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Human Factors and Rca Barsalou

Human Factors and root cause analysis training

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27 views19 pages

Human Factors and Rca Barsalou

Human Factors and root cause analysis training

Uploaded by

Peter Castro
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Human Factors &

Root Cause Analysis

Matthew Barsalou

D54 – May 25, 2021


Learning Objectives
• In this session you will:
– Lean how to classify human errors

– Be able to create an Ishikawa diagram for


human errors

– Describe the Swiss cheese model for


human errors
Introduction to Human Error
• Quality failures happen
– Human error may cause failure

• Examples of human error:

– Data entry errors

– Skipped assembly operation


Error Investigations
• Consider human factors:
– Biomedical considerations
– Psychosocial considerations
– Personnel selection
– Training
– Evaluation
– Job aids
Traditional Ishikawa Diagrams
• Considers the 6Ms:
– Man (people)
– Measurements
– Material
– Milieu (environment)
– Methods
– Machine
• Uses “5 Whys” to investigate problem
Classifications of Human Errors
1. Performance Human Factors Based Ishikawa Diagram
information

2. Individual
considerations

3. Physical situation

4. Error impact

5. Corrective action
Human Factors Based Diagram
• Use “5 Whys” to investigate problem
Subsequent Action Plan
• Prioritize actions to investigate
• Track status of assigning actions
• Example:
Swiss Cheese Model for Human Error
• Aircraft accidents
– Failures happen at multiple levels
– Comparable to the holes in Swiss cheese
lining up
• Medical error categories
– Situation task – errors & violations
– Local climate – producing conditions
– Corporate - management decisions &
organizational processes
Swiss Cheese Model for Human Error
Level Investigative Questions
Failure- What could have prevented the possibility of failure?
proofing How could the failure have been immediately detected?
Operational Is a procedure available?
Yes: Was it followed? No: Was violation intentional?
Yes: Was procedure adequate for the situation?
No: Could a procedure have prevented the failure?
Was the failure due to lack of knowledge, inattention,
inability, or distraction?
Local What, if any, factors (e.g., work area too hot, cold, loud,
conditions cluttered) contributed to the failure?
Management What, if any, organizational decisions or expectations
contributed to the failure?
Human Error Example
• Problem: Customer received wrong part
• 5 Whys investigation:
– Why did customer receive wrong part?
• Parts were mixed up on the production machine
– Why were parts mixed up on the production machine?
• The divider was not being used
– Why was the divider not being used?
• The machine operator removed the divider
– Why did the machine operator remove the divider?
• Because it slowed them down & there was a piece rate bonus
– Why was there a piece rate bonus?
• To increase the quantity of parts shipped
Human Error Example
• Contributing factors at multiple levels:
– Divider removed
– Operator ignored requirement to use a
divider
– Management used a piece rate bonus to
motivate operators
– Operator found the quickest way to work
Human Error Example
• Corrective action:
– Piece rate bonus not discontinued
– Permanent dividers were installed
– Optimal divider height determined with
operators’ input
• Result: Parts no longer mixed up &
divider does not slow down operator
Typical Corrective Actions for
Human Errors
• Retraining

• Updating procedures/work instructions

• Implementing checklists

• Poke Yoke
Typical Corrective Actions
Action Description/Issue
Retraining Operators may forget & new operators may not
receive training; failure conditions will still exist
Updating Documents lessons learned & supports
procedures implementation elsewhere
Implementing Ensures and/or verifies each step is/was taken
checklists
Poke Yoke Prevents failure from occurring and/or moving
to the next operation
Key Take-aways
• Considering human factors during root
cause analysis can help finding the
cause of the problem
– Create an Ishikawa diagram based on
human factors
– Transfer Ishikawa diagram to a tracking list
– Consider the Swiss cheese model
Summary
• In this session you should have learned
how to:
– Classify human errors

– Create an Ishikawa diagram for human


errors

– Describe the Swiss cheese model for


human errors
References
• Barsalou, Matthew A. 2014. Root Cause Analysis: A Step-By-Step Guide to Using the
Right Tool at the Right Time. NY: Productivity Press.
• Dhillion, Balbir S. 1986. Human Reliability: With Human Factors. New York:
Pergamon Press.
• Harris, Douglas H. and Frederick B. Chaney. 1969. Human Factors in Quality
Assurance. New York: John Wiley & Sons, Inc.
• Hutchins, David. 2019. Quality Beyond Borders: Dantotsu or How to Achieve Best in
Business. London: Routledge.
• Ishikawa, Kaoru. 1991. Guide to Quality Control (2nd ed.). Translated by Asian
Productivity Organization. Tokyo, Japan: Asian Productivity Organization
• Reason, Jason. 1995. “Understanding Adverse Events: Human Factors.” BMJ Quality
& Safety. 4:80-89.
• ReVelle, Jack B. 2004. Quality Essentials: A Reference Guide from A to Z.
Milwaukee, WI: ASQ, Quality Press.
• Shingo, Shigeo. 1986. Zero Quality Control: Source Inspection and the Poka-Yoke
System. Portland, OR: Productivity Press.
Questions?

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