1. Human Error Reduction
– A Systems Approach

2. Background
In many organizations, the root cause for Human Error is assigned as ‘Lack of Attention
to detail’ or ‘Failure to follow procedure.’
Corrective action will involve re-training
or discipline.
Such approaches do not typically get
to the true root cause as to why errors occur, and generally will not prevent a re-occurrence of the issue.

5. Cross Functional Project Team EstablishedQA
Team Leads
Operators
Training
Engineering

6. Approach
The project team set about understanding human error by adopting a more systematic structured approach.
The key methodology employed involved ‘Cause and Effect’ analysis and ‘Gap Analysis.’
In addition, an internal training program was
developed to provide a greater theoretical
understanding of human behaviour and
system design.

7. Step 1
Brainstorm all possible reasons for human
error.
Step 2
Generate a cause and effect diagram with
all potential reasons for error identified.
Step 3
Generate a gap analysis study. Critically
evaluate each individual error category.

8. Cause and Effect Diagram

9. Cause and Effect Categories

10. Personnel
Ineffective Training
Focus, motivation and application
Suitability for role
Shift handover and communication between breaks
Repetitive Tasks
Work load and multitasking

11. Methods/Procedures
Lacking detailed instruction
Inconsistent format
No visual images in documentation
Poorly written procedures
Test method variability
Procedures too detailed and difficult to follow

12. Machinery
Reliability of equipment
Preventative Maintenance
Multiple Settings
Equipment Change Control
Suitability for task being performed

13. Materials
Staging and Issuing Process
Material Flow
Identification & Segregation
Labelling

14. Environment
Layout of work area
Insufficient space
Noise and distractions
Temperature/Humidity conditions
Lighting
Ergonomics

15. Gap Analysis Study

16. Summary - Human Error Factors
Physiological Factors
Psychological Factors
Environmental Factors
Material Flow
Segregation and Identification
Documentation Design
Robustness of Test Methods
Multi-tasking & Resourcing
Maintaining employee motivation and engagement
Communication & Shift Handover
Effective system of Training
Reporting of errors

17. Progress to date
Checklists and standard methodology developed to serve as
a guide in performance of root cause investigations into
human errors.
Gap Analysis study performed and from this study,
corrective and preventative actions implemented to reduce
the potential for human error.
Training course on the systems approach to human error
reduction delivered to key personnel on site.

18. Next Steps
Monitor the effectiveness of ‘Human Error’ Training and system improvements through the analysis of deviation metrics.
Continue to employ root cause investigation tools such as Cause and Effect, 5Ys and Fault Tree Analysis in performance of human error investigations.
Risk assess target areas for potential for human error and implement appropriate preventative measures.
Involve operator input more extensively in human error root cause investigations.

19. ‘If you do what you have always done, you will get what you’ve always gotten’
- Anthony Robbins

20. Key Content of Training Program
Review of Disasters – Human Error
Human Error – Facts and Figures
Swiss Cheese Model of Error
Model of Information Processing
Multitasking & Forgetting
Error and Documentation Design
Deviation reports & OOSs
Practical Exercises

21. Well Known Disasters
Challenger Space Shuttle (1986)
Bhopal Chemical Plant (1986)
Herald of Free Enterprise Ferry (1987)
Kegworth Air Crash (1989)
Marc Train Crash (1990)
Chernobyl Nuclear Accident (1986)

22. Model of Information Processing (Atkinson-Shiffrin)

23. The Swiss Cheese model of Error/Accident Causation
James Reason

24. ‘We cannot change the human condition, but we can change the conditions under which humans work’
BMJ 2000;320: J Reason

25. Learning Styles

26. Conclusion
The key to reducing human error is to have an understanding of the human factors that can contribute to error.
Central to this approach is the design of systems and processes that will reduce the potential for error.
By adopting a systematic and structured approach, we can go a long way towards reducing the potential for error.

27. Thank you