes / Procedures for Process Performance Measurement
  37. Criteria for Designing Processes / Procedures for Audit and Organizational Self-assessment
  38. Criteria for Designing Processes / Procedures for Condition Reporting, Causal Factor Analysis and Corrective Action, Including Employee Concerns
  39. Criteria for Designing Processes / Procedures for Process Performance Measurement
  40. Criteria for Designing Processes / Procedures for Management Review
  41. Criteria for Designing Processes / Procedures for New Business Proposals

NoteThroughout the training material, there are substantial additions to the body of knowledge.