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Chapter 17: Error Reduction. ERROR: An event when an action other than desired takes place. Sequence: Consider accidents to be predictable and preventable . i.e., break the sequence. Normality  error  accident  minor loss  major loss  catastrophe.

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chapter 17 error reduction
Chapter 17: Error Reduction
  • ERROR: An event when an action other than desired takes place.
  • Sequence:
  • Consider accidents to be predictable and preventable.
    • i.e., break the sequence

Normality  error  accident  minor loss  major loss  catastrophe

error reduction cognitive ergonomics
Error reduction cognitive ergonomics.
  • Justifications of ergonomics center around …
    • Reduction of physical stress
    • Reduction of errors (waste)
  • Benefits of reducing errors
    • Improves safety
    • Improves quality
    • Improves productivity
causes of errors
Causes of errors
  • Poor design of equipment
  • Poor management of equipment
  • Poor procedures
  • Poor training
  • Other factors
errors in the workplace
Errors in the workplace
  • Costs
    • Range from seconds of time to injury and death.
    • Include cleanup, fines, loss of market share, legal costs.
    • Are difficult to quantify.
    • Are often concealed.
    • Are perceived unequally.
errors in the workplace1
Errors in the workplace
  • Reduce costs by
    • Give more attention to problems where potential cost is higher.
    • Be a scientist, not an advocate.
    • Seek root causes, not blame.
    • Avoid punishment.
types
Types
  • Omission or commission
  • Type 1 or Type 2
  • System or measurement (of the system)
    • Observed error = System + Measurement
  • Perception, decision, or action
  • Slip vs mistake
    • Slip: non-deliberate failure to follow rule
    • Mistake:
      • Conscious planning results in unanticipated action
      • Failure of knowledge
  • Malice: deliberate violation of rules or procedures
error analysis techniques
Error analysis techniques
  • Checklists
  • FMEA / FMECA
  • Decision structure tables
  • Fish diagrams
  • Fault trees
making decisions actions in public
Making decisions/actions in public
  • Eliminating privacy can eliminate many errors.
  • Add lighting or move objects/people to visible places.
  • Require approval for deviations from policy.
  • Increase the number of required decision makers.
  • Decisions tend to be slower but better quality.
  • Exceptions:
    • Emergency situations
    • High risk environments
guideline 1 get enough information
Guideline 1: Get enough information
  • Generate relevant information.
    • May be difficult if information is subjective.
    • Provide additional information for novices.
  • Ensure information reception.
    • Be sure people know how to get and use information.
    • Be sure novices know how to find it.
guideline 2 ensure that information is understood
Guideline 2: Ensure that information is understood
  • Communicating with the general public is more difficult than with employees.
  • For directions, use a series of signs instead of maps.
  • For maps, use “track up” rather than north.
  • Translate and standardize words.
  • Avoid double negatives.
  • Field-test procedures.
  • Use information feedback.
guideline 3 have proper equipment procedures skill
Guideline 3: Have proper equipment / procedures / skill
  • Equipment
    • Design
    • Amount
    • Arrangement
    • Maintenance
  • Procedures
    • Computer procedures
    • Human procedures
  • Skill
    • Consider skill of machine vs. person.
    • Do not assume a fully capable and trained operator.
    • Provide job aids and refresher training.
    • Novices make more errors than experienced operators.
guideline 4 don t forget
Guideline 4: Don’t forget
  • Reduce the need to remember.
    • Avoid verbal orders.
    • Make a list.
    • Do it now.
    • Have standard places for things.
  • Use memory aids.
    • Make them complete, convenient, and accessible.
    • Use forms to indicate when information is missing.
    • Consider downsides.
    • Create a pattern or standard sequence.
    • Use calendars, appointment cards, and reminders.
guideline 5 simplify the task
Guideline 5: Simplify the task
  • Improve communication.
  • Field-test instructions.
  • Use all-letter or all-numeric codes.
  • Avoid complex words.
  • Emphasize important information.
  • Let the operator filter information.
guideline 6 allow enough time
Guideline 6: Allow enough time
  • Too little time results in stress and errors.
  • Time stress is one stress than can be reduced.
  • Assign additional staff when necessary.
  • Cross-train employees to provide flexibility.
guideline 7 have sufficient motivation attention
Guideline 7: Have sufficient motivation /attention
  • Motivation
    • Motivation is not a substitute for engineering.
    • Social pressure can help or hinder performance.
    • What motivates people is not always obvious.
  • Attention
    • Lack of sleep and substance abuse may cause lapses.
    • For critical decisions and actions, minimize distractions.
guideline 8 give immediate feedback
Guideline 8: Give immediate feedback
  • Calibrate instruments periodically.
  • Use closed-loop systems.
  • Notify the operator when an error has been corrected.
  • Make error messages specific and understandable.
  • Consider that operators may disable alarms.
  • Reduce delay between error and detection.
error message guidelines
Error message guidelines
  • Try to reduce or eliminate the need for them.
  • Be specific and precise.
  • Be positive and constructive.
  • Be consistent in language use and display format.
  • Use user-centered phrasing.
  • Test their usability.
guideline 9 improve error detectability
Guideline 9: Improve error detectability
  • Amplify the signal:
    • Match it to enable paired comparison.
    • Do not contradict population stereotypes.
    • Consider location and time.
  • Reduce the noise.
guideline 10 minimize consequences of errors
Guideline 10: Minimize consequences of errors
  • Make important decisions or actions multi-step and reversible.
  • Make equipment and procedures fail-safe.
  • Consider ease of recovery.
  • Ensure recovery does not cause additional problems.
  • Minimize spread of the error through the system.
  • Provide guards.
inspection
Inspection
  • Can be manual, fully automatic, or semiautomatic.
  • Inspect all items for one characteristic at a time.
  • For searches, consider task, environment, and personnel factors.
  • Train inspectors and provide an inspection manual.
  • Inspection Workstations
    • Consider replacing microscopes with video cameras.
    • Use an appropriate colored background.
    • Make chair, work surface, and lighting adjustable.