error management photocopier
TRANSCRIPT
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Error Management
An example for aviation -
the office photocopier
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Error Management
This presentation is designed for self study, or as a formal presentation, or the basis of a practical exercise
undertaken in the office.
It is based on the paper Error Management combating omission error through task analysis and good reminders by J Reason, EmeritusProfessor Department of Psychology, University of Manchester
Last user at nightswitch off after use
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Introduction
Leaving out steps in a task is the single most common humanerror.
This presentation shows how it is possible to identify commonerrors and, with simple memory aids (SOPs) how these errors
may be avoided or their effect mitigated.
The principles of error management shown in this example canbe applied to most operations in aviation.
Making errors is a fact of life, butrecovering them is quite another matter.
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Error the unintended action or inaction
Humans are prone to making errors - a general result of theunique human ability to think and make judgement.
We all make errors; this is not something to be blamed for; butto be investigated as a sign of problems elsewhere.
Errors them selves are not necessarily bad, we can learn fromthem, but their effects may in the extreme be fatal.
We cannot remove all errors, but we can prevent some and
reduce the effect of others this is error management.
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Error Management
Before we can manage error we have to identify what the
error is,
then find either the source or nature of the error,
or the opportunity for error to occur.
Build defences to prevent the error occurring,
or mitigate the effects of the error.
Finally check that the defences work
RISK from errors avoid, contain, mitigate
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Error Management
Principles of error management. RISK
Review the overall task
List all of the steps, sub steps and loops
Identify steps that could be missed
Conduct a survey
Involve a cross section of people
Select a good defensive
A mental reminder
Keep records
Periodic reviews
RI
SK
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Review the overall task - 1
1. Prepare photocopier
Switch onWait for warm-up
2. Select number of copies
3. Prepare first page of original for copyingRaise lid
Place page in position on the glassClose lid
4. Start copying cyclePress start switch
Ensure that the original does not move
5. Check quality of photocopyIf OK, go to step 6
If not OK, select appropriate corrective action
Put in more copy paper
Remove paper jam
Readjust position of original
Adjust toner setting
List all of the steps
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Review the overall task - 2
6. Remove copied original and replace with next page
Raise lidRemove copied originalReplace with next page to be copiedClose lid
7. Repeat steps 4 6 until all pages are copied
8. Remove last page of the original
9. Check that all pages have been copied satisfactorily
10. Switch off photocopier
11. Gather up all materials and depart
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Identify steps that could be missed
Table of errors; most often at the topPlace original wrongly
Leave last page of original *
Copy page already copied
Fail to check copy quality *
Copy selector failures *
Fail to copy all pages *
Leave personal items behind *
Fail to log out or take card *
Lift lid at wrong time
Dont remove all copies, etc *
Fail to insert card at outset *
Fail to allow warm up *
Activate cycle without original *
Fail to switch on copier *
Switch off before completion
* Items involving missed steps
Conduct a survey
Involve a cross section of people
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Select a good defence
A good reminder should:-
Catch the attention at the critical time
Positioned as close as possible in time and space to the
location of the action
Inform about the when and where of the item to beremembered
Inform regarding what has to be done
A mental reminder
Ask the users, they have learnt by their mistakes
Count off the number of actions/tasks that needto be done
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A good defence for a photocopier
Reminders (defences) from a survey of users:
Notes and post-its (65.1%)
Diaries (57.3%)
Lists (55.5%)
Writing on hand (43.8%)
Object positioning (41.8%)
Getting others to remind them (34.9%)
Calendars and timetables (31.5%)
Mental checking (8.2%)
Mental rehearsal (6.8%)
Forming associations (6.2%)
Mental visualising (4.1%)
Clocks and watch alarms (3.4%)
SOPs
Cross check
Checklists
Training
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Keep records
Conduct regular audits
Are the defences working?
Use the procedure assessment tool
Can a defence be applied to other tasks?
Common tasks or SOPs
Those who are engaged in the task areoften the best people to design and applya defence.
Those who conduct the task shouldown any procedure relating to adefence.
link
http://www.skybrary.aero/bookshelf/books/635.pdfhttp://www.skybrary.aero/bookshelf/books/635.pdf -
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Error Management
Set up an error management programme
Evaluate all tasks and activities in which missed steps are likely to
have serious consequences or which have a history of error
Review the task or activity in a practical sequence of steps
Asses each step for possible error, survey several users
Prepare a customised reminder standard operating procedure
Use a good reminder:-
Catch the attention at the critical time
Positioned as close as possible in time and space to the location of the action
Information about the when and where of the item to be remembered
Information regarding what has to be done
Count off the number of actions/tasks that need to be done
Reminders need regular renewal
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e.g
Prevent missing out a step
Checklist design
SOP
Cross check / monitoring
Secret papers dual checks
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Check and recheck
Technical innovation allows new opportunity for error
Always review SOPs with any change of equipment
Remember that the photocopier repair mans name is Murphy
People introduce error, by design of equipment or by process
andWhy is the toner always low when you wish to use
the copier?
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Technical innovation allows new opportunity for errorAlways review SOPs with change of equipment
The photocopier repair mans name is Murphy
People introduce error, by design of equipment or process