Not many times people ask about our logo and since we just revamped it, we would like to talk about it. Logos are a symbol adopted by an organization to identify its products and services. Our logo has 3 commas, each one of them encapsulated in a circle. The circle represents the organization, and the commas are us. Commas are marks of punctuation used for indicating a division in a sentence, especially when such division is accompanied by a slight pause or is to be noted to give the order to the sequential elements of the sentence. What does that have to do with productivity and human error, or even results? Well… The answer is a lot!
Whenever an error event occurs, corrective and preventive actions (CAPA) must be developed to make an organization’s systems stronger. A company will create systems to detect similar future errors or events, which will serve as the alarm that triggers corrective action and recovery.
CAPA procedures should describe what the data sources are, how data is collected, as well as by whom, when and how it is routed to the CAPA system. Procedures can be conducted manually or electronically; there can be separate procedures for collecting data and for evaluating the root cause. The sources of information will vary, but at some point all of the data with the results of the investigation must flow into CAPA. Then, recommended and approved actions can be taken and implementation and verification of those actions can be documented and tracked.
Three Boeing employees failed to follow the rules and created a dangerous fire hazard aboard the world’s most recognizable jet. To read the complete informative article please click here.
So yes, this happened, TO AIR FORCE ONE!. It was human error so we investigated.
Read below the root cause codes and recommendations from our end.
Past errors, if they are not found and fixed, are often predictive of future mistakes. This is why companies must track and trend errors in the manufacturing environment. The causes of the errors must be identified, categorized and analyzed so that they can be dealt with in a systematic way. For instance, if it determined that most of a company’s errors stem from poor SOPs, then the company can put a revision of its SOPs at the top of its action plan. Continue reading
With an understanding of what human error is and how to root it out, companies can focus on what they can do besides training to reduce and prevent error on the manufacturing floor. Among the things that companies can do are improve, prepare and design manufacturing facilities for humans.
Automation has allowed manufacturers to make great strides in reducing variability in their processes, but there will always be moments when humans have to intervene even in automated environments. So companies must be engage in human factors engineering when designing and improving its systems in order to reduce human error.
In addition to the Root Cause Determination Tool, there are other useful tools for dealing with human error. One is the Cognitive Load Tool, which is derived from the Root Cause Determination Tool. The Cognitive Load Tool, shows the cause category, near root cause and the root cause of the problem. It could be called, for example, a protocol for evaluating. It could be used in startup or in process improvements, because when a company makes process changes, if it is not careful, it could inadvertently create conditions that lead to errors. The prediction tool can help companies head off mistakes before they occur.
The prediction process also involves use of the Human Error Prediction Tool Assessment Form. For instance, a company may want to evaluate its procedures, human factors engineering, training, immediate supervision, communication or documentation using the prediction tool. The tool allows categories such as these, as well as multiple tasks, to be assessed and evaluated based on whether specified conditions exist. Continue reading
The concept of error that many are familiar with comes from tests taken. A wrong answer represents an error. In general, a wrong answer comes from not knowing the right answer… The concept of error in human error reduction in manufacturing is much broader.
There are many instances in which an error occurs, and everyone knows that it is an error. And, in fact, everyone knows the right answer. So why was the error made? Answering that question is at the heart of human error reduction techniques. And there are many possible answers. Listed below are a few:
- Poor lighting or other environmental impediments
- Communication failures
- Excessive workload
- Deliberate overriding of established procedure Continue reading
Root cause analysis (RCA) is a step-by-step method of investigation that should lead to the underlying causes of undesirable events within an organization. RCA is the way to help trace the progression of events that led up to an incident or human error, much like solving a crime.
RCA can be performed for an organization’s internal benefit. Or an RCA may be done if an organization is the subject of an FDA for-cause inspection, when a series of adverse events has occurred that have been reported to the FDA, or FDA inspections have revealed problems. Whatever the situation, RCA provides feedback on a company’s operational performance. Through its use, an organization can identify improvements that must be made to prevent and mitigate consequences to adequately control risk.
Most manufacturing facilities have a variety of defenses in place against mistakes and deviations, such as job qualifications, SOPs, training, investigations and verifications as well as batch records review and testing. While these all help to prevent adverse events, they are all created by humans and, therefore, subject to error.
Whenever there is a deviation or an event, it is because one or more of these defenses have failed. Organizations can combat problems by identifying system weaknesses and making them stronger. This can be done by finding minor events that could be the precursors to much larger events those that have not yet resulted in losses. Then, pinpoint the reasons why these minor events happened and correct them. It is similar to what is known in safety systems as near misses.
Research shows that 80 percent of human error can be controlled by managing human factors. This can be done by managing any aspect of the workplace or job that makes it more likely for a worker to make an error. In other words, human factors must be implanted into systems used by employees.
The remaining 20 percent of human errors can be controlled by managing the acquired behaviors of humans, otherwise known as habits, or the internal variables of human performance. So there are external elements, which are systems, and then internal elements, which are things that happen inside human beings. As a result, controlling human error is done 80 percent by managing systems and 20 percent by managing people.