The New Book on Human Error is Here!

Stopping Human Error

If human error negatively impacts your company then you need to learn about this book. Why? Because human errors can cause:

• Fatalities and injuries
• Operational incidents that cost your company money
• Quality issues that cause customer complaints
• Asset reliability problems
• Schedule slippage on projects
• Environmental permit violations

New Book’s Name

The new book about stopping human error is titled Stopping Human Error. What’s in the book? Best practices to help you stop human errors.

Managers often think that if people would just try harder, concentrate, think before they act, and be more careful, then accidents wouldn’t happen. If you think that’s the answer – give it a try! Trying harder isn’t a bad idea but it’s not a sustainable strategy to improve human performance.

What can you do? Try the proven human performance best practices in this book. They are based on human factors research and have been proven in the field.

You might ask, “Can I stop all human errors?” The answer is no. But you can stop important errors, make other errors less likely and easy to catch and add defense in depth to stop major accidents.

Finally, at the end of this book, you will have the knowledge you need to develop a custom program to improve human performance at your facility and stop many important human errors. What can this save your company? Billions. It can prevent fatalities, stop quality issues, improve equipment reliability, and reduce the chance of regulatory fines. That means this book is well worth your time to read.

Table of Contents

Here is the book’s table of contents…

FOREWORD – viii

CHAPTER 1: Can We “Stop” Human Error – 1
1.1 Try Harder – 1
1.2 How Likely is Human Error?  – 3
1.3 Can We Stop Human Error? – 3

CHAPTER 2: Human Factors Design Best Practices – 6
2.1 Designing to Reduce Errors – Human Engineering – 7
2.1.1 Designing for Resilience – 8
2.1.2 Function Allocation – 10
2.1.3 Designing the Human-Machine Interface – 13
2.1.4 Designing the Work Environment – 23
2.1.5 Human Engineering References – 25
2.2 Reducing Communications Misunderstandings – 27
2.2.1 Providing a Means of Communications – 28
2.2.2 Best Practices for Work Turnover – 28
2.2.3 Stopping Misunderstood Communication – 30
2.3 Using Procedures to Reduce Errors – 33
2.3.1 Procedures Accuracy – 35
2.3.2 Procedure Usability – 35
2.3.3 Getting People to Use Procedures – 38
2.4 Training to Develop the Skills, Knowledge, and Abilities Needed for Excellent Human Performance – 39
2.5 Work Supervision to Improve Human Performance – 41
2.5.1 Preparing for the Job – 41
2.5.2 Selecting the Right Workers – 43
2.5.3 Actively Supervising the Job – 44
2.6 Standards – Management System Best Practices – 45
2.6.1 Establishing High Standards – 45
2.6.2 What Happens When Standards Aren’t Used? – 46
2.6.3 Management Oversight and Communications – 47
2.6.4 Learn from Experience – 48
2.6.5 Management System References – 48
2.7 Inspections to Ensure High Quality – 50
2.7.1 When are Inspections Needed? – 50
2.7.2 Best Practices for Inspections – 51
2.7.3 Quality Control/Inspection References – 51

CHAPTER 3: Proactive Techniques for Finding Human Error-Likely Situations – 52
3.1 THERP – 53
3.1.1 Overview of How to Perform THERP – 54
3.1.2 Advantages and Disadvantages of using THERP – 57
3.1.3 THERP and HRA References – 60
3.2 FMEA – 60
3.2.1 Overview of How to Perform a FMEA – 61
3.2.2 Advantages and Disadvantages of using FMEA – 64
3.2.3 FMEA References – 65
3.2 Fault Tree Analysis – 65
3.3.1 How to Perform a Fault Tree Analysis – 66
3.3.2 Advantages and Disadvantages of Using Fault Trees – 67
3.3.3 Fault Tree References – 69
3.4 Pre-Job Hazard Analysis – 70
3.4.1 How to Perform a Pre-Job Hazard Analysis – 70
3.4.2 Advantages and Disadvantages of a Pre-Job Hazard Analysis – 80
3.4.3 Pre-Job Hazard Analysis References – 81
3.5 Proactive TapRooT® RCA – 81
3.5.1 Using TapRooT® to Review Procedures – 82
3.5.2 Using TapRooT® for a Pre-Startup Review – 84
3.5.3 Advantages and Disadvantages of a Proactive TapRooT® RCA – 87
3.5.4 Proactive TapRooT® RCA References- 88

CHAPTER 4: Strategies to Stop Human Error – 89
4.1 Safeguards and Defense in Depth – 89
4.2 Mistake Proofing – 92
4.3 Human Reliability Best Practices – 92
4.3.1 Procedure Use/Adherence – 94
4.3.2 Place Keeping – 96
4.3.3 Independent Verification – 97
4.3.4 Three-Way Communications – 99
4.3.5 Pre-Job Brief/Personal Safety Assessment – 102
4.3.6 Observation and Coaching – 105
4.3.7 Post-Job Brief – 107
4.3.8 Concurrent Verification – 110
4.3.9 Questioning Attitude – 112
4.3.10 STAR – 116
4.3.11 Time Out (Stop When Unsure) – 119
4.3.12 Attention to Detail – 122
4.3.13 Management of Change – 123
4.3.14 Error Traps and Precursors – 126
4.3.15 Validate Assumptions – 130
4.3.16 Do Not Disturb Sign – 134
4.3.17 Conservative Decision-Making – 134

CHAPTER 5: Using TapRooT® to Analyze Human Error – 137
5.1 The Process for Root Cause Analysis – 139
5.2 The SnapCharT® Diagram – 142
5.3 Finding Root Causes Using the Root Cause Tree® – 147
5.4 Developing Fixes Using the Corrective Action Helper® Guide – 149
5.5 Learn More About Root Cause Analysis – 152

