Human performance improvement through human error prevention : a comprehensive implementation guide for protecting employees and maintaining cost efficiency
著者
書誌事項
Human performance improvement through human error prevention : a comprehensive implementation guide for protecting employees and maintaining cost efficiency
Routledge, 2021
- : hbk
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内容説明・目次
内容説明
* Addresses the four fields of focus for error prevention / reduction - namely, (1) hazards and barriers, (2) error traps and counteraction behaviors, (3) erroneous and correct thought process in decision-making and (4) prevention of the recurrence of error. The scope of this book is unique.
* Provides my unique model of performance - using the daisy chain of knowledge, cognition, beliefs, values, attitudes, behavior, results, performance.
* Addresses in detail Dr. Peter Drucker's teaching, as follows: "The task of leadership is to create an alignment of strengths in a way that makes a system's weaknesses irrelevant." My book makes it clear that the "alignment of strengths" are the error prevention, detection and mitigation barriers and the "weaknesses" are the hazards in processes that are or should be made irrelevant by the barriers. My book provides the specifics of how to identify and assess the hazards and how to create effective barriers.
* Provides the most complete list and most comprehensive a discussion of management responsibilities to establish and maintain the quality-conscious work environment.
* Provides my 30+ principles of human error prevention, none of which duplicate Dr. James Reason's 12 principles of error management and a few of which contradict Dr. Reason's principles.
* Provides a unique seven 7 human error causal factors which, when fully understood, enable one to better design processes and better perform root cause analysis.
* Addresses risk management at three levels - (1) risk management of processes, (2) risk management of components and (3) and risk management of hardware systems and the facility as a whole. The techniques for each are significantly different. Neither ISO 9001 not ISO 31000 do this.
* Provides the most complete list of techniques for improving the effectiveness of process barriers and the most comprehensive discussion of these techniques.
* Describes the full scope of the quality function in terms of hazards and barriers.
* Provides a unique nine types of corrective action with examples of each.
* Describes 36 biases that adversely impact decision-making.
* Describes the 10 questions that should be asked and answered before making any significant decision.
* Provides unique templates for root cause analysis - templates that assure the discipline, rigor and logic of the analysis.
* Provides the most complete and comprehensive coverage of the widely known Piper Alpha accident, especially the causal factors of the accident, and introduces a non-fail-safe character of the work permit process as the major cause.
* provides universally applicable criteria for 37 different areas types of processes that may be included in the enterprise business management system - criteria that are designed to prevent human error in the design of the processes. Examples are:
o 12 cross-references to facilitate document change management;
o 100+ different types of records;
o Methods by which to improve inspection and test effectiveness.
Regarding specific incidents, the book:
* Introduces violation of The Precautionary Principle in addition to GroupThink as causes of the Challenger accident.
* Demonstrates that even if Alaska Flight 161 had not crashed due to the change in the lubrication schedule for the jackscrew assembly, sooner or later it would have crashed due to the lack of specificity in the maintenance procedure for the jackscrew assembly.
* Demonstrates that even with all of the error-inducing conditions aboard the Greenville submarine, its sinking of the Ehime Maru could not have occurred without the failure of a barrier. Error-inducing conditions cannot be root causes.
* My book Note: Bold typed items represent my unique additions to the body of knowledge. Non-bold typed items represent my special treatment of items that already exist in the body of knowledge.
目次
1 Major Learning Objectives
2 Introduction
3 1st Field of Focus: Hazards and Barriers
4 2nd Field of Focus: Error-Inducing Conditions, Error-Likely Situations and Counteracting Behaviors
5 3rd Field of Focus: Non-Conservative and Conservative Decision-Making Thought Processes and Behaviors
6 4th Field of Focus: Prevention of the Recurrence of Error7 Strategies
Appendix A: Words and Terms Used in the Course
Appendix B: Format and Writing Conventions for a Procedure/Process Description DocumentAppendix C: Types of Contents of a Procedure/Process Description Document
Appendix D: Types of Design Requirements for Hardware Items and a Facility
Appendix E: Elements of a Design Calculations Management System
Appendix F: Elements of a Software/Firmware Management System
Appendix G: Elements of an Inspection and Test Management System
Appendix H: Elements of a Records Management System and Types of Records
Appendix I: Cross-References for a Configuration Management System
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