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


HUMAN PERFORMANCE IMPROVEMENT through HUMAN ERRO
R PREVENTION 
VIRTUAL COURSE; October 19 – 23; 1:00 – 5:00 PM CDT each day
Sponsored by ASQ, Energy & Environmental Division
Presented by BW (Ben) Marguglio 

Why This Course?  

Regardless of the terms used (“human performance improvement”, “human error prevention”, “human factors”, “human element”), the objective of this course is to impart knowledge as to how to improve performance by reducing human error in the design and implementation of processes.

PROBLEM: Almost all operational loss of lives and $s is attributable to error in process design and implementation, including design of hardware used in processes.

SOLUTION: In this course, you will learn how to improve performance by (1) improving process design and implementation, (2) counteracting process error traps, (3) improving process decision-making and (4) preventing the recurrence of error in process design and implementation. 

This course provides up-to-date, complete and sufficiently specific material, enabling trainees to directly implement the universally applicable principles and practices. 

The material in this course substantially adds to the body of knowledge.

When this course is presented for clients in-house, the material content and material presentation evaluation categories consistently receive average grades greater than 4.5 on a scale of 1 to 5, with “5” being “excellent”.  

Audience  

This highly acclaimed course addresses the prevention of human error in process design and implementation, the mitigation of its effects and the prevention of its recurrence and, therefore, should be of great interest to those who are responsible for improving the quality of production, quality of safety and health, quality of security, of environmental protection, of emergency preparedness and response, among other functions, in a quality-conscious work environment focused on learning without blame. 

Learning Outcomes 

Upon completion of this course, one will understand: 

  • Human performance improvement / human error prevention terminology;
  • The relationships among culture, beliefs, values, attitudes and behavior;
  • Quality culture – quality of production, safety and health, security, environmental protection, emergency preparedness and response;
  • The quality-conscious work environment;
  • Leadership responsibilities for creating and sustaining the quality-conscious work environment;
  • Models describing how adverse effects occur;
  • The seven human error causal factors;
  • The five stages of human error;
  • The three levels of barriers to human error;
  • The four types of barriers within each barrier level;
  • The relationship of barriers to adverse effects and to the full scope of the quality function;
  • Techniques by which to make barriers effective;
  • Error traps (error-inducing conditions and error-likely situations)
  • Operational performance tools / Behaviors by which to counteract error traps;
  • Non-conservative decision thought processes and behaviors;
  • Conservative decision thought processes and behaviors;
  • Coaching to reduce the recurrence of human error;
  • Problem / condition identification, problem / condition reporting, data codification, data grouping, data analysis, Extent of Problem / Condition Analysis, Extent of Cause Analysis, and correction action good practices;
  • The 7 prerequisites to process risk management;
  • The 8-step process risk management technique (The Rule of 8);
  • Component risk management;
  • Facility risk management;
  • Root cause analysis using any of the techniques listed in the Outline, below;
  • The nine types of corrective action;
  • Design of a problem / condition reporting, root cause analysis, and corrective action system;
  • Human performance improvement / human error prevention principles and practices
  • Strategies   

Outline 

Introduction

• Precepts
• Beliefs, Values and Attitudes
• Behavior, Results and Performance
Marguglio’s Model of Behavior
• Hazards to 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   
      * Hazard   
      * Hazard Identification    
      * Initial Level of Risk   
      * Risk Assessment    
      * Risk Treatment   
      * Residual Level of Risk 
   o Based on the Human Error Causal Factor   
      * Dr. Juran’s Taxonomy   
      * Professor 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 Trap-based Error) with Examples     
         ^ Reflexive-based Error / Reactive-based Error with Examples     
         ^ Skill-based Error with Examples     
         ^ Lapse-based Error with Examples
• Exercises and case studies – Demonstrations of Human Error Causal Factors and Principles

