Human ErrorsHow to Identify and reduce them

Human Factors & Errors

Key objectives of HF is to design systems

that

◦ people can use

◦ increase efficiency and performance

◦ minimize the risks of errors

Will define and consider the nature of error

Consider the implications for systems

design

Definition of Human Error

…is an inappropriate or undesirable human

decision or behavior that reduces or has the

potential for reducing the

◦ effectiveness

◦ safety

◦ system performance

Human error

1st blame only the individual

2nd identify other factors. E.g.:-

◦ badly designed or faulty equipment

◦ poor management practices

◦ inaccurate or incomplete procedures

◦ inadequate or inappropriate training

Error Classification

Skill based

◦ controlled by sub-conscious behavior and stored

patterns of behavior

◦ errors usually errors of execution

Rule based

◦ applies to familiar situations - stored rules are applied

◦ errors involve recognizing the salient features of the

situation

Knowledge based - occur in unique & unfamiliar situations

◦ errors result from inadequate analysis or decision

making

Conclusions of Human Errors

Factors are broad & encompass most factors found in other models

Their model includes and emphasizes

◦ management social and psychological factors

Human factors variables are recognized in the categories

◦ physical environment

◦ equipment design

◦ work itself (refer to model diagram in exercise book)

How to Reduce Human

Errors? Human error is inevitable

Consequences and likelihood can be

reduced by:-

◦ better recruitment & selection

◦ training

◦ better design of equipment procedures &

work environment

Reducing Accidents

Apply HF principles to the processes

Provide procedural checklists

Provide training

Provide appropriate & meaningful

feedback

Establish effective employees

feedback system

Eliminate/reduce risk through design

New Employees Hiring &

Training Ensure the hiring policy is attracting

the employees with relevant

experience and skills to perform the

tasks

◦ Provide the new hire with training and

resources to enable employees to

perform the required tasks effectively and

efficiently

◦ Qualify the newly hired employees

training to ensure that employees can

assume and execute their new job

responsibilities

Improve the Performance

Provide effective On the Job Training

Establish robust Standard Operating Procedures to eliminate or reduce the following errors◦ Errors of omission - forget to do something

◦ Errors of commission - doing the task incorrectly

◦ Sequence errors - out of order

◦ Timing errors - too slow - too fast - too late

How to Establish a Robust

SOP Review that the current processes to ensure◦ Adequate Procedures are available for all Major

and minor manufacturing and testing processes

◦ Procedure has clearly stated the process requirements and the personnel responsibilities to complete the tasks

◦ Clear instruction on how to complete the required process tasks Accurately

Sequentially

Timely

◦ If the timing is critical, establish a realistic timeline requirements and provide adequate resources to execute the tasks on time

Monitor the Performance

Classify the source of occurrence as

follows:

◦ Required action is NOT performed or is

performed incorrectly.

◦ Undesired action is exercised.

◦ Information essential for performing the

action is misinterpreted.

◦ Mistake occurs due to complexity.

Fix the Problem

Evaluate the errors according to the following criteria◦ Frequency

◦ Safety

◦ Criticality and consequences

Select the most effective solution(s)

Implement the Corrective Actions to reduce the error sources

Monitor the effectiveness of the solutions