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HUMAN ERROR
PREVENTION
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Words and Terms Used: The following words and terms are used in this Bookinar and have specific management or technical meanings. In this and the next few pages, the explanation following each word or term is intended only to provide an indication of the meaning of the word or term. These pages do NOT constitute a glossary; these pages are NOT intended to provide definitions of the words or terms. The words and terms are defined upon first use in the Bookinar. 80/20 rule a generalization of the Pareto principle Accelerated life testing a technique for design assessment and corrective action verification Active error as a category of error based on the timing of its undesired effect Adequacy no more and no less than is necessary to do the job Administrative process barrier the 1st type of barrier Alert a type of Level 1 Barrier Ameliorate / amelioration the Level 3 Barrier Ameliorative corrective action the 2nd type of corrective action AND gate in a fault tree, all conditions needed for the next higher condition Apparent cause analysis a technique for root cause analysis As is / as found the configuration of a hardware item or the existing condition of a document Attitude an influence on behavior Attribute a defining element of a hardware item, process or human Audit an independent assessment of an item or process Availability a function of reliability and maintainability Bar chart a tool for data analysis Barrier the three levels of barriers to prevent, detect and mitigate / ameliorate error Barrier Level 1 for the prevention of error Barrier Level 2 for the detection of error or of the hazard activated by error Barrier Level 3 for the mitigation / amelioration of the undesired effect of error or the hazard Behavior an action that yields a result Belief a contributor to ones value(s) Binning combining end states in an event tree Blame spiral resulting in an ever worsening loss of communication and trust Boolean logic used in the construction of fault trees Causal factor the three types of causal factors Cause & effects analysis a technique for root cause analysis Caution a type of Level 1 Barrier Certification an independent attestation of qualification Change analysis a technique for root cause analysis Characteristic a defining element of an item, process or human Classification of defects a method of indicating the level of significance of a defect Classification of design characteristics to indicate the level of significance of an attribute Close-in-time bias a type of bias leading to non-conservative decisions Coaching a method of preventing error recurrence Cognition-based error the 2nd human error causal factor Common mode failure a failure resulting in the total loss of the benefit of redundancy Compensatory corrective action the 4th type of corrective action Condition reporting and corrective action tracking a method of preventing error recurrence Confirmation bias a type of bias leading to non-conservative decisions Conservative decision-making the 3rd field of focus Constructability a consideration for the design of a hardware item Containment a type of Level 3 Barrier Contributing cause the 2nd causal factor Co-piloting a type of operational loafing leading to non-conservative decisions Corrective action the four types of corrective action Corrective maintenance a type of maintenance Counteracting behavior a behavior to overcome error-inducing conditions Critical a classification of significance of a defect, design characteristic or undesired effect Culture a pattern of thought and behavior Data element a category of data Defect a non-conformance to a requirement for a hardware or process design characteristic Defective an item of hardware or a process that contains a defect Defense in depth the six levels of defense in depth or the six levels of opportunity Degradation influence a contributor to a failure mechanism Design attribute or characteristic a defining element of a hardware item or process Design margin a spread between a characteristics requirement and its maximum load Designated challenge(r) a behavior by which to counteract an error-inducing condition Detect / detection Barrier Level 2 Detection barrier failure Error Level 3 Direct cause the 1st causal factor Disposability a consideration for the design of a hardware item Document corrective action the 1st type of corrective action Dropping guard a type of operational loafing leading to non-conservative decisions Effectiveness adequacy and efficiency Efficiency adequacy at the least cost EHS&Q environmental (protection), (employee and public) health and safety, and quality EHS&Q culture a type of culture appropriately considerate of EHS&Q EHS&Q-conscious work environment an element of an EHS&Q culture Employee empowerment a counter to risky-shifting; a non-participative management style End state in an event tree Environmental (protection), (employee and public) health and safety, and quality EHS&Q Environmental qualification a consideration for the design of a hardware item Equipment barrier the 3rd type of barrier Error a behavior with an undesired result or effect Error categorization by type of behavior, timing of effect, significance, and causal factor Error the four levels of error Error Level 1 when necessary, the failure to prevent error Error Level 2 an initiating error Error Level 3 the failure to detect error or the hazard activated by error Error Level 4 when necessary, failure to mitigate the undesired effect of an error or hazard Error of commission an error category by type of behavior Error of omission an error category by type of