Table Of ContentHuman Performance
Improvement
through
Human Error
Prevention
Human Performance
Improvement
through
Human Error
Prevention
A Comprehensive Implementation Guide for
Protecting Employees and Maintaining Cost Efficiency
BW (Ben) Marguglio
First published 2021
by Routledge
600 Broken Sound Parkway #300, Boca Raton FL, 33487
and by Routledge
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2021 Taylor & Francis
The right of BW (Ben) Marguglio to be identified as author of this work has been asserted by him in accordance with sections
77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic,
mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information
storage or retrieval system, without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for
identification and explanation without intent to infringe.
ISBN: 9780367672393 (hbk)
ISBN: 9780367672409 (pbk)
ISBN: 9781003130413 (ebk)
Typeset in Garamond
by codeMantra
Contents
Preface ..............................................................................................................vii
Acknowledgment .............................................................................................xi
Author .............................................................................................................xiii
Welcome ...........................................................................................................xv
1 Major Learning Objectives .................................................................1
2 Introduction ......................................................................................15
3 1st Field of Focus: Hazards and Barriers .........................................99
4 2nd Field of Focus: Error-Inducing Conditions, Error-Likely
Situations and Counteracting Behaviors .......................................203
5 3rd Field of Focus: Non-Conservative and Conservative
Decision-Making Thought Processes and Behaviors .....................281
6 4th Field of Focus: Prevention of the Recurrence of Error .............337
7 Strategies ....................................................................................................567
Appendix A: Words and Terms Used in the Course ..............................613
Appendix B: Format and Writing Conventions for a Procedure/
Process Description Document .......................................629
Appendix C: Types of Contents of a Procedure/Process
Description Document .....................................................641
Appendix D: T ypes of Design Requirements for Hardware Items
and a Facility ...................................................................643
Appendix E: Elements of a Design Calculations Management System ...659
Appendix F: Elements of a Software/Firmware Management System ...663
Appendix G: Elements of an Inspection and Test Management
System ..............................................................................671
v
vi ◾ Contents
Appendix H: Elements of a Records Management System and
Types of Records ..............................................................675
Appendix I: Cross-References for a Configuration Management
System ..............................................................................681
Certificate of Completion .....................................................................686
Preface
This book is a simulation of a live course.
There are seven major sections of the book:
• Major Learning Objectives;
• Introduction;
• 1st Field of Focus, Hazards and Barriers;
• 2nd Field of Focus, Error Traps and Counteracting Behaviors;
• 3rd Field of Focus, Bad and Good Thought Processes and Behaviors in
Decision-making;
• 4th Field of Focus, Prevention of the Recurrence of Error;
• Strategies.
The “Major Learning Objectives” provides a brief preview of the course, listing
the topics that are most important and that you, the student, are expected to
learn in detail. Hopefully, you’ll learn every topic covered in the course, major or
otherwise.
The “Introduction” provides terminology, concepts, principles and practices that
apply in all four Fields of Focus. In the subsequent sections of the book, addi-
tional terminology, concepts, principles and practices will be provided as they
apply. The concepts, principles and practices in the “Introduction” comprise the
foundation for human performance improvement (HPI) by means of human error
prevention (HEP) – the foundation for the four Fields of Focus.
For HPI through HEP, there are four major areas of interest. I’ve called them
“Fields of Focus”. They’re listed above. Anything that has to do with HPI through
HEP is a subset of one of these Fields of Focus.
The 1st Field of Focus, Hazards and Barriers, is the most important. There are
hazards in the processes and hardware items that we design and use. This sec-
tion of the book describes the techniques for identifying these hazards and
assessing their initial levels of risk. Different techniques are used for processes,
components, major hardware systems and facilities as a whole. This section also
vii
viii ◾ Preface
describes the means of treating these hazards, the most common means being
the establishment of control barriers – barriers for the prevention of error that
activates the hazard, for the timely detection of error, and for the mitigation of
the error effects. This section also provides principles and practices for making
these barriers the most effective.
The 2nd Field of Focus, Error Traps and Counteracting Behaviors, describes the
sources and types of error-inducing conditions and error-likely situations (error
traps) and the more than two dozen behaviors that should be practiced to pre-
vent these error traps from inducing error.
The 3rd Field of Focus, Bad and Good Thought Processes and Behaviors in
Decision-Making, is the most interesting to me. Do you know the more than two
dozen different types of biases that can adversely impact decision-making? Yes,
more than two dozen. This section also covers other things that adversely impact
decision-making such as operational loafing, satisficing, groupthink, loss of the
precautionary principle and loss of situational awareness. Of course, the things
that benefit decision-making are covered, as well, such as focus, designated chal-
lenger, the precautionary principle, situational awareness with focus and ques-
tions to ask as a prerequisite to major decision-making.
The 4th Field of Focus, Prevention of the Recurrence of Error, covers two busi-
ness management systems – (1) the field observations and coaching system and
(2) the condition reporting, root cause analysis and corrective action system.
Literally, there are dozens of processes comprising the condition reporting, root
cause analysis and corrective action system – everything from the design of
the computerized tool for condition reporting and corrective action tracking to
the ultimate verification and validation of the corrective action and closure of the
condition report. This section covers root cause analysis techniques for process
and hardware problems – techniques such as five Whys, Change Analysis, Failure
Mode and Effects Analysis, the Rule of 8 (a substantial improvement to Hazards-
Barrier-Effects Analysis) and Cause and Effects Analysis (Fishbone diagrams).
The section also covers root cause analysis techniques for management problems.
The final section of the book is Strategies. The Google Dictionary defines “strat-
egy” as “a plan of action or policy designed to achieve a major or overall aim”.
This section covers the following, each of which, as a whole, comprises an
important strategy:
• Performance and Status Reporting;
• Six Levels of Defense in Depth;
• Risk Management for Processes, Components, Major Hardware Systems and
Facilities;
• Major HPI/HEP Principles and Practices;
• The Four Fields of Focus.
Preface ◾ ix
The book has slides as you would see in a live course, except that they are not
PowerPoint slides; they are simulated slides. You’ll read a simulated slide, as you
would in a live course, and then you’ll read the notes below the slide in lieu of
hearing them spoken as you would in a live course. You can re-read the notes as
many times as is necessary for you to learn them because you’ll be working to
your own schedule, at your own pace, a major advantage. Of course, the biggest
advantage is that you’ll be learning from the world’s leading authority on the sub-
ject. Of course, it doesn’t hurt that you’ve purchased this book at a small fraction
of the registration fee that applies for attending this 40-hour course live – in addi-
tion to avoiding travel time and travel expense.
At the end of the course, take advantage of the Certificate of Completion with 4.0
Continuing Education Units that are convertible to recertification units.
In addition to discovery and invention, the greatest contributor to a higher qual-
ity of production, quality of safety and health, quality of environmental protec-
tion, quality of security, quality of emergency preparedness and response, and
quality of similar concerns of the enterprise is human performance improvement
through human error prevention. Therefore, the subject of this course is of great
importance.
This course material is substantially original. For example, there are principles,
practices, taxonomies, models and templates that never before have been
published and that only have been available in my seminars.
Within its scope and intent, this course is complete and presented with
great depth of specificity. The completeness and specificity are such that the
“take-aways” – the principles and practices – can be directly implemented
without outside consulting help. Yes, the course material is that specific!
This course material is universally applicable to industrial, commercial, educa-
tional and governmental enterprises and to their staff members at any organiza-
tional level and in any organizational function.
This course material is for you only. However, your enterprise can purchase a
license for the use of this material to train your trainers and, in turn, for them
to train your entire staff. And it would be easy to train the trainers because, as
noted above, the course material has a great depth of specificity.
Some parts of the material are most suitable for senior executives. All of the
material is most suitable for middle- and first-line managers and professional
individual contributors. Some parts are most suitable for technicians, craftsper-
sons, laborers and clerical personnel, along with their immediate supervisors.
The material can be grouped and rearranged to suit the specific needs of the
enterprise.
