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    Human: - Divya Krishnakumar

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    Gretchen Laurente
    The document discusses human error, including its causes and resolutions. It begins by defining human error as mistakes that cause accidents or bad outcomes. It then explores common causes like mental overload from too much information, poor work environments, ingrained habits, lack of understanding, and flawed decision making. Finally, it proposes solutions such as simplifying processes, improving training and decision tools, managing stress, and using habits and cues to reinforce better behaviors. The overall message is that human error is inevitable given human limitations, so systems must be designed simply and practically to account for human factors.

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    Human: - Divya Krishnakumar

    Uploaded by

    Gretchen Laurente
    31 views35 pages
    The document discusses human error, including its causes and resolutions. It begins by defining human error as mistakes that cause accidents or bad outcomes. It then explores common causes like mental overload from too much information, poor work environments, ingrained habits, lack of understanding, and flawed decision making. Finally, it proposes solutions such as simplifying processes, improving training and decision tools, managing stress, and using habits and cues to reinforce better behaviors. The overall message is that human error is inevitable given human limitations, so systems must be designed simply and practically to account for human factors.

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    The document discusses human error, including its causes and resolutions. It begins by defining human error as mistakes that cause accidents or bad outcomes. It then explores common causes like mental overload from too much information, poor work environments, ingrained habits, lack of understanding, and flawed decision making. Finally, it proposes solutions such as simplifying processes, improving training and decision tools, managing stress, and using habits and cues to reinforce better behaviors. The overall message is that human error is inevitable given human limitations, so systems must be designed simply and practically to account for human factors.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    31 views35 pages

    Human: - Divya Krishnakumar

    Uploaded by

    Gretchen Laurente
    The document discusses human error, including its causes and resolutions. It begins by defining human error as mistakes that cause accidents or bad outcomes. It then explores common causes like mental overload from too much information, poor work environments, ingrained habits, lack of understanding, and flawed decision making. Finally, it proposes solutions such as simplifying processes, improving training and decision tools, managing stress, and using habits and cues to reinforce better behaviors. The overall message is that human error is inevitable given human limitations, so systems must be designed simply and practically to account for human factors.

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    You are on page 1of 35

    HUMAN

    - Divya Krishnakumar
    PURPOSE OF THIS SESSION

    1. Understand Human Error

    2. Underlying causes of Human Error

    3. Resolution of Human Error


    WHAT DO YOU THINK ABOUT THESE IMAGES?

    Can we smoke
    quietly?
    WHAT DO YOU THINK ABOUT THESE IMAGES?

    I only have
    a human
    mom.

    ¯\_( ツ )_/
    ¯
    WHAT DO YOU THINK ABOUT THESE IMAGES?

    Oops, Sorry!
    WHAT DO YOU THINK ABOUT THESE IMAGES?

    Wait. So
    where’s
    the Bus
    Stop?
    WHAT DO YOU THINK ABOUT THESE IMAGES?

    Is a sorry
    sufficient here?
    UNDERSTANDIN
    G HUMAN
    ERROR
    WHAT IS HUMAN ERROR?

    •Human error is when someone makes a


    mistake which causes an accident or causes
    something bad to happen.

    What could be a few examples from


    your work area?
    STORIES IN AVIATION
    • The Gimli Glider – Air • Air Ontario Flight 1363
    Canada’s first Boeing 767

    Who was at fault?


    TO ERR IS HUMAN

    • Studies tell us that EVERYONE commits


    errors

    Human behaviour Human error is rarely People want to do


    explains human error random. the right thing.

    Therefore, looking at why and It is connected to the tools, We do what makes sense to us
    how we behave in certain tasks and environment. That is, at the time given our focus of
    situations helps to explain why it can often be predicted, and in attention, knowledge,
    we do what we do. some situations, is inevitable. resources, time and goals
    PERFECT HUMANS NEED PERFECT SYSTEMS
    • Are systems and SOPs designed to prevent errors?

    • People must create compliance using tools, systems


    and technology

    Therefore, systems that depend on


    perfect behavior are
    fundamentally wrong.
    EXERCISE: Select one SOP from
    your respective area where you find
    maximum NC. Try to find out
    factors that cause the NC other
    than human
    error
    .
    CONTRIBUTING FACTORS FOR SOP NON-
    COMPLIANCE
    Over complexity = confusion

    Written for the


    Written by the
    auditor and not the
    wrong person
    user

    Don’t reflect reality


    Too many words
    and ‘best practice’

    Culture of Non- Poor layout, information inaccessible.


    compliance Insufficient pictures, schematics, drawings
    “JUGAAD” CULTURE
    Most times, operators do the
    job against all odds and do it
    well. – The Great Indian
    ‘Jugaad’ Culture.

    Following SOP and then doing


    the task becomes impossible
    with incompetent SOP and/or
    tools and environment.