CHAPTER 6: CHAP – Critical Human Action Profile – 154
6.1 Introduction to CHAP – 154
6.2 Performing a CHAP – 156

CHAPTER 7: Designing Your Human Performance Improvement Program – 169
7.1 Develop Your Incident Investigation/Root Cause Analysis Program – 170
7.2 Measures and Data to Guide Your Program – 172
7.3 Becoming Proactive – 174
7.4 Becoming Even More Proactive – 175
7.5 Example Human Performance Improvement Program – 177
7.5.1 Sample Facility Status – 177
7.5.2 Where to Start – 179
7.5.3 Results – 181
7.5.4 Continuous Improvement – 183
7.6 Get Started! – 185

INDEX – 186

Who is the Author?

Mark Paradies took his many years of experience and human factors background and poured it into this book. Why kind of experience and education does Mark have?

Mark Paradies has 40 years of experience in high-reliability organizations, process safety, incident investigation, and root cause analysis. His career started as a leader in Admiral Rickover’s Nuclear Navy (where he earned Engineer Qualification). He also worked for DuPont in the areas of human factors, process safety, and performance improvement management before he started System Improvements in 1988. Mark was one of the co-creators of the TapRooT® System and worked with Heinz Bloch on the original development of the Equifactor® Technique. He has a BS in Electrical Engineering and an MS in Nuclear Engineering (with an emphasis on human factors), both from the University of Illinois.

His human factors and human error analysis experience includes:

• Masters Degree with Emphasis on Human Factors from the University of Illinois
• Research on the proper role of automation in the next generation of nuclear power plants (1983-1985)
• Member, Human Factors & Ergonomics Society, 1983-Present)
• Developing a Human Performance Improvement Program at DuPont (1985-1988)
• Contributed to INPO’s HPES (1986)
• Co-Developer of the TapRooT® Root Cause Analysis System (1990-Present)
• Co-Developer of the NRC’s Human Performance Investigation Process, HPIP (1990-1993)
• The 85th Certified Professional Ergonomist, the first human factors professional certification (1993)
• IEEE Human Factors Committee Member and Co-Author: IEEE Root Cause Analysis Standard (2010-2017)
• Committee Co-Author: Recognizing and Responding to Normalization of Deviation, CCPS
• Committee Co-Author: Guidelines for Investigating Chemical Process Incidents, 2nd & 3rd Editions, CCPS

Should Your Company Care About Stopping Human Error?

That depends…

Does your company care about:

• Fatalities and lost time injuries?
• Rework of manufactured products?
• Returned products due to quality issues?
• Regulatory fines or stop-work orders?
• Delays in permits/government approvals?
• Production upsets?
• Needless equipment repairs?
• Lost production due to equipment stoppages?
• Lost business due to schedule slippage/late shipments?
• Project delays and rework due to construction mistakes?
• Bad press after an accident (reputation loss)?
• Insurance costs?

To get an idea about the cost of an accident caused by several human errors, let’s look at one example…

According to The Guardian, one of the most expensive accidents – the Deepwater Horizon explosion, fire, and oil spill – cost BP over $65 billion (The Guardian, “BP’s Deepwater Horizon Bill tops $65bn,” January 16, 2018). Of course, the cost in dollars doesn’t account for the 11 people who lost their lives. On top of that is the environmental damage that will never be entirely known.

Let’s put the cost of that accident ($65 billion) in perspective. First, ExxonMobil bought XTO Energy at the height of the oil boom for $41 billion. Also, besides the direct costs, BP’s stock lost about one-half of its value. Nine years after the accident, the stock had not regained its price before the accident.

Now consider the cost to the oil industry. Drilling for oil in the Gulf of Mexico was suspended by the US government for all companies from July of 2010 until October of that year. Even after that, it took months for many rigs to resume drilling. Some were moved to other areas and drilling was never resumed.

But the cost of one major accident is small compared to the cumulative cost of all human errors. Start thinking about the cost of these errors:

• 250,000 people die each year in the United States due to errors by healthcare professionals (The British Medical Journal, “Medical error – the third leading cause of death in the U.S.,” May 3, 2016).
• $871 billion per year of costs due to motor vehicle accidents in the United States, according to a study released in 2014 by the National Highway Traffic Administration (the number includes lost economic and societal costs, such as: productivity, court costs, medical costs, emergency services, insurance administration costs, and property damage).
• $37 billion per year is the cost of “misunderstandings” for US and UK companies, according to a white paper published in 2008 by IDC, a global analyst firm (IDC Research, “$37 Billion: Counting the Cost of Employee Misunderstanding,” Framingham, MA, 2008).
• $165.6 million was the cost to NASA of a Lockheed Martin engineer confusing feet and meters (metric conversion) and the resulting loss of the Mars orbiter.

Now think about losses at your company. You could save millions by stopping human errors.

Time to Get Started?

If you haven’t started a human performance improvement program, maybe NOW is the time to look into this technology by getting the Stopping Human Error book.

If you have tried some human performance techniques, but would like to learn more about the human factors basis of human performance improvement technology, now is a great time to get this book and dig deeper to develop your knowledge.

How can you get the Stopping Human Error book by Mark Paradies? Order it by CLICKING HERE.

Or you can get your copy of the book when you attend the Stopping Human Error Course. There is a course scheduled on September 15-16 in Knoxville, TN (CLICK HERE for complete details and to register).

No matter how you decide to learn about this important technology, get started soon! Your company can’t afford needless human errors!

Here’s a video of Mark and Alex discussing the new book…