新编文档-Chapter-19-Error-Reduction-Mercer-University19章误差减少美世大学-文档

Chapter17:ErrorReductionERROR:Aneventwhenanactionotherthandesiredtakesplace.Sequence:Consideraccidentstobepredictableandpreventable.i.e.,breakthesequenceNormality

error

accident

minorloss

majorloss

catastropheISE311-171Errorreduction

cognitiveergonomics.Justificationsofergonomicscenteraround…ReductionofphysicalstressReductionoferrors(waste)BenefitsofreducingerrorsImprovessafetyImprovesqualityImprovesproductivityISE311-172CausesoferrorsPoordesignofequipmentPoormanagementofequipmentPoorproceduresPoortrainingOtherfactorsISE311-173ErrorsintheworkplaceCostsRangefromsecondsoftimetoinjuryanddeath.Includecleanup,fines,lossofmarketshare,legalcosts.Aredifficulttoquantify.Areoftenconcealed.Areperceivedunequally.ISE311-174ErrorsintheworkplaceReducecostsbyGivemoreattentiontoproblemswherepotentialcostishigher.Beascientist,notanadvocate.Seekrootcauses,notblame.Avoidpunishment.ISE311-175TypesOmissionorcommissionType1orType2Systemormeasurement(ofthesystem)Observederror=System+MeasurementPerception,decision,oractionSlipvsmistakeSlip:non-deliberatefailuretofollowruleMistake:ConsciousplanningresultsinunanticipatedactionFailureofknowledgeMalice:deliberateviolationofrulesorproceduresISE311-176ErroranalysistechniquesChecklistsFMEA/FMECADecisionstructuretablesFishdiagramsFaulttreesISE311-177Makingdecisions/actionsinpublicEliminatingprivacycaneliminatemanyerrors.Addlightingormoveobjects/peopletovisibleplaces.Requireapprovalfordeviationsfrompolicy.Increasethenumberofrequireddecisionmakers.Decisionstendtobeslowerbutbetterquality.Exceptions:EmergencysituationsHighriskenvironmentsISE311-178Guideline1:GetenoughinformationGeneraterelevantinformation.Maybedifficultifinformationissubjective.Provideadditionalinformationfornovices.Ensureinformationreception.Besurepeopleknowhowtogetanduseinformation.Besurenovicesknowhowtofindit.ISE311-179Guideline2:EnsurethatinformationisunderstoodISE311-1710Guideline3:Haveproperequipment/ procedures/skillEquipmentDesignAmountArrangementMaintenanceProceduresComputerproceduresHumanproceduresSkillConsiderskillofmachinevs.person.Donotassumeafullycapableandtrainedoperator.Providejobaidsandrefreshertraining.Novicesmakemoreerrorsthanexperiencedoperators.ISE311-1711Guideline4:Don’tforgetReducetheneedtoremember.Avoidverbalorders.Makealist.Doitnow.Havestandardplacesforthings.Usememoryaids.Makethemcomplete,convenient,andaccessible.Useformstoindicatewheninformationismissing.Considerdownsides.Createapatternorstandardsequence.Usecalendars,appointmentcards,andreminders.ISE311-1712Guideline5:SimplifythetaskISE311-1713Guideline6:AllowenoughtimeToolittletimeresultsinstressanderrors.Timestressisonestressthancanbereduced.Assignadditionalstaffwhennecessary.Cross-trainemployeestoprovideflexibility.ISE311-1714Guideline7:Havesufficientmotivation /attentionMotivationMotivationisnotasubstituteforengineering.Socialpressurecanhelporhinderperformance.Whatmotivatespeopleisnotalwaysobvious.AttentionLackofsleepandsubstanceabusemaycauselapses.Forcriticaldecisionsandactions,minimizedistractions.ISE311-1715Guideline8:GiveimmediatefeedbackCalibrateinstrumentsperiodically.Useclosed-loopsystems.Notifytheoperatorwhenanerrorhasbeencorrected.Makeerrormessagesspecificandunderstandable.Considerthatoperatorsmaydisablealarms.Reducedelaybetweenerroranddetection.ISE311-1716ErrormessageguidelinesISE311-1717Guideline9:ImproveerrordetectabilityAmplifythesignal:Matchittoenablepairedcomparison.Donotcontradictpopulationstereotypes.Considerlocationandtime.Reducethenoise.ISE311-1718Guideline10:Minimizeconsequences oferrorsMakeimportantdecisionsoractionsmulti-stepandreversible.Makeequipmentandproceduresfail-safe.Considereaseofrecovery.Ensurerecoverydoesnotcauseadditionalproblems.Minimizespreadoftheerrorthroughthesystem.Provideguards.ISE311-1719InspectionCanbemanual,fullyautomatic,orsemiautomatic.Inspectallitemsforonecharacteristicatatime.Forsearches,considertask,environment,andpersonnelfactors.Traininspectorsan