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ASQ Quality Press - Jose (Pepe) Rodriguez-Perez

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For many years, we considered human errors or mistakes as the cause of mishaps or problems. In the manufacturing industries, human error, under whatever label (procedures not followed, lack of attention, or simply error), was the conclusion of any quality problem investigation. The way we look at the human side of problems has evolved during the past few decades. Now we see human errors as the symptoms of deeper causes. In other words, human errors are consequences, not causes.
The basic objective of this book is to provide readers with useful information on theories, methods, and specific techniques that can be applied to control human failure. It is a book of ideas, concepts, and examples from the manufacturing sector. It presents a comprehensive overview of the subject, focusing on the practical application of the subject, specifically on the human side of quality and manufacturing errors. In other words, the primary focus of this book is human failure, including its identification, its causes, and how it can be reasonably controlled or prevented in the manufacturing industry setting. In addition to including a detailed discussion of human error (the inadvertent or involuntary component of human failure), a chapter is devoted to analysis and discussion related to voluntary (intentional) noncompliance.
Written in a direct style, using simple industry language with abundant applied examples and practical references, this book's insights on human failure reduction will improve individual, organizational, and social well-being.

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Industries

Sciences et techniques

Energy

Economics

Business

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Publié par	ASQ Quality Press
Date de parution	13 février 2023
Nombre de lectures	1
EAN13	9781636940915
Langue	English

Informations légales : prix de location à la page 0,3500€. Cette information est donnée uniquement à titre indicatif conformément à la législation en vigueur.

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Human Error Reduction in Manufacturing
Second Edition
José Rodríguez-Pérez

