29 replies to this topic

[Setanta]

cmarchard,

 

Do you have success?  What did you end up doing?

[Jim E.]

Always a month or so behind when I get to read a forum.  I have an issue the same as mentioned above where the employee on the floor seems to do a pretty good job of completing documents.  The problem I run into is verification of the documents by the supervision team.  They are turned in with out thier signatures.  I have reminded and retratined again and again still the issue persists.  I have advised the next management level up, they said they would discuss still no improvement.  When audited and the issue is noted I have said we would retrain but now they have come back with the comment that we have used that corrective action in the past and still the problem pursists. "What will you do now?" theyask.  I do not have an answer.

[Setanta]

Based on what worked with my auditor, you may have to change how you do things.  We got a minor for a maintenance guy leaving a part on a hand sink.  They know that they shouldn't do that, and in fact when I did the retraining to explain what we got the minor on, two of the maintenance guys visibly winced when I told them what happened. We now have a designated cart that is for that part only and is out on the floor for them to use.

 

It took care of the minor.  Now when/if it happens when they don't use the cart...perhaps disciplinary action is next.  A documented verbal should suffice.

[fgjuadi]

Carole,

 

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. 

 

Regards,

Mike

 

 

LEARNING GAP

Employee does not know or does not understand; no training or ineffective training.

ROOT CAUSE

CORRECTIVE ACTION

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.

     

 

 

 

DECISION ERROR

Employee made wrong decision or responded with inappropriate behavior or insufficient understanding of result.

ROOT CAUSE

CORRECTIVE ACTION

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. 

     

 

 

 

MEMORY GAP

Employee trained, but failed to remember - unable to use skill or knowledge as required (e.g. change in a step/order forgotten).

ROOT CAUSE

CORRECTIVE ACTION

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. 

     

 

 

 

 

APPLICATION ERROR

Employee knew, but applied incorrect action or information (e.g. slips, wrong outcomes, transcription errors, mistakes).

ROOT CAUSE

CORRECTIVE ACTION

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. 

     

 

 

 

ATTENTION GAP

Employee believed they did task correctly, but end result was variable or not desired outcome.

ROOT CAUSE

CORRECTIVE ACTION

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.

     

 

 

 

 

OMISSION ERROR

Employee knew, but forgot.  Employee missed or did not verify the steps/actions or used wrong item (e.g. left a field blank).

ROOT CAUSE

CORRECTIVE ACTION

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.

     

 

 

 

PROCEDURAL ERROR

Ineffective Documentation (e.g. batch records, procedures, job aids).

ROOT CAUSE

CORRECTIVE ACTION

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. 

I keep coming back to this because I'd really like a complete tool to plug in human error mistakes to a generate a corrective action....

 

I found this via wikipedia, but is there a program / software / list of possible errors & corrective actions available somewhere?   It looks like this is mostly used in super cool high stress jobs like space shuttle building and air traffic control .   It's really hard to navigate without a "how to" and there seem to be reference numbers along the left hand side, but I don't know what they reference or how to use it.

 

Is it HEART, HRA, THEP, or ?   I like what you've given us, Mike!  But "make procedure error proof" is kind of a hard thing to do :/

[Benni]

Carole,

 

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. 

 

Regards,

Mike

 

 

LEARNING GAP

Employee does not know or does not understand; no training or ineffective training.

ROOT CAUSE

CORRECTIVE ACTION

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.

     

 

 

 

DECISION ERROR

Employee made wrong decision or responded with inappropriate behavior or insufficient understanding of result.

ROOT CAUSE

CORRECTIVE ACTION

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. 

     

 

 

 

MEMORY GAP

Employee trained, but failed to remember - unable to use skill or knowledge as required (e.g. change in a step/order forgotten).

ROOT CAUSE

CORRECTIVE ACTION

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. 

     

 

 

 

 

APPLICATION ERROR

Employee knew, but applied incorrect action or information (e.g. slips, wrong outcomes, transcription errors, mistakes).

ROOT CAUSE

CORRECTIVE ACTION

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. 

     

 

 

 

ATTENTION GAP

Employee believed they did task correctly, but end result was variable or not desired outcome.

ROOT CAUSE

CORRECTIVE ACTION

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.

     

 

 

 

 

OMISSION ERROR

Employee knew, but forgot.  Employee missed or did not verify the steps/actions or used wrong item (e.g. left a field blank).

ROOT CAUSE

CORRECTIVE ACTION

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.

     

 

 

 

PROCEDURAL ERROR

Ineffective Documentation (e.g. batch records, procedures, job aids).

ROOT CAUSE

CORRECTIVE ACTION

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. 

Thank you so much for these examples they are very helpful!