Human Error; Human Error Prevention; Human Performance; Human Performance Improvement; Problem Reporting;
Root Cause Analysis; Corrective Action; Process Improvement Tools; Quality and Environmental Management Systems


Marguglio’s Four Fields of Focus for Human Error Prevention

Concern

Response
Hazards Implement techniques by which to recognize hazards. Eliminate hazards.  Create administrative process, technical process, equipment and personal barriers to prevent and detect error and hazards activated by error and to mitigate the effects of activated hazards.  Implement techniques by which to avoid holes in barriers.   Implement techniques by which to increase the effectiveness of barriers.
Error-Inducing Conditions and Error-Likely Situations Recognize error-inducing conditions and error-likely situations.  Eliminate these conditions/situations.  Use behavioral tools and techniques (for individual contributors, supervisors and managers) by which to counteract error- inducing conditions and error-likely situations.
Inappropriate Risk-Taking Recognize the behaviors that lead to inappropriate risk-taking.  Practice behaviors that lead to conservative decision-making.
Recurrence of Past Errors Implement a field observation and coaching system.  Implement a problem reporting, root cause analysis, and preventive corrective action system.  Implement performance metrics.

Marguglio’s Human Error Causal Factor Taxonomy
Causal Factor Description
Knowledge-based Lack of knowledge of the standard, requirement or need.
Cognition-based
 		 Lack of the appropriate level of cognition; lack of ability to understand, apply, analyze, synthesize or evaluate such as to be able to meet the standard, requirement or need. 
Value-based
Belief-based		 Lack of respect for or acceptance of the standard, requirement or need.
Error-Inducing Condition-based
Error-Likely Situation-based		 Lack of recognition of the condition or situation and/or lack of counteracting behavior.
Reflexive-based Lack of thought processes and behavioral techniques for conservative decision-making in reacting to an immediate "field stimulus".
Skill-based Lack of dexterity.
Lapse-based Nothing lacking; simply “blew it”.

 © - B.W. (Ben) Marguglio - 2005

Human Error Prevention
BW (Ben) Marguglio; President; BW (Ben) Marguglio, LLC

Why this Seminar?

 In addition to discovery and invention, human error prevention can be the greatest contributor to improved productivity, safety and quality. This seminar provides the most current developments in human error prevention.

Audience

 This seminar is designed for anyone whose objective is to improve productivity, safety and quality. The principles and practices of human error prevention are universally applicable regardless of the type of industrial, commercial or governmental enterprise, and regardless of the type of function performed within the enterprise.

Learning Outcomes

 Upon completion of this seminar, one will understand:                                                                                 · Human error prevention terminology;                                                                                                       · The relationships among culture, beliefs, values, attitudes and behavior;                                                     · The seven human error causal factors;                                                                                                     · The four levels of human error;                                                                                                               · The three levels of barriers to human error;                                                                                             · The four types of barriers within each barrier level;                                                                                   · Techniques by which to make barriers effective;                                                                                       · Error-inducing conditions and behaviors by which to counteract these conditions;                                         · Non-conservative decision thought processes and behaviors;                                                                     · Conservative decision thought processes and behaviors;                                                                           · Coaching to reduce the recurrence of human error;                                                                                   · Human error root causes;                                                                                                                       · Human error measurement;                                                                                                                    · Design and implementation of a Human Error Prevention Program.

Outline

1. Definitions of human performance and human error
2. Classifications of human error                                                                                                               3. Behavior model                                                                                                                                  4. Marguglio's taxonomy of the seven human error causal factors with an example and case study to demonstrate the application of the taxonomy                                                                                            5. Human error and barrier models describing the four levels of human error and the three levels of barriers to human error with a case study to demonstrate the application of the models                                            6. The relationship of barriers to the total quality / safety function                                                               7. Techniques by which to strengthen administrative, equipment and human barriers, with an emphasis on procedural and training barriers, with a case study to demonstrate the application of the techniques              8. Poka yoke                                                                                                                                          9. Types of error-inducing conditions and error-likely situations existing in the task demands, work environment and humans and behaviors to counteract these conditions and situations, with examples and a case study to demonstrate their application                                                                                              10. Thought processes and behaviors leading to non-conservative decisions and those leading to conservative decisions, with examples and a case study for demonstration                                                                     11. Coaching to reduce human error recurrence with coaching exercises                                                   12. Human error root causes                                                                                                                  13. Human error measurements                                                                                                             14. Defense in depth                                                                                                                             15. Review of the universally applicable principles of human error prevention                                             16. Review of the elements of a Human Error Prevention Program.

Handouts

 • Copy of the visual aids
• Compilation of recommended behaviors to prevent human error
• Case study and exercise materials
• Root cause logic diagrams
• Certificate of Completion, with Continuing Education Units
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