Milwaukee, Wisconsin

American Society for Quality, Quality Press, Milwaukee 53203
© 2023 by ASQ Quality Press
All rights reserved. Published 2023
Library of Congress Cataloging-in-Publication Data
Names: Rodriguez-Perez, Jose, 1961-, author.
Title: Human error reduction in manufacturing, second edition / Jose Rodriguez-Perez.
Description: Includes bibliographical references and index. | Milwaukee, WI: Quality Press, 2023.
Identifiers: LCCN: 2022952229 | ISBN: 978-1-63694-089-2 (paperback) | 978-1-63694-090-8 (pdf) | 978-1-63694-091-5 (epub)
Subjects: LCSH Accidents—Prevention. | Industrial safety. | Human engineering. | Quality control. | BISAC BUSINESS & ECONOMICS / Industries / Energy | BUSINESS & ECONOMICS / Industries / Manufacturing | BUSINESS & ECONOMICS / Industries / Pharmaceutical & Biotechnology | BUSINESS & ECONOMICS / Production & Operations Management | BUSINESS & ECONOMICS / Quality Control
Classification: LCC HD7262 .R63 2023| DDC 658.4/013—dc23
ASQ advances individual, organizational, and community excellence worldwide through learning, quality improvement, and knowledge exchange.
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Printed in the United States of America .
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Preface
F or many years, we considered human errors or mistakes to be the cause of mishaps or problems. In the manufacturing industries, human error, under whatever label (procedures not followed, lack of attention, or simply error), was the conclusion of any quality problem investigation. Very often it was coupled with some kind of training activity (most frequently retraining) as corrective action. We even have an old adage— To err is human —to explain it.
The way we look at the human side of problems has evolved during the past few decades. Industrial psychologists and human reliability professionals took command during the investigation of catastrophic accidents, such as the Chernobyl, Challenger , and aviation accidents, and our view on human error changed. Now we see human errors as the symptoms of deeper causes. In other words, human errors are consequences, not causes.
Humans vary considerably in their capabilities and limitations. It is not easy to predict how they will behave, although an extensive body of knowledge regarding this subject has developed that helps us understand how humans interact with machines and systems.
The scope of this book may seem broad, and it does have widespread applications. However, its intent is to apply those known general principles to help prevent worker failures and managerial mistakes within any kind of industry or sector. Managers and organizations must incorporate in their decision-making processes considerations of why errors occur, what errors are likely to occur, and what can be done about them. Managing human errors is one of the main areas on which to focus when trying to improve safety and business performance within any kind of operation.
The primary objective of this book is to provide readers with useful information on theories, methods, and specific techniques that can be applied to control human failure. It is a book of ideas, concepts, and examples, many of them from the manufacturing sector. It presents a comprehensive overview that focuses on the practical application of the subject, specifically the human side of quality and manufacturing errors. For readers who are interested in how human errors and mistakes create accidents and huge disasters, there are numerous authoritative sources, some of which are included in the Bibliography of this book.
In other words, the primary focus of this book is human failure, including its identification, its causes, and how it can be reasonably controlled or prevented in the manufacturing industry setting. In addition to including a detailed discussion of human error (the inadvertent or involuntary component of human failure), we also devote a whole chapter to analyzing voluntary (intentional) noncompliance.
The topics throughout this book are interconnected. An effective approach to achieving a significant reduction in human failures requires both a profound knowledge of the subject and a holistic approach.
Chapter 1 provides an introduction to the human error topic, covering areas such as the importance of the subject and some astonishing statistics.
Chapter 2 focuses on the nature and variety of human error. To limit the occurrence of errors and improve their chances of detection and recovery, we must understand their cognitive origins and the circumstances likely to promote them.
Chapter 3 covers the aspect of intentional noncompliance or trying to understand why people violate rules. We also discuss sabotage.
Chapter 4 focuses on the main human factors affecting human performance, from organizational culture and adequate supervision and staffing to the design of the workplace and work documentation, including the influence of training, and explains how performance is directly influenced. This updated chapter includes two new sections. One discusses the importance and benefits of a strong and positive quality culture in the reduction of human failures, including errors. Another discusses the importance and benefits of people engagement to enhance the quality culture.
Chapter 5 discusses how organizations deal with human errors, and it has been enhanced with new sections about using consequences to modify behaviors and for commitment to resilience.
Chapter 6 covers the critical element of the investigation of human errors. A helpful diagnostic tool has been completely revised and updated with new categories.
Chapter 7 describes the root causes associated with human performance.
Chapter 8 presents a review of human errors and human factors within risk management and the benefits of an integrated approach with other risk management tools and techniques.
Chapter 9 explains how we can reduce the probability of human errors. A hierarchy of actions is presented along with an appeal to the use of checklists within our processes. Elements for mistake-proofing our processes are also discussed.
Chapter 10 presents a selection of topics, including the use of retraining as corrective action for human errors, and the effect of working from memory or multitasking on the occurrence of human errors. A section of this chapter is devoted to discussing a very popular topic within regulated industries: data integrity and good documentation practices.
Finally, Chapter 11 contains important closing remarks that serve as a summary of the most significant content of this book.
I am convinced that human failure reduction is a necessary objective that will improve individual, organizational, and social well-being. This book has been written in a direct style, using simple “industry” language with abundant applied examples and practical references.
I had three goals when preparing the manuscript of this book. All of them focus on you, dear reader. I wanted to:
1.Help you understand the human error concept.
2.Allow you to identify human factors affecting the performance of your processes.
3.Enable you to establish effective barriers and corrective and preventive actions related to those human factors.
Your comments are more than welcome at pepe.rodriguez@bec-global.com .
—José (Pepe) Rodríguez-Pérez
Puerto Rico

Acknowledgments
T his book is dedicated to thse in various disciplines who established the basics of understanding human failures. Their work has been integrated into this volume.

List of Acronyms
AAMI Association for the Advancement of Medical Instrumentation
ANDA Abbreviated New Drug Application
CAPA Corrective action and preventive action
CDC U.S. Centers for Disease Control and Prevention
FDA U.S. Food and Drug Administration
FMEA Failure mode and effects analysis
FMECA Failure mode, effects, and criticality analysis
FTE Fault tree analysis
HCI Human–computer interaction
HEP Human error probability
HRA Human reliability analysis
HRO High-reliability organizations
IOM Institute of Medicine
ISO International Organization for Standardization
NASA U.S. National Aeronautics and Space Administration
NTSB U.S. National Transportation Safety Board
PSF Performance shape factor
RLD Reference listed drug
THERP Technique for human error-rate prediction
TNA Training needs analysis
UDA U.S. Army Research Institute’s User’s Decision AID
WHO World Health Organization

1
About Human Error
Introduction and Some Statistics
To err is human.
Human error is a symptom, not a cause.
Good people plus bad systems = A recipe for error.
All of us have experienced human errors and mistakes. When we interact with machines or complex systems, we often do things that are different from our intentions. People make errors and mistakes because to err is human, as the adage explains it. Does this mean errors will inevitably happen from time to time and there is nothing we can do about it? Can something be done to better understand, and indeed control, this subject?
Prevention of human error is generally seen as a major contributor to the reliability and safety of processes and systems. On the other h