1st Edition

Human Performance Improvement through Human Error Prevention
A Comprehensive Implementation Guide for Protecting Employees and Maintaining Cost Efficiency



  • Available for pre-order. Item will ship after June 8, 2021
ISBN 9780367672393
June 8, 2021 Forthcoming by Productivity Press
544 Pages 105 Color Illustrations

USD $499.95

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Book Description

The 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. This book has 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. It digs below the surface of issues and looks to fix the real causes of human error and mistakes. This book presents a complete seminar from the thought leader universally 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: • The fundamental precept explaining the importance of human error prevention / reduction. • Human error prevention terminology. • The relationships among culture, beliefs, values, attitudes and behavior. • The seven human error causal factors. • The five levels of human error. • The three levels of barriers to human error. • The four types of things in which the barriers may exist at each barrier level. • Techniques by which to make barriers effective. • Poka yoke techniques. • The spectrum of barrier effectiveness. • The relationship of human error prevention / reduction to the total quality / safety function. • Error-inducing conditions and behaviors by which to counteract these conditions. • Non-conservative decisions and thought processes and behaviors for conservative decisions. • Coaching to reduce the recurrence of human error. • Human error root causes. • Human error measurement. • How to design, implement, manage and assess a Human Error Prevention initiative.

Table of Contents

TABLE of CONTENTS

TOPIC

PAGE #

  

Preface

ii

Acknowledgment

v

Table of Contents

vi

Welcome

1

Quality of (a) production, (b) safety and health, (c) environmental protection,
(d) security, (e) emergency preparedness and response, (f) etc.

1

Major Learning Objectives

3

Introduction

18

Major Precepts

19

Culture

23

Culture – Quality Culture

24

Culture – Quality-Conscious Work Environment

26

Culture – Questioning Attitude – Why? When? How?

28

Culture – The Daisy Chain (Information, Beliefs, Values, Attitudes, Behavior and Results) and Marguglio’s Model of Performance

32

Culture – The Blame Spiral

34

Culture – Leadership Responsibilities – Quality-Conscious Work Environment 

36

Terminology – Human Performance

45

Terminology – Human Error

46

Terminology – Not Human Error

48

Terminology – Human Factors vs. HPI/HEP

50

Human Error Classification – Based on Action or Inaction

51

Human Error Classification – Based on the Timing of the Effect

52

Human Error Classification – Based on Risk / Significance of the Effect

54

Human Error Classification – Based on the Human Error Causal Factor

66

Human Error Causal Factors – Professor James Reason’s Taxonomy

70

Human Error Causal Factors – Dr. Joseph Juran’s Taxonomy

 

