January 15, 2020 | Mark Paradies

What is Stopping Human Error All About?

You Can't Say That!

What is Stopping Human Error All About?

When I wrote a book titled Stopping Human Error, several people told me:

You can’t say that!

They said that it was impossible to stop ALL human errors.

Of course, they were right.

But the title of the book isn’t:

Stopping ALL Human Errors.

The point of the book and our new course (also titled “Stopping Human Error”) is that you can stop some human errors and thereby prevent major accidents, significant losses, patient safety incidents, and other costly failures.

The History of Human Performance Improvement

Back in the 80s, the nuclear industry started a push to improve nuclear plant performance. This push was led by the Institute of Nuclear Power Operations (INPO). They had some good ideas. I actually participated in the review of their HPES System and contributed the Management System evaluation piece.

With the good ideas came some bad ones. Some of the techniques that were developed and spread throughout the nuclear industry were not very effective. They were blame oriented and they were NOT based on human factors principles.

Also, in an attempt to cover all problems, the set of tools became unwieldy. There were too many tools with too many triggers. They were just too hard to implement.

Finally, even with a large number of tools, they overlooked many important human factors principles and, thereby, failed to correct human factors problems that cause many errors.

This led to some being dissatisfied with the human performance improvement program (including many operations folks that saw it as blame oriented).

Going Beyond the 80s Human Performance Improvement Program

Even though over the decades since their invention, INPO and others have tried (and did) improve the industry’s human performance improvement efforts, the basic weaknesses that haunt the program still remain. These weaknesses were brought to other industries when consultants brought the nuclear industry practices to other industries.

We have seen many TapRooT® Users struggle to implement human performance improvement programs and never really figure out why they weren’t making the progress they thought they should achieve. And people in the field become jaded because they kept being told to:

“Have a Questioning Attitude”

OR

“Use STAR”

OR

“Have Attention to Detail”

OR

“Watch for Error Traps and Precursors”

OR

“Validate Their Assumptions”

These are all “blame-oriented” tools that were built into many human performance improvement programs.

I watched this with concern as we built the grandaddy of all human performance improvement programs, TapRooT® Root Cause Analysis. Many TapRooT® Users didn’t understand that they had the basis for their proactive human performance improvement program built into their reactive root cause analysis system.

Finally, I decided that we need to write a book and develop a course to show how to combine the human factors best practices that are built into TapRooT® Root Cause Analysis with other proactive techniques (some from the nuclear industry, some from other places) to build a custom program to Stop Human Errors.

This work took several years and comes as the final book in the ten-book set that documents the TapRooT® System.

The book is at the printers and should be out just in time for the 2020 Global TapRooT® Summit.

The first course to help you learn the techniques and build an effective, custom process to improve human performance at your facility will be held on March 9-10 (just before the TapRooT® Global Summit) at the Horseshoe Bay Resort near Austin, TX.

What’s in the Stopping Human Error Course?

The Stopping Human Error Course explains how to use the human performance best practices built into the TapRooT® System and the best practices from the nuclear industry and other industries to develop a human performance improvement program to stop human errors. It also explains the problems built into some of the common nuclear industry techniques so that you can make an intelligent decision which techniques NOT to use.

This isn’t a “one size fits all” program. You will use your knowledge of the issues that your facility faces to pick just the right techniques to get the most bang-for-the-buck for your implementation efforts. And you can decide which techniques you will implement first and the pace for your improvement so you don’t overwhelm your managers and workers with too many new initiatives at once.

At the end of the course, participants in the course will present their improvement plan to benchmark it with other participants and get feedback from the instructors so that the ideas they bring back to work to their managers to implement have been refined and are ready for management approval.

