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
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
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Marguglio’s Four Fields of Focus for Human Error Prevention |
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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. |
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Marguglio’s Human Error Causal Factor Taxonomy |
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| Causal Factor | Description |
| Knowledge-based | Lack of knowledge of the standard, requirement or need. |
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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. |
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Value-based Belief-based |
Lack of respect for or acceptance of the standard, requirement or need. |
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Error-Inducing Condition-based Error-Likely Situation-based |
Lack of recognition of the condition or situation and/or lack of behavior to counteract the condition or situation. |
| Reflexive-based | Lack of conservative behavior in immediately reacting to a "field stimulus". |
| Skill-based | Lack of dexterity. |
| Lapse-based | Lack of attention. |
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© - B.W. (Ben) Marguglio - 2005-2009 |
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Human Error Prevention |
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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. |
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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. |
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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. |
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Outline |
1. Definitions of human performance and human error 2. Classifications of human error 3. Behavior model 4. The seven human error causal factors with an example and case study to demonstrate their applicability 5. Human error and barrier models describing the four levels of human error and the three levels of barriers with a case study to demonstrate their applicability 6. The relationship of barriers to the total quality / safety function 7. Techniques by which to strengthen administrative, technical, equipment and human barriers, with an emphasis on procedure and training barriers, and with a case study to demonstrate the application of these 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 applicability 10. Thought processes and behaviors leading to non-conservative decisions and those leading to conservative decisions, with a case study to demonstrate their applicability 11. Coaching to reduce the recurrence of human error, 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 |
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Handouts |
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Copy of the visual aids · Compilation of recommended behaviors to prevent human error · Case study and exercise materials · Certificate of Completion, with Continuing Education Units |
 Click
here to register for the “Human Error Prevention” Seminar |
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Click here for Ben Marguglio’s credentials |
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