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Human Factor Tools Basic analysis Webinar 2017

Human Factor Tools Basic analysis Webinar 2017. Julie Avery. Purpose of this meeting. The purpose of this live meeting is to share some of the Human Factor tools and approaches that we use in problem solving and proactively for improvement and get feedback

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Human Factor Tools Basic analysis Webinar 2017

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  1. Human Factor Tools Basic analysis Webinar 2017 Julie Avery

  2. Purpose of this meeting The purpose of this live meeting is to share some of the Human Factor tools and approaches that we use in problem solving and proactively for improvement and get feedback Hear from the group about what subjects they would like to follow up What items and approaches can the group share on future sessions Infractions in a Manufacturing Environment

  3. Human FactorsAll journeys start here

  4. WEAR HUMAN FACTOR GLASSES…. ASK HOW, NOT WHO …. SEE THE DIFFERENCE IT MAKES to achieve your goal 4

  5. Human Factors approachPrevention and effective Response • Prevention: Proactive identification of error likely situations through Human Reliability Assessments (HRA) • Employment of error prevention tools and techniques at all levels of the organisation Response: Work with sites to understand how to respond to a human factor related event, through the use of alternate investigational methodologies. Educate leaders to understand and embrace the difference in a human factor investigation from a standard cause and effect investigation and the insight it brings

  6. Do you get what you measure?Moving to a balanced, brighter horizon

  7. How do or can we measure success?

  8. People make our processes work People are the solution to harness, not the problem to solve (S. Dekker 2010)

  9. It’s all about better understanding • Biggest opportunities for HF- right here

  10. Human Factor Tools in problem solving Work as a team – if one person makes a mistake – anyone can FIRST STORY..... Human Factors Problem Statement Intentional behaviour unintended outcome Unintentional behaviour HUMAN ERROR Not a root cause Learn Type of behaviour or error so you can target the solution Corrective Preventive Action CAPA Action based SLIP Memory based L APSE Knowledge or rule based MISTAKE SECOND STORY..... Routine Violation Situational Violation Exceptional Violation Open Questions to understand the underlying story Add info into Fishbone & 5-Whys

  11. Most important thing in the Human Factors tool box YOU! Infractions in a Manufacturing Environment

  12. TOOL 1Human error categories are defined as consequences Knowing the behaviour types helps you create a good solution Signals of system weakness Use Open questions examples included for each type of behaviour 12

  13. The first and second story Standard for Safety from Aviation, Nuclear Power Presentation title

  14. Tool 2 The second story (causal factors) Performance shaping factors OUTCOME Understand the difference between what we imagine happens and actually happens

  15. CAPA Solution Matrix (Human Factor Example) How you will achieve it What you want from your CAPA Simple Yes / No scoring

  16. STEP 6 - CAPA Solution Matrix

  17. CAPA strength Presentation title in footer

  18. Score CAPA against the Error Control Hierarchy Consider risk to human reliability HIGH CONTROL LOW

  19. The Power of Assuming Innocence vs. Motives Remain objective in the local assessment My Internal “State”or feelings My Response or how people experience me My Assumptions or reaction Innocence Unintentional Empathy Understanding Be Helpful Coach Me Negligence ‘They do not care’ Be Distant Negative Irritation Feel bothered Event (What someone does or how they behave) ‘They are doing it on purpose’ Disrespectful Critical Harsh Resentment Frustration Source: Senn Delaney

  20. Key takeaways • Wear your human factor glasses • Assuming innocence and adopting a no blame environment is fundamental for success in problem solving – human factors tools can help you • You are the most effective human factors tool. How you listen and learn from the user. Go to the Gemba • Understand the first story from the person’s point of view • Use the 3 circles and look for the second story - hold the system accountable • Develop CAPAs that will help people to maximise potential for success Infractions in a Manufacturing Environment

  21. CAPA for human factors If human factors are involved in failures…… • Reduce risk of reoccurrence • CAPA the items discovered to have influenced the event, remove the traps, build better barriers, increase organizational resilience. • Create the conditions for success

  22. CAPA Solution Matrix (Human Factor Example) How you will achieve it What you want from your CAPA Simple Yes / No scoring

  23. STEP 6 - CAPA Solution Matrix

  24. Key takeaways • Wear your human factor glasses • Assuming innocence and adopting a no blame environment is fundamental for success in problem solving – human factors tools can help you • You are the most effective human factors tool. How you listen and learn from the user. Go to the Gemba • Understand the first story, use the behaviour type tool – it will help you target a good CAPA • Use the 3 circles and look for the second story - hold the system accountable Infractions in a Manufacturing Environment

  25. Feedback / Q&A Infractions in a Manufacturing Environment

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