Here is the course outline:

Course Outline

Day 1 (8:00am to 5:00pm)

  • Foundations of Improving Human Performance
  • Resilience and Safeguards
  • Using TapRooT® Root Cause Analysis for Reactive Problem Analysis
  • Using TapRooT® Human Performance Best Practices Proactively
    • Human Engineering
    • Procedures
    • Training
    • Communications
    • Management System
    • Work Direction
    • Quality Control
  • Stopping Normalization of Deviation
  • Pre-Job Hazard Analysis
  • Pre-Job Briefs
  • Personal Safety Assessment

Day 2 (8:00am to 5:00pm)

  • Applying Critical Human Action Profile Proactively
  • Human Performance Improvement Technology
    • Procedure Use/Adherence
    • Place Keeping
    • Independent Verification
    • Three-Way Communication
    • Pre-Job Brief
    • Personal Safety Assessment
    • Observation and Coaching
    • Post-Job Brief
    • Concurrent Verification
    • Questioning Attitude
    • Stop-Think-Act-Review
    • Time Out
    • Attention to Detail
    • Management of Change
    • Error Traps and Precursors
    • Validate Assumptions
    • Do Not Disturb Sign
    • Conservative Decision Making
  • Admiral Rickover and “Facing the Facts”
  • Which Tools Will Work Best for You?
  • Sample Plan/Suggested Plan
  • Customizing Your Plan
  • Present Your Plan, Benchmarking, and Feedback

With the exercises built-in to try some of the techniques, this will be an active, quick-moving 2-day course.

If you would like to:

  • Evaluate your current human performance improvement program, or
  • Develop a custom program from scratch to help you Stop Human Errors

then you need to register for this course NOW!

Are You Ready for More?

The 2-Day Stopping Human Error Course is just the start of your performance improvement learning. On March 11-13 at the same location is the 2020 Global TapRooT® Summit.

The Summit includes the Improving Human Performance Track where you can benchmark and hear about best practices from industry leaders. In addition to the five Keynote Speakers, you can participate in eight Best Practice Breakout Sessions (from 30 to choose from). The eight that are included in the Improving Human Performance Track are:

  • Human Performance Best Practices
  • What’s Stopping Human Error All About?
  • Automation and Awareness
  • Lessons Learned from Space
  • Improving Your Manufacturing Practices
  • CHAP Workshop
  • Where Does Discipline Fit In During Investigations
  • Roadmap to Success

To see the complete Summit schedule and all the best practice sessions to choose from, visit:

https://summit.taproot.com/schedule

One more tip … You can SAVE $200 off the combined course/Summit price when you register for both at once. For registration see:

https://summit.taproot.com/register

Don’t wait. Seats in the course are limited. Register today!

Here are Mark and Benna discussing what stopping human error is all about…

(This video works even though the preview picture is not working.)

Categories
Courses & Training, Human Performance
Show Comments

4 Replies to “What is Stopping Human Error All About?”

  • Chuck(Chan-Ho) Tae says:

    I’m Korean and I’m working at oil company as a safety engineer. I’m interested in the book you introduced,”Stopping human error”. It is difficult to attend the training course, but can I buy the book separately?

  • Tim McGrath says:

    Mark,
    I haven’t looked at Tap Root since 2006 because it was light on for human performance so I opted to use other methodologies. Please can you share how you have modified the sheet and the guidebook to improve the ability of RCA Facilitators to get to the root cause?

    • Mark Paradies says:

      I see that you went to a 2-Day TapRooT® Course back in 2006. That is a basic course and we don’t explain the human factors link in TapRooT® in that course. It is built-in and easy to use and doesn’t require any special explanation to get the benefits from the technique.

      The 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course does a much better job explaining all the human performance analysis concepts built into the TapRooT® System.

      The new Stopping Human Error book and course explains the link in even more detail as well as other techniques to improve human performance.

      I am one of the developers of TapRooT® and my background is in Human Factors. Here is some of my experience:

      Mark Paradies has 40 years of experience in high-reliability organizations, process safety, incident investigation, human factors, 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. Mark worked with Linda Unger and Dr. Paul Haas on a contract to develop the Nuclear Regulatory Commission’s Human Performance Investigation Process. 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 in Nuclear Engineering with an emphasis on Human Factors from the University of Illinois (1985)
      • 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 Human Performance Evaluation System (HPES) (1986)
      • Co-Developer of the TapRooT® Root Cause Analysis System (1988-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
      • Author of the book, Stopping Human Error (2020)

      For more on the human factors concepts built into TapRooT®, see:

      https://www.taproot.com/about/history/

      I hope that helps you understand the strength of the knowledge of human factors and human performance analysis that is built into the TapRooT® Root Cause Analysis System.

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