error management photocopier

7/29/2019 Error Management Photocopier

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Error Management

An example for aviation -

the office photocopier


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Error Management

This presentation is designed for self study, or as a formal presentation, or the basis of a practical exercise

undertaken in the office.

It is based on the paper Error Management combating omission error through task analysis and good reminders by J Reason, EmeritusProfessor Department of Psychology, University of Manchester

Last user at nightswitch off after use


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Introduction

Leaving out steps in a task is the single most common humanerror.

This presentation shows how it is possible to identify commonerrors and, with simple memory aids (SOPs) how these errors

may be avoided or their effect mitigated.

The principles of error management shown in this example canbe applied to most operations in aviation.

Making errors is a fact of life, butrecovering them is quite another matter.


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Error the unintended action or inaction

Humans are prone to making errors - a general result of theunique human ability to think and make judgement.

We all make errors; this is not something to be blamed for; butto be investigated as a sign of problems elsewhere.

Errors them selves are not necessarily bad, we can learn fromthem, but their effects may in the extreme be fatal.

We cannot remove all errors, but we can prevent some and

reduce the effect of others this is error management.


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Error Management

Before we can manage error we have to identify what the

error is,

then find either the source or nature of the error,

or the opportunity for error to occur.

Build defences to prevent the error occurring,

or mitigate the effects of the error.

Finally check that the defences work

RISK from errors avoid, contain, mitigate


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Error Management

Principles of error management. RISK

Review the overall task

List all of the steps, sub steps and loops

Identify steps that could be missed

Conduct a survey

Involve a cross section of people

Select a good defensive

A mental reminder

Keep records

Periodic reviews

RI

SK


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Review the overall task - 1

1. Prepare photocopier

Switch onWait for warm-up

2. Select number of copies

3. Prepare first page of original for copyingRaise lid

Place page in position on the glassClose lid

4. Start copying cyclePress start switch

Ensure that the original does not move

5. Check quality of photocopyIf OK, go to step 6

If not OK, select appropriate corrective action

Put in more copy paper

Remove paper jam

Readjust position of original

Adjust toner setting

List all of the steps


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Review the overall task - 2

6. Remove copied original and replace with next page

Raise lidRemove copied originalReplace with next page to be copiedClose lid

7. Repeat steps 4 6 until all pages are copied

8. Remove last page of the original

9. Check that all pages have been copied satisfactorily

10. Switch off photocopier

11. Gather up all materials and depart


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Identify steps that could be missed

Table of errors; most often at the topPlace original wrongly

Leave last page of original *

Copy page already copied

Fail to check copy quality *

Copy selector failures *

Fail to copy all pages *

Leave personal items behind *

Fail to log out or take card *

Lift lid at wrong time

Dont remove all copies, etc *

Fail to insert card at outset *

Fail to allow warm up *

Activate cycle without original *

Fail to switch on copier *

Switch off before completion

* Items involving missed steps

Conduct a survey

Involve a cross section of people


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Select a good defence

A good reminder should:-

Catch the attention at the critical time

Positioned as close as possible in time and space to the

location of the action

Inform about the when and where of the item to beremembered

Inform regarding what has to be done

A mental reminder

Ask the users, they have learnt by their mistakes

Count off the number of actions/tasks that needto be done


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A good defence for a photocopier

Reminders (defences) from a survey of users:

Notes and post-its (65.1%)

Diaries (57.3%)

Lists (55.5%)

Writing on hand (43.8%)

Object positioning (41.8%)

Getting others to remind them (34.9%)

Calendars and timetables (31.5%)

Mental checking (8.2%)

Mental rehearsal (6.8%)

Forming associations (6.2%)

Mental visualising (4.1%)

Clocks and watch alarms (3.4%)

SOPs

Cross check

Checklists

Training


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Keep records

Conduct regular audits

Are the defences working?

Use the procedure assessment tool

Can a defence be applied to other tasks?

Common tasks or SOPs

Those who are engaged in the task areoften the best people to design and applya defence.

Those who conduct the task shouldown any procedure relating to adefence.

link
http://www.skybrary.aero/bookshelf/books/635.pdfhttp://www.skybrary.aero/bookshelf/books/635.pdf


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Error Management

Set up an error management programme

Evaluate all tasks and activities in which missed steps are likely to

have serious consequences or which have a history of error

Review the task or activity in a practical sequence of steps

Asses each step for possible error, survey several users

Prepare a customised reminder standard operating procedure

Use a good reminder:-

Catch the attention at the critical time

Positioned as close as possible in time and space to the location of the action

Information about the when and where of the item to be remembered

Information regarding what has to be done

Count off the number of actions/tasks that need to be done

Reminders need regular renewal


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e.g

Prevent missing out a step

Checklist design

SOP

Cross check / monitoring

Secret papers dual checks


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Check and recheck

Technical innovation allows new opportunity for error

Always review SOPs with any change of equipment

Remember that the photocopier repair mans name is Murphy

People introduce error, by design of equipment or by process

andWhy is the toner always low when you wish to use

the copier?


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Technical innovation allows new opportunity for errorAlways review SOPs with change of equipment

The photocopier repair mans name is Murphy

People introduce error, by design of equipment or process

error management photocopier

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