Investigating human error usually begins with collecting evidence, uncovering facts, putting together the story of what happened and then discerning the why. The main goal is to prevent occurrences from happening again. Essentially, to fix the problem. When the root cause points to Operator or Human Error, there is a tendency for hindsight bias to cloud our thinking. Thoughts of “should of, could of, would of” rush to the fore front of our mind. The new view of human errors interrupts the blame game and reshapes our perspective towards the operator’s point of view at the moment the incident occurred. As investigators, we need to understand how the error occurred and to explore if our system interfaces are a contributing factor to the root cause. And then align appropriately matched corrective actions that map back to the true root cause.
This blended training course will provide updated insights and best practice techniques to help investigators get beyond operator error-retrain-repeat incidents to include pre-course assignment, webinar content/participation, and post-course assignment.
Attendees will participate in activities and exercises, covering these content sections:
- Training Root Cause Analysis (Pre-course assignment to be completed 1 week prior to virtual training course)
- New View of Human Error (virtual content)
- 3 Classic Sets of Human Errors (virtual content)
- 11 System Interfaces as Factors (virtual content)
- Corrective Actions Aligned with Human Error Categories (Post-course assignment to be completed within 30 days of virtual training course)
Please note that familiarity with Root Cause Analysis and CAPA Investigations is highly recommended prior to attending this training course.