1st Field of Focus – Hazards and Barriers 

• The 1 Predominant Source of Operation Loss – Human Error
• The 2 Critical Elements – Hazards and Barriers In More Detail 
   o Hazards 
   o Risk 
   o Hazard Identification  
   o Initial Level of Risk 
   o Risk Assessment  
   o Risk Treatment 
   o Residual Level of Risk   
      * Examples of Different Levels of Risk or Significance 
   o Barriers  o Hazard and Barrier Models   
      * Professor 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 Ms 
   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   
      * Benjamin Bloom’s Six Levels of Cognition 
   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
• 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 Technique for Concurrently Strengthening Training and Process Barriers
• Hardware Item Barriers
• 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 9 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 Process Designs
• Types of Error-Inducing Conditions and Error-Likely Situations in Work Environments
• Types of Error-Inducing Conditions in Humans• 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 Outs  o Stop Work Orders 
   o QVV 
   o Flagging 
   o Fencing 
   o Three-Way Communications 
   o Four-Way Communications 
   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
• Case Study – Demonstration of Principles and Practices to this Point

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 GroupThink 
   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 (e.g., Problem, Anomaly, Good Practice) Reporting, Root Cause Analysis and Corrective Action System 
   o 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 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 Ws 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 
      * Risk, Priority and Significance 
      * Risk / Significance Matrices 
      * Criteria for Action 
   o Extent of Problem Analysis 
   o Direct Cause 
   o Contributing Cause 
   o Root Cause 
   o Root Cause Analysis   
      * Root Cause Analysis Logic   
      * Root Cause Analysis Team Qualifications   
      * Administration of Root Cause Analysis     
         ^ Charter     
         ^ Plan     
         ^ Data Collection / 5 Sources of Data     
         ^ Etc.   
      * Interviewing     
         ^ Actions Immediately Following the Adverse Effect     
         ^ Interviewing Preparedness     
         ^ Criteria for Interview Questions     
         ^ Interview Questions, Template for     
         ^ Success Factors   
      * Criteria for Effective Root Cause Analysis Techniques   
      * 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 Rule of 8       
            # 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       
            # Prioritizing Improvement Actions     
         ^ Probabilistic Risk Analysis       
            # Event Tree       
            # Fault Trees       
            # Examples     
         ^ Process Flow Diagrams       
            # Examples     
         ^ Value Stream Diagrams       
            # Examples     
         ^ Spaghetti Diagrams       
            # Examples 
         ^ Gap Analysis       
            # Example   
      * Hardware Failure Modes   
      * Hardware Failure Causes   
      * Human Performance Root Causes
• Extent of Cause Analysis
• Corrective Action 
   o Objectives 
   o Decision Rules 
   o Prioritizing 
   o Corrective Actions, 9 Types of 
   o Corrective Action Commitment, 7 Elements of 
   o Verification and Validation 
   o Conditions Yielding Ineffective Corrective Actions 
   o Corrective Action Verification and Validation Techniques 
   o The Ds
Root Cause Analysis Report, Contents of

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 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 (NOTE: THE APPENDICES ARE NOT COVERED IN THE PUBLIC COURSES.)

1.  List of Appendices
2.  Training Outline
3.  Words and Terms Used
4.  Criteria for Designing Processes / Procedures, Including (a) Standard Types of Content of a Process Description Document / Procedure and (b) Standard Types of Conventions for Writing a Process Description Document / Procedure 
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 (Process Qualification)
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
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 (a) Standard Criteria for Placement of Checks, Inspections and Tests and (b) 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 Start-up and Shift Turnover
24. Criteria for Designing Processes / Procedures for Out-of-service Hardware and Return to Service
25. Criteria for Designing Processes / Procedures for Records, Including ~ 200 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.
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, Root Cause Analysis and Corrective Action, Including Employee Concerns
39. Criteria for Designing Processes / Procedures for Management Review 
40. Criteria for Designing Processes / Procedures for New Business Proposals

Notes: 
• Throughout the training material, there are additions to the body of knowledge (BOK); items in bold font provide major additions to the BOK.
• The content of each appendix is universally applicable to the subject of the appendix.

Upon one’s completion of this e-book course, one’s employer should provide a certificate of completion with 4.0 continuing education units.

• You get HPI-HEP, including “Root Cause Analysis” training materials from the thought leader acclaimed by hundreds of satisfied clients.
• You get specific and unique HPI-HEP principles, practices, models, and templates.
• You get comprehensive and comprehensible information.
• You get “take-aways” that can be directly implemented.
• You get the complete HPI-HEP body of knowledge.
• You get criteria for incorporation into your business management system.

As well as anyone, or far better, Marguglio can teach you how to improve performance through the prevention of error!