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