decoding human error
TRANSCRIPT
Human Error Prevention
CLS Human Error Prevention
TheHumanErrorPrevention(HEP)processisaboutunderstandingthatHumanErrorisnevera true root cause for an issue. The basicassumptionisthatpeopledonotwanttomakemistakes. Thinking systemically, HEP allowsyou topeel backmore layers of theproblem,uncover the true root cause and implementpermanent�ixes.Thereare4maincategoriesofHumanError,eachwithitsownsubcategories(someofwhichareillultratedover-leaf).
HumanErrorCategories(theCODE)
Ÿ DevelopacultureofHumanErrorPrevention
Ÿ MinimiseRiskofHumanErrorŸ NearMissesandAccidentsreduced
Ÿ QualityDefectsreduced
Ÿ ImproveJobSatisfactionŸ ReduceCostofPoorQuality
Human Error Decoded
De�initions
HumanError:An or involvingAction Decision,a human, which results in an unintended orundesirableoutcome.
How Can CLS Help You?
Decoding Human Error
CompetenceErrorsoccurwhenapersondidnothavetheknowledgeorskilltoperformthetaskcorrectly.
Output
Procedures
Forms
Training
Work Design
Communication
Workplace Design
KPIs
HEP
Competence Omission
ExecutionDecision
Ÿ HEPforLeadershipŸ HumanErrorProblemSolvingProcessŸ HumanErrorRiskOverviewScore(HERO)Ÿ ToolboxforHumanErrorPreventionŸ VisualSOPTraining02
03
0401
Strategy Development
HERO Baseline
Manage the Change
Training
OmissionErrorsoccurwhenapersonmissedastepordidnotperformanaction.
Execution Errors occur when a task isperformedincorrectly,althoughthepersonwascompetenttocarryitout.
DecisionErrorsoccurwhenapersonmakesadecisionwhichinadvertentlyleadstoanerror.
Ÿ StrategyDevelopmentŸ ProgramMentoringŸ HEROWorkShopŸ HumanErrorRootCauseAnalysisFacilitation
Training
Consultancy
Step1:De�inetheStrategy
Ÿ De�inepurposeoftheHEPprogramŸ Plantoin�luencechangeŸ CommunicationPlanŸ SelectPilotProgram
Step2:TrainingonHEP
Ÿ IdentifyHEPtrainingRequirementsŸ LeadershipTrainingŸ HEProblemSolvingTraining(seeoverleaf)Ÿ HEToolsTraining
Step3:DevelopHEROScore
Ÿ IdentifyBaselineHumanErrorRiskOverview(HERO)score
Step4:ManagetheChange
Ÿ CreateanActionPlanŸ EstablishaRecognitionProcessŸ MonitortheChange
TheCLSHEPProgram
Bene�itsoftheHEPProcess
+353 (87) 6226899
Loughlinstown, Fedamore, Co. Limerick
www.crystalleansolutions.ieHEROBaseline:TheHumanErrorRiskOverviewscore(HERO)providesaprocessformeasuringoverallriskofHumanError.
1. P
rob
lem
Defi
nit
ion
Co
mp
lete
d B
Y :
J O
Bri
en
+ T
eam
D
ate
: 10/A
PR
/2017
The in
corr
ect
movi
e w
as
announ
ced a
s th
e w
inner
of th
e “
Best
Pic
ture
” aw
ard
at th
e 2
017 O
scars
aw
ard
cere
mony.
“La L
a L
and”
was
nam
ed
as
the w
inner
when
in fact
, M
oonlig
ht w
as
the A
cadem
y’s
choic
e.
2. M
ap
Ou
t S
eq
uen
ce o
s e
ven
ts L
ead
ing
to
th
e E
rro
r
Aw
ard
E
nve
lopes
Se
quence
d
3.
Ide
nti
fy a
nd
Ve
rify
Ro
ot
Ca
us
e3b
. P
rio
riti
se a
nd
Veri
fy R
oo
t C
au
se
3a. C
ate
gorise
Cause
s of H
um
an E
rror
Cau
se
Lik
ely
E
vid
en
ce
Diffi
cult
to r
ead e
nve
lope
Yes
Ne
w d
esi
gn
(se
e
Belo
w)
Audito
r w
as
dis
tract
ed
Yes
Usi
ng
Tw
itte
r
Act
ress
enve
lope t
oo
close
to b
est
pic
ture
enve
lope
Yes
Inco
rre
ct e
nve
lop
e
han
de
d to
WB
Sce
nario p
lan f
or
pre
sente
rs n
ot
in p
lace
Yes
Sce
na
rio
ide
ntifi
ed
but N
o tra
inin
g
pro
vid
ed
Ro
ot
Cau
se
Best
Act
ress
enve
lop
e to
o c
lose
to
B
est
Pic
ture
enve
lop
e
5. E
ffe
cti
ven
ess E
valu
ati
on
We
re C
han
ges E
ffecti
ve?
