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Causes and Prevention of Human Error


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#1 Simon

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Posted 28 February 2011 - 07:56 PM

File Name: Causes and Prevention of Human Error
File Submitter: Simon
File Submitted: 28 Feb 2011
File Category: Quality & Productivity Tools

To err is to be human.

Of course the statement is true, but "management" should understand ‘human error’ is not always willfulness or being unlucky, rather it is preventable with a systematic approach to good management. I created the attached from a Health & Safety point of view, but it relates to any worker including food safety, quality and production errors.

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#2 GMO

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Posted 28 February 2011 - 08:52 PM

Interesting. I've felt for a while that food safety has a lot to learn from health and safety. A lot of concepts overlap and can be applied.

I remember reading about the swiss cheese effect a few years back as applied to health and safety (here's a link to one article on it). Basically it's the idea that for a major incident to occur, lots of small errors have to coincide but any one of those small "holes" could have prevented the issue.

If you think about it, there is a lot of mileage in this for food safety incidents. How many times when something has happened has at least one of the factors occurred before? E.g. a meal in a ready meal factory is packed in the wrong sleeve, to prevent this, similar sleeves are put in geographically different places (e.g. different shelves), there is a scanning system in place, there is a start and end of run check and clear down procedure between products which the team leader signs off on.

Then you have an incident, it makes it to store and you realise the shelving had been changed, the scanning system was routinely switched off because it cost OEE, the start and end checks were done "at some time" if at all due to production pressures and lines were never properly cleared down due to pressure from the high risk department...

Just like with an accident there will be many near misses or hazards reported (or there should be) before the accident occurs, we should encourage our teams to report issues like this which could lead to food safety incidents and we must act on them.



#3 Simon

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Posted 01 March 2011 - 07:45 PM

Agreed.

I think we've discussed this topic earlier and the Swiss cheese theory also. It's a good analogy, as there are usually many errors or omissions that conspire to allow the major incident to occur. I agree incident reporting is a very good preventive tool that food safety could borrow from health & safety. To have an effective incident reporting system is not easy as it requires a no-blame, open and proactive culture to work, and most companies struggle to get people to even report accidents. Hard work but worth it.

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Simon


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#4 GMO

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Posted 01 March 2011 - 08:22 PM

Ah probably. I'm getting old and forgetful. I've introduced a reporting system before and it did work (kinda) with a fairly tough approach from the ops manager.



#5 Simon

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Posted 18 March 2011 - 08:22 AM

Ah probably. I'm getting old and forgetful. I've introduced a reporting system before and it did work (kinda) with a fairly tough approach from the ops manager.

Very, very important with any change initiative.

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#6 GMO

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Posted 18 March 2011 - 06:40 PM

Very, very important with any change initiative.


Yes but this went beyond supportive, onto dictatorial. "You shall all identify one positive or negative quality behaviour or situation every day and bring them to this meeting or face my wrath" does not help you win hearts and minds (or hearths and minds as I just wrote. It's been a long day... Posted Image)

#7 Tony-C

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Posted 20 March 2011 - 03:45 PM

Yes but this went beyond supportive, onto dictatorial. "You shall all identify one positive or negative quality behaviour or situation every day and bring them to this meeting or face my wrath" does not help you win hearts and minds (or hearths and minds as I just wrote. It's been a long day... Posted Image)


From your posts I can see you've been working for the wrong sort of people/companies and it can be frustrating when there is not much choice. I've been there. Company Politics is always the thing I find frustrating.

One of my bosses in the past said I could vote with my heart or my head. I voted with my heart.

Edited by Tony-C, 20 March 2011 - 03:46 PM.


#8 Tony-C

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Posted 20 March 2011 - 03:51 PM

File Name: Causes and Prevention of Human Error
File Submitter: Simon
File Submitted: 28 Feb 2011
File Category: Quality & Productivity Tools

To err is to be human.

Of course the statement is true, but "management" should understand ‘human error’ is not always willfulness or being unlucky, rather it is preventable with a systematic approach to good management. I created the attached from a Health & Safety point of view, but it relates to any worker including food safety, quality and production errors.

Click here to download this file


Interesting stuff but fundamental for me : Ensuring training is effective, simplifying jobs and tasks, clear procedures.


#9 GMO

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Posted 20 March 2011 - 05:59 PM

From your posts I can see you've been working for the wrong sort of people/companies and it can be frustrating when there is not much choice. I've been there. Company Politics is always the thing I find frustrating.

One of my bosses in the past said I could vote with my heart or my head. I voted with my heart.



Posted Image

I think the wrong sort of people are in every company. In the past due to youth and inexperience I've not always handled it the way I would now and ended up being "played" by colleagues. Now I can see it coming a little better and care a little less about being popular. I think any company also can become very political when people are in fear of their jobs.

Here's a fine example of politics in action. One colleague who shall remain nameless asked me to be part of a project team which I knew I was unlikely to be available for the implementation stage. I was aware what was going on, asked to be kept involved but that week particularly I had too much work on (BRC prep). My boss told me to drop this project and ask for assistance from group. Now I did this and someone from group obviously took exception to this and emailed the project manager with some criticism of me. This project manager was a political a***hole as proven by his next actions. He then cut and paste this email into the meeting minutes which were circulated to some people higher up in the company (I think even the chief exec was on the circulation list.)

Of course I was angry but I figured whatever I did it would not undo what had been done by this guy and I also figured I wasn't the only person who knew what he was like; so in the end I emailed the person who had written the email, apologised for not being available to work on the project and explained why and said how unreasonable I thought it was that her private comments had been relayed. She never replied but I'm sure she expressed her anger to her seniors with the person who had made her comments public. I realised after a bit of soul searching that anyone reading the minutes would have had a negative view of the person who wrote them and the person who had been critical of me and I couldn't do anything about any negative view they had of me anyway. Any explanation would have just looked like I was trying to make excuses (and chances are it would direct people to something they didn't read anyway). 10 years ago, I would have been emailing everyone back, knocking on peoples doors and telling them what I thought. Frankly it doesn't help, you kind of have to find ways to manage your boss and colleagues and beware of the sharks.

Oh and they always get their comeuppance in the end.




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