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 Error Prevention (Saving Lives and Dollars)

BW (Ben) Marguglio

To acquire a license to use the material in this course to self-train your employees, please call Ben Marguglio at +1-845-265-0123.

LEARNING OUTCOMES

Upon completion of this course, one will understand: 

  • HPI-HEP terminology;
  • The relationships among culture, beliefs, values, attitudes, behavior, results and performance;
  • Quality culture – quality of production, quality of safety and health, of security, of environmental protection, of emergency preparedness and response, etc.;
  • The quality-conscious work environment;
  • Leadership responsibilities for creating and sustaining the quality-conscious work environment;
  • Models describing how adverse effects occur;
  • The 1 source of operational loss; 2 essentials; 3 levels of barriers to human error; 4 types of barriers; 5 stages of human error; 6 Ms; 7 human error causal factors;
  • Process risk management (The Rule of 8);
  • Hardware item risk management;
  • Facility risk management;
  • Techniques by which to make barrier controls effective;
  • Techniques by which to make training effective;
  • The full scope of the quality function in terms of hazards and barriers;
  • Error inducing conditions and error likely situations (error traps);
  • 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 identification, problem reporting, data codification, data grouping, data analysis, extent of condition, root cause analysis, extent of cause, and corrective action;
  • Root cause analysis techniques;
  • Human error root causes;
  • Strategies;
  • Design and implementation of a problem reporting, root cause analysis, and corrective action system;
  • Design and implementation of a HPI-HEP system.
  • Quality-related criteria for business management systems 

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 

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!