人因工具卡培训.pptVIP

人因工具卡 业绩金字塔 Prevention Detection Correction Equipment Failures Individual Errors Organizational and Programmatic Failures Executive Management Errors Supervision’s Role Management’s Role 3 strategies to use 4 areas to look in Human Performance Philosophies Everyone makes mistakes!人总是会犯错的！ Error-likely situations are predictable, manageable, and preventable. 可能失误工况是能够预见、控制和避免的 Individual behavior is strongly influenced by organizational, programmatic, and management performance.个人行为很大程度上受组织、制度和管理水平的影响 High levels of human performance can be achieved if the right behaviors are encouraged, taught, and reinforced.鼓励、传授、强化正确行为，个人行为就能得到高水平发挥。 Undesirable events can be avoided by understanding and monitoring precursor conditions and by applying lessons-learned from past significant events.理解并追踪历史事件同时吸取先前重大事故中的教训，就能避免所不愿意看到的事件发生。 “Error Prone” Mental States * 231 production facilities and service organizations (1990-1997) with a constant reporting threshold. State 1 警觉性低 State 2 压抑 State 3 迷惑 State 4 过于自信 失误几率* State 0 – 可以忽略 State 1 - 17% State 2 - 16% State 3 - 33% State 4 - 31% 技能型失误 程序型失误 知识型失误 失误的影响 低 高 时间压力 环境干扰 任务繁重 面临新情况 休息后第一个工作日 沟通不准确 工作压力过重 环境干扰 休息后第一个工作日 醒来、餐后半小时 时间压力 环境干扰 任务繁重 面临新情况 指令含糊或有误 沟通不准确 过于自信的诱因 FIST - 面临新情况 - 二手经验 短期行为 - 时间压力 State 0 – 反应机敏遵规守矩 Anatomy of an Event “Barrier Model” Organizational Barriers组织屏障 Programmatic Barriers制度屏障 Triggering Event始发事件 Significant Event重大事件 Individual Errors - such as:个人失误包括 Weak Knowledge / Skills知识 /技能欠缺 Poor Work Practices经验不足 Management Barriers管理屏障 Individual Barriers个人屏障 Latent Organizational Weaknesses - such as:组织的潜在不足 包括 Poorly Written Procedures,程序编写低劣 Failed / Nonexistent Work Process Barriers 工作过程屏障失效 / 不存在 Ineffective Management 管理不善 “纵深防御模式” Dr. James Reason, Managing the Risks of Organizational Accidents, 1997. (工作环境) (Work Process工作过程) 减少人因失误方法 – 适用每一个人 不确定或不安全时停下来 良好的沟通 质疑的态度 (质疑三部曲) ??? 自查 (明星自检) 按程序办事 正确使用Correct Usage 无任何偏差No Deviation 不确定或不安全时停下来Stop if uncertain