2 BackgroundIn many organizations, the root cause for Human Error is assigned as ‘Lack of Attentionto detail’ or ‘Failure to follow procedure.’Corrective action will involve re-trainingor discipline.Such approaches do not typically getto 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 Established QATeam LeadsOperatorsTrainingEngineering
6 ApproachThe 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 wasdeveloped to provide a greater theoreticalunderstanding of human behaviour andsystem design.
7 Step 1Brainstorm all possible reasons for humanerror.Step 2Generate a cause and effect diagram withall potential reasons for error identified.Step 3Generate a gap analysis study. Criticallyevaluate each individual error category.
16 Summary - Human Error Factors Physiological FactorsPsychological FactorsEnvironmental FactorsMaterial FlowSegregation and IdentificationDocumentation DesignRobustness of Test MethodsMulti-tasking & ResourcingMaintaining employee motivation and engagementCommunication & Shift HandoverEffective system of TrainingReporting of errors
17 Progress to dateChecklists and standard methodology developed to serve asa guide in performance of root cause investigations intohuman errors.Gap Analysis study performed and from this study,corrective and preventative actions implemented to reducethe potential for human error.Training course on the systems approach to human errorreduction delivered to key personnel on site.
18 Next StepsMonitor 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 ErrorHuman Error – Facts and FiguresSwiss Cheese Model of ErrorModel of Information ProcessingMultitasking & ForgettingError and Documentation DesignDeviation reports & OOSsPractical Exercises
21 Well Known DisastersChallenger 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
26 ConclusionThe 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.