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Human Error Prevention


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How can we prevent accidents caused by human error? This presentation deals with typical examples of severe accidents related to human errors, and shows methods to prevent them.

Published in: Business, Technology

Human Error Prevention

  1. 1. Human Error — Theory and Prevention Dr. Toru Nakata National Institute of Advanced Science and Technology, Japan. Nov. 20, 20111
  2. 2. Part I Theory of Human Error Prevention2
  3. 3. 1-1 How we make mistakes3
  4. 4. Why do we err?  Unknown  Even masters of chess sometime commit easy mistakes.  A lot of typical pattern of “misconception” are found.  Four-card problem  Monty Hall problem  Horse Trading problem  …  But there is no universal tendency among them  Change the question more productive.  “Why can we usually avoid errors?”  Because we can notice and fix errors before they break out.4
  5. 5. Horse Trading Problem  Frank sells Sue a horse for $60.  Then he decides he wants it back, but Sue makes him pay $70 for it.  Then Sue changes her mind and buys it back from Frank, but for $80 (Frank is no dummy).  Finally, Frank buys it back from Sue for—you guessed it—$90 (Sue is no dummy, either).  At this point, who comes out ahead?  d=1285
  6. 6. 1-2 Typical Example of Human Error Accidents6
  7. 7. Case 1: Confusing patients (1999, Japan)  Patient A: 74 yrs old. Plan to be undergone surgery on his heart.  Patient B: 84 yrs old. Plan to be undergone surgery on his lung.  Loaded an elevator together,  Mistaken each other, when they brought out of the elevator.7 7
  8. 8. But, it was doubtful…  Some staffs in the operatin room said, “Is he patient A?”  Different face, vital signs, etc  Reconfirm by telephone to the patient room  “Have Patient A been moved to the operation floor?”  The answer was “yes”  Yoshida Kenko, a famous author, said in his book “Tsure- zure-gusa”,  The top secret skill of horse riding is “do not ride the horse, when you cannot convince the situation is perfect.”8
  9. 9. Case 2: Bhopal accident (1984, India) Safeguards are not safe.  Because, the management for safety becomes reluctant.  Multiple Safeguards seem highly enough.  In actual, all safeguard did not work enough.  Not maintenance for them. 9
  10. 10. 1-3 What is real meaning of Human Error?10
  11. 11. Don’t say “error”, use term “uncertainty”  Is “error” wrong? Some errors bring good results at last. We cannot define “error” as a bad.  What you are thinking is “uncertainty” in the work flow.11
  12. 12. Three ability for human error prevention Ability Meaning Power Detectabilty/ Can you (or work team) Only this ability can prevent Sensitivity against find hidden mistakes in the accident. Most important the front of you? ability. mistakes Traceability for Can you specify the Greatly reduce the cost to mistake cause of the mistake? recovery. Secondary important. Dexterity Can you do your task Reduce running cost of the without errors? task. But no grantee for prevention of accident. (Even you are OK, other workers might sow seeds of accidents)12
  13. 13. Part 2 Solutions for Human Error Prevention13
  14. 14. 2-1 Techniques to ensure human ability14
  15. 15. Wake!  1) Fool-proof  If the driver sleep, the train will stop automatically (Fig.1)  2) Fool-Trap  If the driver violates speed limit, he will be injured before he hit somebody else.15 Fig. 1 Train console Fig.2 Bump of the road.
  16. 16. Look your task!  3) Keep consious about your task.  Sing work songs. Boring line work  “Cell Production system”  4) Comfortable weather  People become thoughless when it is too hot or cold. Cell Production16
  17. 17. Check with objectiveness 5) Use body and voice together  Pointing and Calling 6) Check by pair  “Pair programming” in software Check with production. argument Check with reporting number Yes/No check Most easy and unreliable.17
  18. 18. This is not end! 7. Prevent sense of achievement at too early timing Staffs are making a line when their task already finished. They think they have to keep their tension until this ceremony.18
  19. 19. 2-2 Tool and System to prevent human errors19
  20. 20. Zoning Zoning No zoning Zoning for sanitary20
  21. 21. Metaphor Remove before flight strap Tablet representing representing the mode of door safeguard right to go forward Starbucks21
  22. 22. Pop-out effectWhich is reverse? Which is reverse?22 Is somebody there?
  23. 23. 2-3 Planning the strategy23
  24. 24. Event Tree Analysis (ETA) Loose file Mistake files Reek files Mistake buttons Mistake Business Email address stopsOrdinary problem Other Other  Think risk of severe accidents from ordinary problem.24
  25. 25. Fault Tree Analysis (FTA) Iceberg shipwreck Collision with other ships No aids Titanic Lack of Boats No rescue Paticular accident High sea you have to prevent  Think the cause of a particular severe accident by asking why.25
  26. 26. How to gather incidents reports easily When Where What How Reaction Who Review comment 9-2-Mon- 9:00 Milling Drill Broken Renewal Tanaka OK (Suzuki) cutter No.3 9-4-Wef- 13:00 Heater Intake Dirty Clean Sato To be No.5 inspected (Suzuki) 9-9-Mon- Heater Holder Screw Tight Tanaka OK (Suzuki) 10:03 No.5 loosen •Easy to write in. •Bring the data into Excel, and sort them. •By sorting, you can find which features (when, where, ….) have got the most reports. •That are the most dangerous features.26
  27. 27. Slogan: “Safety by walking around” Hawthorne effect:  Under the situation that somebody may watch your working scene, you tend to perform better, quicker, and safer.  The watcher is NOT his boss.  Without duty, people naturally try to show themselves as good workers.  Walking around. Meet various staffs who are not bosses nor subordinates in order to encourage them. Open Kitchen. The cook tend to Negative Hawthorne effect: perform better and  Under the situation that your supervisor more is watching you closely, you fell uneasy moderate, because27 and tend to refuse the observation. somebody may