Try using the Human Error Assessment Tool (HEAT) system...
I'm incorporating it into a procedure for my supervisors to use in solving human errors. It comes from a now-defunct company called Talsico that was based in NJ. I don't know who to credit it to other than that.
Employee does not know or does not understand; no training or ineffective training.
c Employee did not have prerequisite qualifications
Provide employee remedial training in prerequisites or reassign employee.
c Employee not trained and qualified on task
Reassign employee until trained. Improve job specifications for task to include the training and qualification missed.
c First time employee performed task
Improve training to include "team paired" qualification with skill check for first performances.
c Employee did not perform task as trained
Reassign employee until retrained and re-qualified with skill check.
c Employee did not understand results of deviation from correct procedure
Improve training to include "scenario" to show results of deviation.
c Training was ineffective
Review and improve skill checks to show training is effective.
Employee made wrong decision or responded with inappropriate behavior or insufficient understanding of result.
c Situation not covered in procedure or training, incorrect logic used
Improve training to include the situation.
c Employee forced to make a decision without supervision input
Improve training to include "scenario" to show variations. Create a "decision tree" or "flow chart" for decision making; with feedback channels and embed it in the procedure.
c Situation unclear as to "normal operation" or "troubleshooting"
Improve training to segregate "normal operation" from "troubleshooting" in the task/procedure.
c Employee failed to make decision based on dilution of responsibility or blind eye ("not my job")
Improve training to include "scenario" for elevation of decision in chain of command.
c Employee did not understand results of decision or failure to make to decision
Improve training to include "scenario" to show results of failure to make decision. Change balance of results. Clarify expectations.
Employee trained, but failed to remember - unable to use skill or knowledge as required (e.g. change in a step/order forgotten).
c Extended time since employee last performed task
Improve training and qualification schedule to reduce extended time between task performances.
c Employee forgot or skipped task steps that are regularly performed without error
Improve work area to reduce interruptions. Confirm working environment is suitable. Create "error-proof" solution (task can only be performed one way).
c No "job aids" or "visual controls" available
Create "job aids" or "visual controls" to support recognition of tasks. Confirm they are readily available and changes highlighted.
Employee knew, but applied incorrect action or information (e.g. slips, wrong outcomes, transcription errors, mistakes).
c Several tasks involved simultaneously, i.e. too many things happening at once
Reduce or balance cognitive load. Re-order or re-assign tasks.
c Not enough resources or incorrect resources to perform task
Perform resource gap analysis and confirm employee has the resources to do the task. Confirm correct items are at hand each time before task begins (e.g. check list).
c Environment disorganized
Improve organization and structure the environment to the task.
c Health or fitness issues involved
Confirm employee is physically fit for the task.
c Data input or design of documentation
Error-proof the input system to prevent mistakes.
c Design of equipment
Error-proof the equipment and usage steps. Upgrade equipment.
c Employee knew the task, but applied the incorrect action/steps (e.g. perceived a color check incorrectly)
Provide symbols/signs/color standards/written descriptions in documentation and job aids.
Employee believed they did task correctly, but end result was variable or not desired outcome.
c Employee relied on "recall" rather than "recognition"
Provide recognition aids rather than relying on recall (e.g. use colors/sounds/symbols/signs). Prevent interference with operators.
c Distractions or disruptions present caused "recognition" failure.
Improve work area by minimizing distractions and disruptions. Isolate or rotate the task.
c Competing priorities caused loss of focus
Separate in-order tasks of a similar nature and of similar priority.
Employee knew, but forgot. Employee missed or did not verify the steps/actions or used wrong item (e.g. left a field blank).
c Employee had no double check of activity/information/results
Improve task an "over check" system. Have a second qualified person verify the activity/information/results.
c Distractions or disruptions present in schedule (break, shift change, holiday) caused failure
Improve task with "attention activators" (e.g. job aids, checklists, colored labels/highlighting, auditory/visual alerts, symbols, signs, form design). Activators must be appropriate in strength, number, and location.
c Not enough time in schedule to complete the task
Restructure or reschedule the type of task to fit time requirements.
c Employee perceived higher pressure than normal or concern due to unusual circumstance
Reduce pressure (e.g. restructure task with more personnel or other resources).
c Items required to complete task not available
Improve task with pre-work check list for required items.
Ineffective Documentation (e.g. batch records, procedures, job aids).
c Documentation not same as actual practice or unclear to employee
Improve document to reflect actual practice. Clarify practices used.
c Documentation missing step(s) or step(s) out of order
Improve document to capture missing steps or reorder steps to reflect actual practice.
c No "job aids" or "attention activators" available
Create a job aid with pictures to accompany the document, or include pictures or "attention activator symbols" in the procedure.
c Terminology of task unclear to employee
Improve document with help and input of end-user employee(s) to confirm clarity of terms.
c Order of action unclear to employee
Improve document with help and input of end-user employee(s) to confirm clarity of order.