E-Books: Human Performance Improvement through Human Error Prevention
6 min readHuman Performance Improvement through Human Error
Prevention is a Comprehensive Implementation Guide for Protecting Employees and Maintaining Cost Efficiency
This book is a simulation of a live course.
There are seven major sections of the book:
- Major Learning Objectives;
- Introduction;
- 1st Field of Focus, Hazards, and Barriers;
- 2nd Field of Focus, Error Traps and Counteracting Behaviors;
- 3rd Field of Focus, Bad and Good Thought Processes and Behaviors in Decision-making;
- 4th Field of Focus, Prevention of the Recurrence of Error;
- Strategies.
The “Major Learning Objectives” provides a brief preview of the course, listing the topics that are most important and that you, the student, are expected to learn in detail. Hopefully, you’ll learn every topic covered in the course, major or otherwise.
The “Introduction” provides terminology, concepts, principles, and practices that apply in all four Fields of Focus. In the subsequent sections of the book, additional terminology, concepts, principles, and practices will be provided as they apply. The concepts, principles, and practices in the “Introduction” comprise the foundation for human performance improvement (HPI) by means of human error prevention (HEP) – the foundation for the four Fields of Focus.
For HPI through HEP, there are four major areas of interest. I’ve called them “Fields of Focus”. They’re listed above. Anything that has to do with HPI through HEP is a subset of one of these Fields of Focus.
Human Performance Improvement through Human Error
Prevention Book’s cover
The 1st Field of Focus, Hazards, and Barriers, is the most important. There are hazards in the processes and hardware items that we design and use. This section of the book describes the techniques for identifying these hazards and assessing their initial levels of risk. Different techniques are used for processes, components, major hardware systems, and facilities as a whole. This section also describes the means of treating these hazards, the most common means being the establishment of control barriers – barriers for the prevention of error that activates the hazard, for the timely detection of an error, and for the mitigation of the error effects. This section also provides principles and practices for making these barriers the most effective.
The 2nd Field of Focus, Error Traps and Counteracting Behaviors, describes the sources and types of error-inducing conditions and error-likely situations (error traps) and the more than two dozen behaviors that should be practiced to prevent these error traps from inducing error.
The 3rd Field of Focus, Bad and Good Thought Processes and Behaviors in
Decision-Making is the most interesting to me. Do you know the more than two dozen different types of biases that can adversely impact decision-making? Yes, more than two dozen. This section also covers other things that adversely impact decision-making such as operational loafing, satisficing, groupthink, loss of the precautionary principle, and loss of situational awareness. Of course, the things that benefit decision-making are covered, as well, such as focus, designated challenger, the precautionary principle, situational awareness with focus, and questions
to ask as a prerequisite to major decision-making.
The 4th Field of Focus, Prevention of the Recurrence of Error, covers two business management systems – (1) the field observations and coaching system and (2) the condition reporting, root cause analysis, and corrective action system. Literally, there are dozens of processes comprising the condition reporting, root cause analysis, and corrective action system – everything from the design of the computerized tool for condition reporting and corrective action tracking to the ultimate verification and validation of the corrective action and closure of the condition report. This section covers root cause analysis techniques for process and hardware problems – techniques such as five Whys, Change Analysis, Failure Mode and Effects Analysis, the Rule of 8 (a substantial improvement to Hazards- Barrier-Effects Analysis), and Cause and Effects Analysis (Fishbone diagrams).
The section also covers root cause analysis techniques for management problems.
The final section of the book is Strategies. The Google Dictionary defines “strategy” as “a plan of action or policy designed to achieve a major or overall aim”.
This section covers the following, each of which, as a whole, comprises an
important strategy:
- Performance and Status Reporting;
- Six Levels of Defense in Depth;
- Risk Management for Processes, Components, Major Hardware Systems, and Facilities;
- Major HPI/HEP Principles and Practices;
- The Four Fields of Focus.
Contents
The Contents of Principles Of Human Performance Improvement through Human Error Prevention
- Preface vii
- Acknowledgment xi
- Author xiii
- Welcome xv
- 1 Major Learning Objectives 1
- 2 Introduction 15
- 3 1st Field of Focus: Hazards and Barriers99
- 4 2nd Field of Focus: Error-Inducing Conditions, Error-Likely Situations and Counteracting Behaviors 203
- 5 3rd Field of Focus: Non-Conservative and Conservative Decision-Making Thought Processes and Behaviors 281
- 6 4th Field of Focus: Prevention of the Recurrence of Error 337
- 7 Strategies 567
- Appendix A: Words and Terms Used in the Course 613
- Appendix B: Format and Writing Conventions for a Procedure/Process Description Document 629
- Appendix C: Types of Contents of a Procedure/Process Description Document 641
- Appendix D: Types of Design Requirements for Hardware Items and a Facility 643
- Appendix E: Elements of a Design Calculations Management System 659
- Appendix F: Elements of a Software/Firmware Management System 663
- Appendix G: Elements of an Inspection and Test Management System 671
- Appendix H: Elements of a Records Management System and Types of Records 675
- Appendix I: Cross-References for a Configuration Management System 681
- Certificate of Completion 686
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Human Performance Improvement through Human Error Prevention
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