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 over 10,000 human error incidents. These errors were made during that time by the thousands of workers who prepared the Space Shuttles for launch at the Kennedy Space Center. This book should be considered to be 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. This book was written for people who are 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 correct 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 within the process. