Don’t Blame Training: Part-ll

Originally Published on October 21, 2015

To recap my previous post, citing training as the only corrective action in a human error incident, more times than not, is a waste of time and resources. Sure, it allows you to close your investigation on time and keep your metrics green, but at what cost? In most cases, the employee was performing the task correctly, and then something happened to cause their performance to change…but what? It’s that “what” an investigator needs to uncover.

Here’s a short list of questions to help guide you through the investigation process. I like lists such as this because they are great for human error investigations and can guide the design and development of new performance systems or conduct a “Performance Hazard Analysis” (PHA) on your existing programs. (OK, I know that PHA stands for “Process Hazard Analysis,” but I wanted to have some fun with the acronym.)

Feel free to modify this list to fit your organizational needs or industry. A more extensive list in a checklist format is available on my site.

Tools and Materials

• Did the employee have access to the right tools? Did they work? Were they calibrated?
• Are tools, equipment, and materials ergonomically designed?
• Did the employee have access to the right materials and resources?

Environment

• Does the work environment (lighting, visual presence, noise, smell, and temperature) have a negative impact on performance?
• Is the work area laid out to support proper performance? (Colors, workflow, ergonomics, etc.)
• Is the work environment stressful or hostile?

Information

• Did the employee have access to applicable procedures?
• Are the procedures written clearly for end-users? (Versus, according to the author.)
• Did the employee understand the procedure?
• Are job aids available?

Organization

• Is there confusion over work priorities?
• Is the employee properly incentivized?
• Does the employee’s leadership support appropriate behavior?
• Does the employee have clear expectations for their performance?

Skills/Knowledge

• Is the task new to the employee?
• Was the employee trained in their primary language?
• Were all steps in the procedure followed/instructed during training?

Inherent Ability

• Is the task part of the employee’s job description?
• Are the employee’s knowledge/skills appropriate for their current position? (Right person, right job.)
• Did the employee have to perform more than one task at a time?
• Does the job require above-average memory to perform?

Take care, and keep your saws sharp!

Dr. D