Human Error Causal Factors – Marguglio’s Taxonomy

69

Knowledge-based Error

74

Cognition-based Error

76

Value-based Error / Belief-based Error

80

Error-inducing Condition-based Error / Error-likely Situation-based Error

83

Reflexive-based Error / Reactive-based Error

90

Skill-based Error

92

Lapse-based Error

94

Exercise – Human Error Causal Factors and HPI/HEP Principles 

97

Case Study – Human Error Causal Factors and HPI/HEP Principles

101

1st Field of Focus – Hazards and Barriers

107

Prerequisites to the Rule of 8 for Process Risk Management

108

Prerequisite – 1 Predominant Source of Operational Loss

109

Prerequisite – 2 Essential Elements

110

Prerequisite – 3 Types of Barriers

113

Prerequisite – 4 Things in which Barriers Exist

115

Prerequisite – 5 Stages of Error

116

Prerequisite – 6 "M"s

119

Prerequisite – 7 Human Error Causal Factors

120

Rule of 8 for Process Risk Management

121

When Holes in Barriers Are Aligned

129

Airline Threat and Error Management

131

Process Barrier Effectiveness

135

Sources of Administrative and Technical Process Barriers

136

Process Design and Communication

138

Process Design Quality Attributes

139

Strengthening Process Barriers / Criteria for Procedure Preparation

141

Case Study – Lack of Consideration for Procedures

152

Case Study – Lack of Consideration for Procedure / Barrier Criteria

155

Institute of Nuclear Power Study

159

Process Design and Procedure Major Issues

161

Challenge

162

Training Barriers

163

Training Barriers – Systematic Approach to Training - ADDIE

164

Training Barriers – Task Analysis

166

Training Barriers – Training and Process Barriers, Concurrently Strengthening

170

Hardware Item Barriers

172

Hardware Item Barriers, Preventing Holes in

172

Hardware Item Barriers – Component Risk Management – FMEA During Design

178

Hardware Item Barriers – Facility Risk Management – PRA During Design

183

Probabilistic Risk Analysis, Tools for

184

Probabilistic Risk Analysis, Event Tree for

185

Probabilistic Risk Analysis, Fault Tree for

186

Probabilistic Risk Analysis – Event Tree Terminology

187

Probabilistic Risk Analysis – System Model

188

Probabilistic Risk Analysis, Examples of Event Trees for

189

Probabilistic Risk Analysis, Examples of a Fault Tree for

193

Probabilistic Risk Analysis, Event and Fault Trees Combined for

195

Fault Tree – Avoiding a Single Failure that Causes Loss of the Top Tier Function

197

Human Barriers

199

Exercise – Barrier Objectives and Types

201

Automation, Why

204

Spectrum of Barrier Dependability

205

Full Scope of the Quality Function

207

Full Scope of the Quality Function – Dr. Feigenbaum’s Model

208

Full Scope of the Quality Function – Marguglio’s Adaptations of Dr. Feigenbaum’s Model in Terms of Hazards and Barriers

210

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

214

Sources of Error-inducing Conditions and Error-Likely Situations (Error Traps)

215

Types of Error Traps in Processes

216

Types of Error Traps in the Work Environment

218

Types of Error Traps in Humans

221

Case Study

224

Examples of Error Traps

230

Top 10 Error Traps

231

Exercise – Error Traps

232

Eliminating Error Traps

235

Counteracting Error Traps

237

Counteracting Error Traps – Poka Yoke Applications

239

Counteracting Error Traps – Walk-Downs / Walk-Arounds, the 5 Types of

241

Counteracting Error Traps – Pre-job Briefings, Including Reverse Briefings

243

Counteracting Error Traps – Pre-job Briefings for Engineers

246

Counteracting Error Traps – Post-job Assessments

248

Counteracting Error Traps – Turnover Meeting

249

Counteracting Error Traps – STAR / STOP

251

Counteracting Error Traps – Time Out and Stop Work Order

252

Counteracting Error Traps – QVV

254

Counteracting Error Traps – Three-part and Four-part Communication

257

Counteracting Error Traps – Standardized Acronyms

258

Counteracting Error Traps – NATO Phonetic Alphabet

259

Counteracting Error Traps – Marguglio’s Phonetic Alphabet

261

Counteracting Error Traps – Procedure Usage

262

Procedure Usage – Risk-based "Red-lining"

265

Procedure Usage – Quick-pace Procedure Change Process

265

Procedure Usage – Elimination of Value-based Error

265

Procedure Usage – Procedure Usage Categorization

267

Procedure Usage – Place-keeping

268

Counteracting Error Traps – Verbalization

270

Counteracting Error Traps – Fencing

272

Counteracting Error Traps – Flagging

273

Counteracting Error Traps – Signage

274

Counteracting Error Traps – Peer Review / Peer Check / Peer Inspection or Test

276

Counteracting Error Traps – Independent Review / Inspection / Test

280

Counteracting Error Traps – Questioning Attitude – Why, When and How

282

Counteracting Error Traps – Daisy Chain

285

Counteracting Error Traps – Reinforcement

286

Counteracting Error Traps – Other Tools

287

Case Study – Hazards and Barriers and Error Traps and Counteracting Behaviors 

289

3rd Field of Focus – Non-conservative (Bad) and Conservative (Good) Decision-making Thought Processes and Behaviors

298

Pressures Influencing Bad Decision

299

Thought Processes Influencing Bad Decisions

300

Thought Processes Influencing Bad Decisions – Biases, 25 Types of

301

Thought Processes Influencing Bad Decisions – Satisficing, Bad and Good

312

Thought Processes Influencing Bad Decisions – Operational Loafing, 6 Types

313

Thought Processes Influencing Bad Decisions – Groupthink

320

Case Study

322

Thought Processes Influencing Good Decisions – Team Involvement

324

Thought Processes Influencing Good Decisions – Designated Challenger 

326

Thought Processes Influencing Good Decisions – Precautionary Principle

327

Thought Processes Influencing Good Decisions – Situational Awareness        

329

Situational Awareness – Focus Versus Fixation

329

Situational Awareness – Tips for Good Situational Awareness

331

Situational Awareness – Clues to the Loss of Situational Awareness

332

Thought Processes Influencing Good Decisions – Questions to Ask

333

Summary of Conservative Decision-making Behaviors

335

Advocate for Quality

336

Case Study – Decision-making

337

Case Study – Error Traps and Decision-making

342

4th Field of Focus – Prevention of Error Recurrence 

356

Field Observation and Coaching System

357

Coaching, Objectives of

359

Coaching, Functions of

360

Coaching Observations Verses Other Formal Observations

361

Coaching, Skills for

362

Coaching, Preparations for

363

Coaching Method, the 7 Steps

364

Coaching Outcomes, the 5 Types

365

Coaching, Feedback for

369

Coaching for Engineers

370

Condition Reporting, Root Cause Analysis and Corrective Action System

372

CR, RCA and CA System – Types of Conditions

373

CR, RCA and CA System – Elements of the System

376

CR, RCA and CA System – Participants and Their Responsibilities

380

CR, RCA and CA System – Initial Screening of the CR

386

CR, RCA and CA System – Risk / Significance Level vs. Priority Level

390

CR, RCA and CA System – Criteria for Requiring Further Action

392

CR, RCA and CA System – Design of the CR and CA Tracking Tool

400

CR, RCA and CA System – Criteria for Data, including Data Attributes, 15 Types

402

CR, RCA and CA System – Standard Data Tables, 12 Different

413

CR, RCA and CA System – Problem

417

Problem – What’s Happened

418

Problem – Actions for Problem Definition

419

Problem – 4 "W"s and How, Combined with IS / IS NOT for Problem Definition

420

Problem – 3 Types of Things in Which a Problem Can Exist

422

Problem – Data Elements for Problem Definition

423

Problem – Fact Versus Conclusion

430

CR, RCA and CA System – Capabilities of the CR and CA Tracking Tool

431

CR, RCA and CA System – Operating Experience

432

CR, RCA and CA System – Extent of Condition Analysis

434

CR, RCA and CA System – Root Cause Analysis

437

Root Cause Analysis – Causal Factor

439

Root Cause Analysis – Direct Cause

441

Root Cause Analysis – Contributing Cause

442

Root Cause Analysis – Root Cause

443

Root Cause Analysis – Guidelines – e.g., Charter, Plan, Team Needs, Independence

444

Root Cause Analysis – Review – 5 Stages of Human Error

451

Root Cause Analysis – Review – 7 Human Error Causal Factors

452

Root Cause Analysis – Logic

453

Root Cause Analysis – Investigation – Sources of Data

456

Root Cause Analysis – Actions Immediately Following the Adverse Effect

458

Root Cause Analysis – Interviewing Preparedness

460

Root Cause Analysis – Criteria for Interview Questions and Template for Questions

463

Root Cause Analysis – Success Factors

468

Root Cause Analysis – Criteria for Effective Root Cause Analysis Techniques

469

Root Cause Analysis – Techniques

470

RCA Techniques – 5 WHYs Analysis Criteria for Use

471

RCA Techniques – 5 WHYs Analysis Logic

472

RCA Techniques – 5 WHYs Analysis "Therefore" Convention

475

RCA Techniques – 5 WHYs Analysis Example

477

RCA Techniques – Scenario of a Hardware Item Failure

479

RCA Techniques – Reasons for Component Failure, Acceptable and Unacceptable

481

RCA Techniques – Failure Mode & Effects Analysis Criteria for Use 

483

RCA Techniques – Failure Mode & Effects Analysis Logic

484

RCA Techniques – Change Analysis Criteria for Use

487

RCA Techniques – Change Analysis – Review – 6 "M"s

488

RCA Techniques – Change Analysis Logic

489

RCA Techniques – Rule of 8 Criteria for Use

493

RCA Techniques – Rule of 8 Logic

494

RCA Techniques – Rule of 8 Templates

496

RCA Techniques – Rule of 8 Case Study

501

RCA Techniques – Time-Line Analysis Criteria for Use

512

RCA Techniques – Time-line Analysis Logic

513

RCA Techniques – Time-line Analysis Templates

515

RCA Techniques – Time-line Analysis Case Study

519

RCA Techniques – Cause & Effects Analysis / Fishbone Diagram Criteria for Use

527

RCA Techniques – Cause & Effects Analysis / Fishbone Diagram Logic

528

RCA Techniques – Cause & Effects Analysis / Fishbone Diagram Example

528

RCA Techniques – Cause & Effects Analysis / Fishbone Diagram Data Collection

530

RCA Techniques – Cause & Effects Analysis / Fishbone Diagram, Task-by-Task

532

Cause and Effects Analysis / Fishbone Diagrams for Improvement Projects

534

RCA Techniques – Probabilistic Risk / Safety Analysis Criteria for Use

536

Probabilistic Risk / Safety Analysis Tools

537

Probabilistic Risk / Safety Analysis Event Tree

538

Probabilistic Risk / Safety Analysis Fault Tree

539

Probabilistic Risk / Safety Analysis Event Tree Terminology

540

Probabilistic Risk / Safety Analysis Model

541

Probabilistic Risk / Safety Analysis Examples of Event Trees

543

Probabilistic Risk / Safety Analysis Examples of a Fault Tree

547

Probabilistic Risk / Safety Analysis – Event and Fault Trees Combined

549

Fault Tree – Avoiding a Single Failure that Causes Loss of the Top Tier Function

551

RCA Techniques – Process Flow Diagram – Use and Examples

553

RCA Techniques – Gap Analysis – Use and Example

558

RCA Techniques – Value Stream Chain – Use and Example

566

RCA Techniques – Spaghetti Diagrams – Use and Examples

568

RCA Techniques – Common Errors

571

CR, RCA and CA System – Extent of Cause Analysis 

573

CR, RCA and CA System – RCA Report Content

575

CR, RCA and CA System – Corrective Action, Objectives of

582

Corrective Action, Decision Rules for

583

Corrective Action, Prioritizing of

585

Corrective Actions, 9 Types of

587

Corrective Action Commitment, 7 Elements of

591

Corrective Action, Verification and Validation of

593

Corrective Action, Concern for

596

Corrective Action, Conditions Yielding Ineffective

597

Corrective Action, "D"s of

598

Now, What Possibly Could Go Wrong?

600

Strategies

602

Strategies – Performance and Status Reporting, Collectively Comprising Strategy

604

Strategies – Performance and Status Reporting – Leading and Lagging Indicators

605

Strategies – Strategies – Performance and Status Reporting – Indicators of Attitude

607

Strategies – Performance and Status Reporting – Strategies – Indicators of Culture

609

Strategies – Performance and Status Reporting – Process Performance Indicators

614

Strategies – HPI/HEP Major Principles, Collectively Comprising Strategy

621

Strategies – Defense in Depth Strategy

633

Strategies – Defense in Depth – Levels of Defense / Levels of Opportunity

634

Strategies – Defense in Depth – Descriptions of the Levels of Defense

635

Strategies – Defense in Depth – Problem ID & Correction at Each Level of Defense

637

Strategies – Defense in Depth – Frequency & Independence of Each Level

638

Strategies – Risk Management, Collectively Comprising Strategy

639

Strategies – Risk Management – Process, Component, Hardware System & Facility

639

Strategies – Risk Management – Process, the Rule of 8

640

Strategies – 4 Fields of Focus, Collectively Comprising Strategy

645

Strategies – 4 Fields of Focus – Hazards and Responses

646

Strategies – 4 Fields of Focus – Error Traps and Responses

647

Strategies – 4 Fields of Focus – Non-Conservative Thought Processes & Responses

648

Strategies – 4 Fields of Focus – Recurring Problems and Responses

649

Thank You

650

Purchase of a License

651

Appendix A: Words and Terms Used in the Course

653

Appendix B: Types of Design Requirements for Hardware Items and a Facility

665

Appendix C: Elements of a Design Calculations Management System

682

Appendix D: Elements of a Software / Firmware Management System

685

Appendix E: Cross-References for a Configuration Management System

693

Appendix F: Format and Writing Conventions for a Procedure

696

Appendix G: Elements of Information in a Procedure

706

Appendix H: Elements of an Inspection and Test Management System

708

Appendix I: Elements of a Records Management System and Types of Records

712

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Author(s)

Biography

Ben Marguglio is a management and technical consultant with decades of experience in high technology enterprises, and was previously a corporate executive with positions at Aerojet Nuclear Company and Consumers Power Company. He is a former management team leader for multi-million-dollar design and construction projects and management team member for a multi-billion-dollar design and construction project. Ben is a preeminent subject matter expert on: • Human performance improvement / human error prevention / human factors. • Process, component and facility risk management (hazard identification, risk assessment and risk treatment). • Problem / incident / failure investigation, root cause analysis and corrective action. • Management systems – including systems for project management; design engineering; procurement; fabrication, assembly, construction and installation; maintenance; and operations – with considerations for the quality of production, of safety and health, of environmental protection, security, and emergency preparedness and response. Ben has served as a fellow of the American Society for Quality (ASQ) since 1973 and is a ASQ Certified Quality Engineer, Reliability Engineer, Quality Auditor, and Manager of Quality / Organizational Excellence.