Event Free Tool Book Flashcards
What are the 4 key questions?
- What are the critical steps?
- What are the error likely situations?
- What’s the worst thing that could happen?
- What defenses are in place?
What are 4 areas of human error traps?
- task demands
- work environment
- human nature
- individual capabilities
Task demands, human error traps
Time pressures
High work load
Vague or poor work guidance
Simultaneous, multiple tasks
Unclear goals, roles or responsibilities
Repetitive or irreversible actions
Interpretation requirements
Lack of or unclear standards
Individual capabilities, human error traps
1st time doing task
Poor communication
1st working day following time off
30 minutes after a meal
Illness or fatigue
Lack of knowledge or proficiency
Inadequate problem solving skills
Work environment, human error traps
Distractions
Changes from the routine
Confusing displays/controls
Workarounds or poor instrumentation
Hidden system responses
Unexpected equipment conditions
Lack of confirming information
Personality conflicts
Human nature, human error traps
Stress
Overconfidence in work or abilities
Habit patterns
Assumptions
Mindset
Inaccurate risk perception
Mental shortcuts or biases
Limited short-term memory
“Can do” attitude for crucial task
Top 10 human error traps
Distractions
Stress
Overconfidence in work or abilities
Time pressures
High work load
Vague or poor work guidance
1st time doing a task
Poor communications
1st working day following time off
30 minutes after a meal
Job brief 4 key parts
Critical tasks - identify 2 minute pause points
Spotter - uses and responsibilities
Job turnover - review and record information on checklist to ensure clear communication between shifts
Tactical work zone - a well-defined and clearly marked distraction-free zone
Job brief sheet includes 8 parts
Specific location
Work scope and critical steps in order
Hazards and protections
Order and coordination of activities
Identify and assign individual responsibilities
Barriers and defenses for special precautions
Proper PPE
When to do the job brief
Before work takes place
As scope or condition changes
At mid-shift
At job turnovers
When a new person joins the job site
After a meal or break
After work is complete
Name 4 goals of the Event Free Tool Book
1 prevention
2 detection
3 correction
4 sharing
What is 1st check?
A verbal check in when working alone and before starting a task.
A knowledgeable, qualified person is contacted to confirm the employee is at the exact location and about to work on the correct equipment and knows the task to be performed.
What is OOPS?
Outside of procedures, parameters, or processes - STOP!
A work practice of stopping when uncertainty arises, unsafe conditions are identified, or when results aren’t consistent with expectations.
