Human Performance Improvement through Human Error Prevention

A Comprehensive Implementation Guide for Protecting Employees and Maintaining Cost Efficiency

BW (Ben) Marguglio

• Publisher: Productivity Press
• Year: 2021
• Print ISBN:
  9780367672393
• Edition: 1
• eBook ISBN:
  9781000397215
• Topic: Business
• Subtopic: Human Resource Management
• Index: Business

This book is a simulation of a live course on human performance improvement/human error prevention (HPI/HEP) created by the preeminent authority on HPI/HEP. It presents the greatest breadth of scope and specificity on this topic. This book comprises a focused, challenging human error prevention training course designed to improve understanding of error causation. It will dramatically reduce human error and repeat deviations, and it digs below the surface of issues and looks to fix the real causes of human error and mistakes.

In addition, this book presents a complete seminar from the thought leader acclaimed by hundreds of clients, and includes unique principles, practices, models, and templates. Information is comprehensive and can be directly implemented. 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. The application of the information in this book will significantly contribute to improved productivity, safety, and quality.

After fully using this book, you will understand:

• Human error prevention/reduction terminology and definitions.
• The relationships among culture, beliefs, values, attitudes, behavior, results, and performance.
• The roles of leadership in establishing and maintaining a quality/safety-conscious work environment.
• The one fundamental precept explaining the importance of human error prevention/reduction.
• The two most critical elements of human error prevention/reduction.
• The three levels of barriers to human error.
• The four types of things in which the barriers may exist at each barrier level.
• The five stages of human error.
• The six "M"s that can emit or receive hazards activated by human error.
• The seven universally applicable human error causal factors.
• The Rule of 8 by which to prevent human error and mitigate its effects.
• Techniques for making barriers effective and the spectrum of barrier effectiveness.
• The relationship of human error prevention/reduction to the total quality/safety function.
• Error-inducing conditions (error traps) and behaviors for counteracting these conditions.
• Non-conservative and conservative thought processes and behaviors in decision-making.
• Coaching for preventing the recurrence of human error.
• Root cause analysis techniques for identifying human error causal factors.
• The nine types of corrective action.
• Human error measurement.
• Strategies for a human error prevention/reduction initiative.
• How to design, implement, and manage a human error prevention/reduction initiative.

Chapter 1

Major Learning Objectives

Introduction

• Precepts
• Terminology
• Culture
• Quality culture
• Quality-conscious work environment
• Leadership responsibilities
• Daisy chain
• Blame spiral

• Initially, we’ll cover the most important precept and a few other important ones. However, there are lots of other precepts that will be presented throughout this course.
• The management- and technique-specific terms and words that are applicable to HPI through HEP will be defined. You’ll be able to understand and use these terms and words with accuracy and precision.
• If you’re advanced with regard to terminology, the “Terminology” section may be somewhat of a review. However, I strongly suspect that you’ll get new perspectives on some words and terms and, therefore, that you’ll also better understand the subsequent material in which the words and terms are used.
• Recognizing that “culture” is at the foundation of any improvement, human performance improvement or otherwise, we’ll cover the meaning of “culture”, progress to the attributes of a “quality culture”, keeping in mind that we mean quality of production, of safety and health, of environmental protection, etc. Then, we’ll progress to the still more specific attributes of the “quality-conscious work environment” through which quality culture is implemented.
• We’ll cover the responsibilities of leaders in transitioning to and maintaining a quality-conscious work environment. We’ll discuss some of the problems in making the transition and methods of overcoming these problems.
• The daisy chain of information, beliefs, values and attitudes leading to behavior and results will be covered from different perspectives.
• When the quality-conscious work environment and daisy chain break down, we get the “blame spiral”. We’ll discuss how that happens and its adverse effects.

Introduction (Cont’d)

• Human error
• Human error classifications by:
  • – Action–inaction
  • – Timing of the adverse effect
  • – Level of significance of the adverse effect
  • – Causal factor

• We’ll cover that which constitutes human error and that which does not. And why.
• We’ll cover how human error can be classified in the ways shown on the screen (Read the four bullets.), and we’ll cover the reasons for and importance of each type of classification.
• We’ll compare the taxonomies of human error causal factors created by Professor James Reason, Dr. Joseph Juran and by me.
• A “taxonomy” is a scheme of classification of things within a given field of interest.
• James Reason is Professor Emeritus of Psychology at the University of Manchester, England. He is also a speaker and author. He is most highly acclaimed for his creation of models describing the nature of accidents. Professor Reason’s work will be referred to in later slides, but at those points, without meaning any disrespect, his accolades will not be repeated.
• Dr. Joseph Juran (1904–2008) was an engineer, management consultant, speaker and author on quality management. He was an honorary member of the American Society for Quality and one of the greatest contributors to the quality body of knowledge. Dr. Juran’s work will be referred to in later slides, but at those points, without meaning any disrespect, his accolades will not be repeated.

1 st Field of Focus – Hazards and Barriers

• Process risk management
  • – Prerequisites to process risk management
    • 1 source of operational loss
    • 2 levels of risk
    • 3 types of barriers
    • 4 things in which barriers exist
    • 5 stages of error
    • 6 “M”s
    • 7 human error causal factors
  • – Process risk management – the Rule of 8
  • – Techniques for process barrier effectiveness
  • – Training processes
    • ADDIE
    • Beyond ADDIE

• “Hazards and Barriers” is the first of the “Four Fields of Focus” or major areas of interest for error prevention, error detection and mitigation of the adverse effects of hazards activated by error.
• The word “hazard” has a very broad meaning – anything that can cause or contribute to an adverse effect. A hazard can apply to the quality of production, quality of safety and health, quality of environmental protection, of security, including cyber-security, of emergency preparedness and response, etc.
• Hazards and barriers will be covered as they apply to process risk management.
• You’ll learn to use or at the very least to facilitate the use of a technique for the management of risk in administrative and technical processes, but first you’ll learn the seven prerequisites to the effective use of this technique which I call the “Rule of 8”. The seven prerequisites are: (From the slide, read the seven prerequisites to the Rule of 8.)
• In discussing the second prerequisite, the word “risk” means exposure to a hazard. You’ll learn the constituents of risk levels, the relationship of “risk levels” to problem “significance” and the difference between “significance” and “priority”.
• Given that barriers for prevention, detection and mitigation are used to reduce the initial level of process risk, we’ll cover techniques by which to improve the effectiveness of these barriers.
• Obviously, the enterprise training system is or should be a major contributor to the prevention of human error, but the training processes that comprise the system, themselves, may have hazards for which barriers are required.
• We’ll cover ADDIE, a sequence of activities to make the training system effective – analysis, design, development, implementation and evaluation.
• We’ll also cover a technique by which to concurrently improve the effectiveness of the training processes and the effectiveness of the processes that are the subjects of the training

1st Field of Focus – Hazards and Barriers (Cont’d)

• Component risk management
  • – Failure mode & effects analysis
• Hardware system risk management
  • – Abilities, etc.
  • – Processes needed to achieve the abilities
  • – Probabilistic risk analysis – with event trees, fault trees and probability statistics
• Facility risk management
  • – Probabilistic risk analysis – with event trees, fault trees and probability statistics

• At this point, we’ll transition FROM hazards and barriers in the context of risk management for processes TO hazards and barriers in the context of risk management for components, for hardware systems and then for the facility as a whole.
• We’ll cover the types of abilities that should be incorporated into the design of hardware items and the types of administrative and technical processes in which there must be barriers in order to achieve these abilities.
• We’ll cover Failure Mode & Effects Analysis (FMEA), which is essential to component risk management. You’ll learn how to perform or at the very least how to facilitate FMEA.
• Then, we’ll transition to hazards and barriers in the context of risk management for hardware systems and for the overall facility. We’ll cover the fundamentals of Probabilistic Risk Management using an event tree, fault trees and probability statistics.

1st Field of Focus – Hazards and Barriers (Cont’d)

• Human barriers
  • – Types of human barriers
• Range of barrier dependability
• Full scope of the quality function in terms of hazards and barriers

• Having addressed barriers that exist in administrative and technical processes, and in hardware items, we’ll then cover the types of barriers that exist in humans.
• We’ll cover barrier dependability or effectiveness for different types of barriers ranging from automated passive hardware barriers, the most effective, to various types of administrative barriers that are less effective.
• And, finally, we’ll complete the coverage of the 1st Field of Focus, Hazards and Barriers, with a model showing how the full scope of the enterprise quality function can be described in terms of hazards and barriers.
• This “1st Field of Focus, Hazards and Barriers”, is critical. Errors allow hazards to uneconomically exist and errors activate hazards and, of course, barriers prevent and detect error and also mitigate the adverse effects of hazards activated by error.

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

• Types of error traps
• Sources of error traps
• 25 behavioral techniques for counteracting error traps
  • – Process and hardware item design techniques – e.g., poka-yoke
  • – Individual techniques
  • – Group techniques

• The 2nd Field of Focus or major area of interest is “Error-Inducing Conditions and Error-Likely Situations (‘error traps’) and Counteracting Behaviors”.
• We’ll cover various types of error traps that may exist in the process task, in the work environment, and in the inherent and acquired traits of humans. An example of an error trap in a task is a requirement to perform the task within a short time constraint.
• We’ll cover dozens of different types of behaviors by which to counteract error traps such as to reduce the likelihood of initiating error.
• Persons working alone or working as a group can use these counteracting behaviors – persons at all levels, managers, supervisors and individual contributors.
• We’ll stress the point that these counteracting behaviors can only help to prevent error, but that they cannot mitigate adverse effects, as can barriers. Therefore, rarely can an error-inducing condition or error-likely situation be the single root cause of a significant adverse effect. Almost always, the root causes must include the absence or ineffectiveness of one or more barriers. This is a very important principle.
• Subsequent to the occurrence of an adverse effect, these counteracting behaviors can help to prevent further error which could exacerbate the adverse effect.

3rd Field of Focus – Bad and Good Decision-Making Thought Processes and Behaviors

• Field decisions
• Bad decision-making thought processes and behaviors
  • – Biases
  • – “Satisficing”
  • – Operational loafing
  • – Groupthink
• Good decision-making thought processes and behaviors
  • – Designated challenger
  • – Situational awareness and focus
  • – Precautionary principle
• Questions to ask before making a decision

• The 3rd Field of Focus is “Bad and Good Decision-Making Thought Processes and Behaviors”.
• Bad decisions that are also non-conservative constitute errors with higher levels of severity of the adverse effects and/or with higher probabilities of occurrence of the adverse effects. In other words, non-conservative decisions result in higher levels of risk or higher levels of actual adverse effects.
• We’ll cover the significant differences between field decisions and analytical decisions.
• We’ll cover various types of thought processes and behaviors that can contribute to non-conservative decisions, such as the dozens of types of biases, “satisficing”, the six types of operational loafing, and groupthink, the most serious. Being conscious of these, you’ll be in a better position to avoid them.
• We’ll cover the thought processes and behaviors that lead ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Acknowledgment
• Author
• Welcome
• 1 Major Learning Objectives
• 2 Introduction
• 3 1st Field of Focus: Hazards and Barriers
• 4 2nd Field of Focus: Error-Inducing Conditions, Error-Likely Situations and Counteracting Behaviors
• 5 3rd Field of Focus: Non-Conservative and Conservative Decision-Making Thought Processes and Behaviors
• 6 4th Field of Focus: Prevention of the Recurrence of Error
• 7 Strategies
• Appendix A: Words and Terms Used in the Course
• Appendix B: Format and Writing Conventions for a Procedure/Process Description Document
• Appendix C: Types of Contents of a Procedure/Process Description Document
• Appendix D: Types of Design Requirements for Hardware Items and a Facility
• Appendix E: Elements of a Design Calculations Management System
• Appendix F: Elements of a Software/Firmware Management System
• Appendix G: Elements of an Inspection and Test Management System
• Appendix H: Elements of a Records Management System and Types of Records
• Appendix I: Cross-References for a Configuration Management System
• Certificate of Completion