Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Amélioration de la performance : Réduire le risque d'erreur

1,143 views

Published on

Cas des activités avec exigence de fiabilité - 4 Types de précurseurs d'erreurs à repérer et prévenir.

Published in: Leadership & Management
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (Unlimited) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/qURD } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/qURD } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download doc Ebook here { https://soo.gd/qURD } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • DOWNLOAD THAT BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download Full EPUB Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download Full doc Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download PDF EBOOK here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download EPUB Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download doc Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book that can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer that is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story That Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money That the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths that Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • DOWNLOAD THAT BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download Full EPUB Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download Full doc Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download PDF EBOOK here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download EPUB Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download doc Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book that can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer that is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story That Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money That the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths that Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • DOWNLOAD THAT BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { http://bit.ly/2m77EgH } ......................................................................................................................... Download Full EPUB Ebook here { http://bit.ly/2m77EgH } ......................................................................................................................... Download Full doc Ebook here { http://bit.ly/2m77EgH } ......................................................................................................................... Download PDF EBOOK here { http://bit.ly/2m77EgH } ......................................................................................................................... Download EPUB Ebook here { http://bit.ly/2m77EgH } ......................................................................................................................... Download doc Ebook here { http://bit.ly/2m77EgH } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book that can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer that is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story That Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money That the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths that Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Amélioration de la performance : Réduire le risque d'erreur

  1. 1. AMÉLIORATION DE LA PERFORMANCE RÉDUIRE LE RISQUE D'ERREUR
  2. 2. 2 QUESTIONS2 QUESTIONS POUR 1 RÉPONSEPOUR 1 RÉPONSE Qui aime faire des erreurs ? Qui est infaillible ? PERSONNE !PERSONNE !
  3. 3. COMMENT PRÉVENIR L'ERREUR HUMAINE ? LA CLÉ DE LA FIABILITÉ : ● Réduction des erreurs + ● Management des défenses ● = 0 événement indésirable.
  4. 4. Réduction des erreurs LA CLÉ DE LA FIABILITÉ Défenses en profondeur (Reason) + = + Management des défenses = Zéro événement indésirable
  5. 5. Défenses en profondeur (Reason) MANAGEMENT DES DÉFENSES  Défenses en profondeur  Modèle du « Gruyère Suisse » de REASON  Aligner des lignes redondantes de Défenses  Éviter les « trous dans la raquette »  Traiter causes immédiates et causes profondes – Rattraper des erreurs et empêcher des défaillances
  6. 6. CONCEPT DES BARRIÈRES Ex Santé Sécurité Sûreté
  7. 7. APPLICATION À TOUS LES PROCESSUS Dès lors qu'il existe POUR UNE ACTIVITÉ DONNÉE UNE EXIGENCE DE FIABILITÉ, les mêmes principes sont applicables : Facteurs Humains ET Organisationnels Prévention de l'erreur humaine L'erreur est humaine, certes, mais l'être humain est perfectible L'humain ne travaille pas seul et hors sol La prévention se double de dispositifs de rattrapage et d'atténuation Management des défenses
  8. 8. THE DIRTY DOZEN LES 12 MAUX DU FACTEUR HUMAIN LAISSER - ALLER 12 Principaux facteurs humains pouvant causer des événements indésirables Gordon DuPont, The Dirty Dozen, 1993.
  9. 9. 12 MAUX DU FACTEUR HUMAIN THE DIRTY DOZEN LES 12 MAUX DU FACTEUR HUMAIN FATIGUE physique et mentale Problèmes d'ATTENTION DISTRACTIONS STRESS PRESSION MANQUE DE RESSOURCES Soutien et matérielDéfaut de TRAVAIL D'ÉQUIPE COMMUNICATION Défaut, manque Manque d'ASSERTIVITÉ Affirmation de soi NORMES Usages du groupe CONNAISSANCES Manque ou obsolescence LAISSER-ALLER Routine, excès de confiance, complaisance
  10. 10. CONNAÎTRE LES PRÉCURSEURS D'ERREURS Savoir repérer, prévenir, et agir sur les précurseurs d'erreurs relatifs aux 4 domaines suivants : PRÉCURSEURS D'ERREURS EXIGENCES DE LA TÂCHE ENVIRONNEMENT DE TRAVAIL NATURE HUMAINE CAPACITÉS INDIVIDUELLES
  11. 11. PRÉCURSEURS D'ERREURS LIÉS AUX EXIGENCES DE LA TÂCHE Pression temporelle (urgence) Charge de travail (exigences cognitives) Simultanéité, multiplicité des tâches Actions répétitives, activités monotones Actes sans retour possible Nécessités d'interprétation Manque de clarté des buts, rôles et responsabilités Absence ou manque de clarté des règles
  12. 12. PRÉCURSEURS D'ERREURS LIÉS À L'ENVIRONNEMENT DE TRAVAIL Distractions, interruptions Changements, écarts par rapport à la routine Affichages et indicateurs de contrôle trompeurs Solutions de contournement, pis-aller Réponse non explicite du système Disposition ou fonctionnement inattendus de l'équipement Manque d'indications complémentaires Conflits de personnes
  13. 13. PRÉCURSEURS D'ERREURS LIÉS À LA NATURE HUMAINE Stress (limite l'attention) Habitudes Suppositions (image mentale inadéquate) Laisser-aller, complaisance, excès de confiance État d'esprit, mentalité (programmé à voir) Mauvaise perception du risque Raccourcis mentaux (biais) Mémoire à court-terme limitée
  14. 14. PRÉCURSEURS D'ERREURS LIÉS AUX CAPACITÉS INDIVIDUELLES Manque de familiarité avec la tâche / Première fois Manque de connaissances Nouvelle technique non encore expérimentée Communication imprécise Manque de compétence, d'expérience Lacunes en résolution de problèmes Attitude risquée dans les tâches critiques Maladie, fatigue
  15. 15. LES PRÉCURSEURS D'ERREURS Exigences de la Tâche Capacités individuelles Pression temporelle (urgence) Manque de familiarité avec la tâche /Première fois Charge de travail (exigences cognitives) Manque de connaissances Simultanéité, multiplicité des tâches Nouvelle technique non encore expérimentée Actions répétitives, activités monotones Communication imprécise Actes sans retour possible Manque de compétence, d'expérience Nécessités d'interprétation Lacunes en résolution de problèmes Manque de clarté des buts, rôles et responsabilités Attitude risquée dans les tâches critiques Absence ou manque de clarté des règles Maladie, fatigue Environnement de Travail Nature Humaine Distractions, interruptions Stress (limite l'attention) Changements, écarts par rapport à la routine Habitudes Affichages et indicateurs de contrôle trompeurs Suppositions (image mentale inadéquate) Solutions de contournement, pis-aller Laisser-aller, complaisance, excès de confiance Réponse non explicite du système État d'esprit, mentalité (programmé à voir) Disposition ou fonctionnement inattendus de l'équipement Mauvaise perception du risque Manque d'indications complémentaires Raccourcis mentaux (biais) Conflits de personnes Mémoire à court-terme limitée Liste non limitative
  16. 16. RESSOURCES & REFERENCES  Human Performance Tool Training, Paul Merritt  Dirty Dozen, AviationKnowledge Wiki (lien)  12 Most Common Human Error Preconditions (lien)  Pratiques de fiabilisation (lien)

×