Human Performance Troubleshooting Guide: Start Here [PDF]

Zitiervorschau

Causal Factor/Issue:

START HERE with each causal factor/issue and select or eliminate each category to find root causes.

HUMAN PERFORMANCE DIFFICULTY

EQUIPMENT DIFFICULTY*

NATURAL DISASTER / SABOTAGE

Pages 5-21

OTHER (SPECIFY)

*Note: Consider Equifactor™ Analysis EQUIPMENT / PARTS DEFECTIVE

DESIGN

TOLERABLE FAILURE

DESIGN REVIEW

DESIGN SPECS

REPEAT FAILURE

PREVENTIVE / PREDICTIVE MAINTENANCE

MANAGEMENT SYSTEM

PROCUREMENT PM NI MANUFACTURING

Specs NI

Design Not To Specs

Problem Not Anticipated

Independent Review NI

equipment environment not considered

Human Performance Troubleshooting Guide (15 Questions)

HANDLING

management of change (moc) NI hazard analysis NI

Was a person excessively fatigued, impaired, upset, bored, distracted or overwhelmed?

Yes

PM for Equip NI

QUALITY CONTROL

HUMAN ENGINEERING WORK DIRECTION

corrective action NI corrective action not yet implemented trending NI

NI = NEEDS IMPROVEMENT May also substitute LTA (Less Than Adequate) or PIO (Potential Improvement Opportunity) Team Performance

Pages 22-31

Directions: Answer all questions and then refer to the indicated Basic Cause Categories on the back of this sheet to investigate the causes of the problem.

No PM for Equip

STORAGE

Basic Cause Categories (on back) to investigate

Individual Performance

Corrective Action

Basic Cause Categories (on back) to investigate

Pages 31-33 Did verbal communications Yes or shift change play a role COMMUNICATIONS in this problem?

WORK DIRECTION Should the person have had and used a written procedure but did not?

Yes

Yes PROCEDURES HUMAN ENGINEERING

PROCEDURES

Were alarms or displays to recognize or to respond to a condition unavailable or misunderstood?

Yes

COMMUNICATIONS

HUMAN ENGINEERING

Were displays, alarms, controls, tools, or equipment identified or operated improperly?

TRAINING PROCEDURES

Basic Cause Categories (on back) to investigate

Management System Pages 33-35 Yes

HUMAN ENGINEERING Did the person need more skill/ Yes knowledge to perform the job or to respond to conditions or to understand system response?

Revised 3/20/00 Copyright © 2000 by System Improvements, Inc. Knoxville, Tennessee, USA All Rights Reserved Duplication Prohibited

WORK DIRECTION

Yes

Yes

Did work involve repetitive motion, uncomfortable positions, vibration, or heavy lifting?

Was communication needed across organizational boundaries or with other facilities?

TRAINING COMMUNICATIONS

Yes

Was a mistake made while using a procedure?

Was work performed in an adverse environment (such as hot, humid, dark, cramped, or hazardous)?

Did failure to agree about the who/what/when/where of performing the job play a role in this problem?

Was a task performed in a hurry or a shortcut used?

MANAGEMENT SYSTEM WORK DIRECTION

TRAINING WORK DIRECTION

Had management been warned of this problem or had it happened before?

Yes

Yes Yes HUMAN ENGINEERING

Were policies, admin. controls, or procedures not used, missing, or in need of improvement?

MANAGEMENT SYSTEM

MANAGEMENT SYSTEM WORK DIRECTION PROCEDURES

TRAINING Yes HUMAN ENGINEERING

Should an independent quality control check have caught the problem?

Yes QUALITY CONTROL

WORK DIRECTION Continue on back by analyzing the indicated Basic Cause Categories

TapRooT® Root Cause Tree® Basic Cause Categories PROCEDURES Pages 36-52

Not Used / Not Followed no procedure procedure not available or inconvenient for use procedure difficult to use procedure use not required but should be

QUALITY CONTROL

TRAINING Pages 53-61

No Training

Followed Incorrectly

Wrong typo sequence wrong facts wrong situation not covered wrong revision used

task not analyzed

details NI data/computations wrong or incomplete

no learning objective

no checkoff

No Inspection

Understanding NI

format confusing > 1 action / step excess references mult unit references limits NI

graphics NI

second checker needed

Pages 62-67

learning objective NI lesson plan NI

decided not to train

checkoff misused misused second check ambiguous instructions equip identification NI

inspection instructions NI

inspection not required

inspection techniques NI

no hold point

instruction NI practice/ repetition NI testing NI

missed required training

QC NI

hold point not performed

foreign material exclusion during work NI

continuing training NI

MANAGEMENT SYSTEM

COMMUNICATIONS Pages 68-76

No Comm. or Not Timely comm. system NI late communication

Pages 77-92

Misunderstood Verbal Comm.

Turnover NI

standard terminology not used

no standard turnover process turnover process not used turnover process NI

Standards, Policies, or Admin Controls (SPAC) NI no SPAC

standard terminology NI

not strict enough

repeat back not used

confusing or incomplete

long message

technical error

noisy environment

drawings/ prints NI

SPAC Not Used comm. of SPAC NI recently changed enforcement NI no way to implement

Oversight / Corrective Employee Action Relations corrective infrequent action NI audits & evaluations corrective (a & e) action a & e lack not yet depth implemented a & e not trending NI independent

accountability NI

HUMAN ENGINEERING

employee communications NI employee feedback NI

WORK DIRECTION

Pages 93-112

Pages 113-124

Human - Machine Interface

Work Environment

labels NI arrangement/ placement displays NI controls NI monitoring alertness NI plant/unit differences excessive lifting

Complex System

housekeeping NI hot/cold

knowledgebased decision required

wet/slick

monitoring too many items

lights NI

Non-Fault Tolerant System

Preparation

errors not detectable errors not recoverable

no preparation work package/ permit NI pre-job briefing NI

Selection of Worker

Supervision During Work

not qualified

no supervision

fatigued

crew teamwork NI

upset

noisy

walk-thru NI

substance abuse

obstruction cramped quarters equipment guard NI

scheduling NI

team selection NI

high radiation/contamination

tools/instruments NI NI = NEEDS IMPROVEMENT May also substitute LTA (Less Than Adequate) or PIO (Potential Improvement Opportunity)

lock out/ tag out NI fall protection NI Revised 3/20/00 Copyright © 2000 by System Improvements, Inc. All Rights Reserved – Duplication Prohibited