behavior Error recurrence prevention the 4th field of focus Error-inducing condition anything that increases the probability of error Error-inducing condition-based error the 4th human error causal factor Error-inducing conditions & counteracting behaviors the 2nd field of focus Error-likely situation anything that increases the probability of error Escape a type of 3rd level barrier Event a classification of significance of an undesired effect Event tree a tool for design quality assessment and root cause analysis Extent of cause analysis a technique to find all locations of a given or similar cause Extent of problem analysis a technique to find all locations of a given or similar problem Fail-safe the most undesired kind of failure Failure mechanism a contributor to failure mode Failure mode the way by which a design characteristic or attribute fails Failure mode & effects analysis a technique for design assessment and root cause analysis Failure rate a measure of reliability Fault tree a tool for design quality assessment and root cause analysis Field of focus the four fields of focus for human error prevention Fitness for duty a human responsibility Fitness for use a term indicating quality Five Ds deterrents to preventive corrective action Five-part communication a behavior by which to counteract an error-inducing condition Flinch the inspection acceptance of a marginal defect Focus an element of situational awareness Free-riding a type of operational loafing leading to non-conservative decisions Frequency and similarity bias a type of bias leading to non-conservative decisions Functionability a consideration for the design of a hardware item Good practice a method providing an exceptional technical or economic benefit Groupthink behavior of individuals in a group leading to a non-conservative decision Hazard anything that can impart an undesired effect Hazard-barrier-effects analysis a technique for design assessment and root cause analysis Hazards & barriers the 1st field of focus Human barrier the 4th type of barrier Human corrective action preventive corrective action for non-conforming behavior Human error behavior leading to an undesired result or effect Human error causal factor the seven universally applicable reasons for error Human error clock a tool to provide a training opportunity Human error prevention the subject of this BookinarTM Human factors an element of human error prevention Human performance behavior yielding results Independence a contributor to objectivity Initiating action a direct cause of an occurrence yielding an undesired effect Initiating error Error Level 2 Initiating occurrence / initiating event in an event tree In-service inspection a method of maintaining the quality and safety of a hardware item Inspectability a consideration for the design of a hardware item Inspection a method of determining the acceptability of a item or process characteristic Inspection hold point a step in a process at which an inspection is required Institutionalizing corrective action a means of precluding the return to an undesired state Interpretation different understandings from the language in a procedure Intervention taking the opportunity to correct an undesired effect Investigation data collection as a prerequisite to root cause analysis Job analysis a means for identifying gaps between needed and available training Knowledge-based error the 1st human error causal factor Lagging PI a performance measure that does not enable timely intervention Lapse-based error the 7th human error causal factor Latent defect a defect that cannot be identified upon initial inspection or test Latent error a category of error based on the timing of its undesired effect Leading PI a performance measure that provides the opportunity for timely intervention Level of opportunity / level of defense the six levels of opportunity or defense Level of cognition the six levels of cognition Life a measure of reliability M the six Ms Maintainability a consideration for the design of a hardware item Major classification of significance for a defect, design characteristic, or undesired effect Malicious behavior sabotage in contrast to error Malicious compliance conformance knowing that an undesired effect will result Management oversight and risk tree analysis a technique for root cause analysis Manufacturability a consideration for the design of a hardware item Mean time to restore a measure of maintainability Minor a classification of significance of a defect, design characteristic or undesired effect Mitigate / mitigation Barrier Level 3 Mitigation barrier failure Error Level 4 Near miss a classification of significance of an undesired effect Node in an event tree Non-conformance a departure from a requirement Operability a consideration for the design of a hardware item Operating experience program a means of learning from conditions existing elsewhere OR gate in a fault tree, any one condition needed for the next higher condition Order bias a type of bias leading to non-conservative decisions Outward neutralizing a type of operational loafing leading to non-conservative decisions Overload bias a type of bias leading to non-conservative decisions Over-simplification bias a type of bias leading to non-conservative decisions Pareto principle of the distribution of wealth as described by Professor Wilfredo Pareto Pareto chart / Pareto diagram a tool for data analysis Part corrective action the 1st type of corrective action Peer inspection a type of inspection Peer review a type of document review Performance indicator / performance measure a presentation of quantitative grouped data Phonetic alphabet a behavior by which to counteract an error-inducing condition