    Most days, it holds the fort, but


    some unfortunate day, it
    doesn’t go as planned…
    ROOT CAUSE OF ERROR

    Factors leading to
    Human Error
    Human Error

    Surface of the
    Actual Problems
    Problem
    TRAINING – NOT A
    SOLUTION!

    TRAINING
    Factors leading to
    Human Error
    Human Error

    Surface of the
    Actual Problems
    Problem
    REGULATORY EXPECTATIONS

    EU GMP Guidelines, Vol 4, Chapter 1

    What do you think this means?


    APPROACHING HUMAN ERROR RESOLUTION

    “People don’t intentionally make mistakes. They do


    the best they can with what they have
    available.”

    Human error is the consequence of a


    desire to get the job done
    UNDERLYING
    CAUSES OF
    HUMAN ERROR
    WHY DO PEOPLE MAKE MISTAKES?

    Mental Overload

    Work Environment

    Habituated Behaviour

    Poor Understanding

    Decision Making Issues


    1. MENTAL OVERLOAD

    Undefined
    practices/ too
    much choice
    Too much text

    Information
    overload

    Extreme Multi-
    tasking
    2. WORK ENVIRONMENT

    • GIGO : Garbage in, Garbage


    out.
    • Stress, Fatigue, Dehydration
    • Ergonomics - Comfort/
    Discomfort of the operator
    • Distractions – Noise, Sounds,
    Smells etc.

    Brain has limited capacity. Particularly what we call “Executive brain” – the brain we use
    to try and understand, and for logical analysis and calculation
    3. HABITUATED BEHAVIOUR

    • Habits are patterns that allow us to


    act without conscious thought

    • Habits are a way of survival -> Free


    up thinking space.

    • Once formed, its impossible to break.


    You can only replace!

    • The strongest habit is always default.


    4. POOR UNDERSTANDING
    • Two areas :
    1. Poor understanding
    (education)
    2. Lack of risk awareness
    (consequences)

    • Ineffective training

    • Trainings are done but there is


    failure to habituate it.
    5. DECISION MAKING ISSUES

    1.

    2.

    3.
    REDUCING
    HUMAN ERROR
    APPROACHING HUMAN ERROR RESOLUTION

    “Science of
    Simplification”

    Simplification is hard work. But it would


    significantly reduce problems related to
    human error.
    1. MENTAL OVERLOAD - SOLUTIONS

    Undefined
    User Centered
    practices/
    Designs &too
    much
    Precise choice
    practices Better design of
    Too much
    SOPs andtext
    Batch
    records

    Information
    Standardization
    Minimize need overload
    Multi-tasking
    to multi-task
    2. WORK ENVIRONMENT - SOLUTIONS

    • Stress
    GIGO –: Garbage
    Leads to in,
    adrenaline
    Garbage
    rush
    out. – FFF response and
    ‘cloudy’ thinking
    • Stress, Fatigue, Dehydration
    • Ergonomics – Comfortable
    • Ergonomics - Comfort/
    atmosphere prevents less
    Discomfort
    distractions of
    andthe operator
    aids work –
    • ISO requirement
    Distractions – Noise, Sounds,
    • Shift
    Smellstimings
    etc. (might have
    increased error rates) Monitor
    shift timings continuously.

    Avoiding
    Brain stresscapacity.
    has limited will lead to
    Particularly what we call “Executive brain” – the brain we use
    to try and understand,
    reduction and for
    in reverting tological
    old analysis and calculation
    3. HABITUATED BEHAVIOUR - SOLUTION

    • Direct and analyze every mistake


    • Habits are patterns that allow us to
    quickly
    act without conscious thought
    • Precise practice and feedback (coach)
    • • Processes
    Habits aretoahave
    way good (simple
    of survival ->and
    Free
    standardized) design. Easy to form
    up thinking space.
    habits with this.
    • • Use
    Oncetheformed,
    habit loop to enforce new
    its impossible to break. HABIT LOOP
    habits.
    You canColours/ symbols/ sounds can be
    only replace!
    good cues. Design SOP and train in a
    way to incorporate these.
    • The strongest habit is always default.
    4. POOR UNDERSTANDING SOLUTION
    • Two areas :
    1. Poor understanding
    (education)
    2. Lack of risk awareness
    (consequences)

    • Ineffective training

    • Trainings are done but there is


    failure to habituate it.
    5. DECISION MAKING ISSUES - SOLUTION

    Use systematic approach – decision should be


    1. simple, practical and evaluated

    2. Fact based and risk-based decisions to be made

    Use tools & techniques – FMEA, Information


    3. management, decision trees etc.
    EXERCISE: FORM
    GROUPS OF 5
    Take an Error cause and
    find solutions. Try to
    simplify things.
    THANK
    YOU

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