TB
CV
eri
fied
by
TB
CD
ate
April 1
0th
2018
Com
pete
nce
Deci
sion
Om
issi
on
Exe
cutio
n
Pre
sente
rs n
ot tr
ain
ed o
n
Sce
nario o
f in
corr
ect
enve
lope b
ein
g p
rovi
ded
Audito
r dis
tract
ed u
sing
twitt
er
back
sta
ge
Bys
tander
Effect
pass
ing
enve
lope to 2
nd p
rese
nte
r
New
enve
lope d
esi
gn d
ifficu
lt to
re
ad
Best
Act
ress
ava
ilable
in s
am
e
loca
tion a
s B
est
Pic
ture
enve
lope
3c.
5 W
hy
Analy
sis
of R
oot C
ause
4. P
reven
tati
ve A
cti
on
Pla
n
Ro
ot
Ca
us
eB
est
Act
ress
enve
lope t
oo c
lose
to B
est
Pic
ture
enve
lope
No
.A
cti
on
Wh
o ?
Wh
en
?S
tatu
s
Wh
y?Tw
o e
nve
lopes
co-loca
ted
1 D
esi
gn p
roce
ss s
o o
nly
one e
nve
lope a
vaila
ble
at
a t
ime
PW
CJa
n/2
018
Ongoin
g
Wh
y?D
esi
gn o
f enve
lope s
tag
ing a
rea a
llow
ed it
2M
ake
aw
ard
enve
lopes
visu
ally
diff
ere
nt
for
each
cate
gory
PW
CJa
n/2
018
Ongoin
g
Wh
y?It h
as
work
ed e
ffect
ively
for
ove
r 80 y
ears
3T
rain
ing o
n s
cenarios
for
aw
ard
pre
sente
rs in
the e
vent
of
an is
sue a
risi
ng
PW
CJa
n/2
018
Ongoin
g
Wh
y?4
Ban
the u
se o
f so
cial m
edia
for
all
back
sta
ge s
taff d
uring
cere
mony
Aca
dem
yJa
n/2
018
Ongoin
g
Wh
y?5
Redesi
gn o
f E
nve
lopes
sim
ilar
to 2
016 d
esi
gn (
easi
er
to
rea
dP
WC
Jan/2
018
Ongoin
g
Inco
rrect
Movi
e
Announce
d a
s W
inner
Aw
ard
E
nve
lope
Handed t
o
WB
*
WB
& F
D*
Take
Sta
ge
with
E
nve
lope
WB
Op
en
ed
E
nve
lop
e
an
d R
ea
d
WB
Pa
ssse
d
En
velo
pe
to
F
D
FD
Re
ad
an
d
An
no
un
ced
L
a L
a L
an
d
Ca
st a
nd
C
rew
of
La
L
a L
an
d
Acc
ep
t A
wa
rd
Acc
ep
tan
ce
Sp
ee
ch
Inte
rru
pte
d to
H
igh
ligh
t E
rro
r
* W
B=
Warr
en B
eatty
F
D =
Faye
Dunaw
ay
What H
appened o
n the n
ight?
Th
e t
rain
ing
of
the
pre
sen
ters
fo
r th
e s
cen
ario
of
som
eth
ing
go
ing
w
ron
g n
ee
ds
to b
e t
est
ed
fo
r e
ffe
ctiv
ity in
re
he
ars
al.
Aft
er
cha
ng
es
are
imp
lem
en
ted
th
e
pro
cess
will
ne
ed
to
be
mo
nito
red
fo
r e
ffe
ctiv
en
ess
. M
on
itorin
g w
ill
ne
ed
to
be
ove
r a
n e
xte
nd
ed
pe
rio
d
an
d o
ng
oin
g im
pro
vem
en
ts s
ho
uld
b
e im
ple
me
nte
d w
ith e
ach
ru
n.
20
17 E
nve
lop
e2
01
6 E
nve
lop
e
Ca
use
Effect
Sce
nario P
lannin
g
Bys
tander
Effect
Focu
s
Intu
itive
Desi
gn
Subca
tegories
in B
lue