Place-keeping a behavior by which to counteract an error-inducing condition Poka yoke a technique for error prevention and detection Post-job assessment a behavior by which to counteract an error-inducing condition Precautionary principle a fundamental approach to employee and public safety Precursor a classification of significance of an undesired effect Pre-job briefing a behavior by which to counteract an error-inducing condition Pre-production item a thing used to assess design and manufacturing process quality Prevention Barrier Level 1 Prevention barrier failure Error Level 1 Preventive corrective action the 3rd type of corrective action Preventive maintenance a type of maintenance Probabilistic risk analysis a technique for design assessment or root cause analysis Probabilistic risk assessment same as probabilistic risk analysis Probabilistic safety analysis same as probabilistic risk analysis Probabilistic safety assessments same as probabilistic risk analysis Problem an error, anomaly or departure from logic Problem thing the three things in which a problem may exist Problem statement the various data elements necessary to adequately describe the problem Process flow diagram / process flow chart a tool for design analysis and root cause analysis Process qualification an action to help to assure the quality of a process Protection a type of 3rd level barrier Prototype item a thing used to assess design quality Qualification the ability to perform a specific task Quality of design an element of the scope of the total quality and safety function Questioning attitude an element of a EHS&Q-conscious work environment QVV question, verify and validate Recovery a type of 3rd level barrier Reflexive-based or reactive-based error the 5th human error causal factor Reliability a consideration for the design of a hardware item Reliability centered maintenance a type of preventive maintenance Risk an element of significance; effect times probability of recurrence of effect Risky-shifting a type of operational loafing leading to non-conservative decisions Root cause the 3rd type of causal factor Root cause analysis techniques to ID things to be corrected to prevent problem recurrence Run to failure a decision to not replace a hardware item prior to its failure Sampling plan an economically and technically beneficial scheme for inspection and test Satisficing a type of non-conservative decision-making Self-assessment an evaluation of ones own hardware, processes and performance Self-revealing problem a problem for which the undesired effect has been experienced Sentinel event an occurrence with a physical adverse effect on a patient in a hospital Significance of a design characteristic, of a defect, of an undesired effect Significance classification for a defect, design characteristic or undesired effect Significance level same as significance classification Single failure analysis a technique to avoid a single items failure from causing an event Situational awareness a behavior by which to counteract an error-inducing condition Six levels of opportunity / six levels of defense to avoid error from escaping the enterprise Skill-based error the 6th human error causal factor Spatial diagram a tool for data analysis Specificity the level of detail needed to retain technical and economic benefits of a method Standard data table to enable the grouping of data for performance and status measurement STAR a behavior by which to counteract an error-inducing condition Statistical process control chart a tool for data analysis Statistical t test to determine if there is a significant difference between sets of data Statistically significant difference for verifying the effectiveness of corrective action Stop work order an external behavior by which to counteract an error-inducing condition Surveillance a process assessment technique Systematic approach to training an approach to improve the effectiveness of training Task analysis a means for identifying gaps between needed and available training Taxonomy of human error causal factors the universally applicable reasons for human error Technical process barrier the 2nd type of barrier Testability a consideration for the design of a hardware item Three-part communication a behavior by which to counteract an error-inducing condition Time-line analysis a techniques for root cause analysis Time-out a behavior by which to counteract an error-inducing condition Top response / top event in an event tree, a system responding to a undesired challenge Track and trend for problems of lesser significance Truncation of an analysis Turn-over meeting a behavior by which to counteract an error-inducing condition Ultimate event in an event tree Undesired effect a result of an error or hazard activated by an error Unsharing a type of operational loafing leading to non-conservative decisions Urgency an element of significance Value chain diagram / value chain table / value stream a tool for analysis of a process Value-based error the 3rd human error causal factor Values contributors to attitude Verbalization a behavior by which to counteract an error-inducing condition Vital few the causes for which preventive corrective action resources should be applied Walk-down a behavior by which to counteract an error-inducing condition Warning as a 1st level barrier Workability a consideration for the design of a hardware item Working instrument a measurement device at the lowest level in the hierarchy of accuracy Working calibration standard a measurement device used to calibrate a working instrument The reader is referred to the Glossary of Terms published by the American Society for Quality.
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