Publisher's Synopsis
I am writing this book with the purpose of capturing what a group of Corrective Action Engineers, of which I was a member, learned during 24 years of investigating the mistakes made by the thousands of workers who prepared the Space Shuttles for launch at the Kennedy Space Center. This book was not written for people who study human error. In fact, this book should be considered to be more of a "shop manual" for those individuals whose job requires them to actually deal hands on with human error on a daily basis. This book was written for managers that want to make sure their processes will be performed correctly and their people are working safely with no one at risk of being hurt as a result of a human error. This book was written for people who get handed a human error incident and told to investigate it, find out the real reason for why it happened, and make sure it never happens again. This book was written for the person whose management tells him that the workforce is making far too many mistakes and they expect him to find out why and do something about it. This book was written for the engineer who is responsible for some critical process and wants to limit the possibility of a human error occurring while the process is being worked. Over the years, we developed simple concepts and methods to assist us in performing human error investigations, risk assessments, process design, as well as the determination of suitable corrective/preventative actions. These concepts and methods that we developed had to be quick and easy to use since we dealt with a workforce of several thousand and our NASA counterparts expected some level of preliminary investigation and understanding of every workforce error within hours of the occurrence. NASA also expected the fixes for any human error issue to be implemented in a timely manner and be effective. What my group learned applies to a workforce of 2 or even 20,000. This book explains how the 30 Minute Risk Assessment concept came about, the basis on why it works, and how any organization can use it to assure all of their processes can be counted upon when needed. I am completely confident that anyone having read this book will look at workforce error differently. A reader will be able to recognize those processes where errors are likely to occur that they would not have identified previously. A reader will understand how risk assessments can be performed that are quick, simple, repeatable, and capable of identifying high-risk situations correctly. These risk assessments will also be suitable for clearly identifying exactly what actions need to be taken to reduce the risk identified and assist in prioritizing the order for addressing the required actions.
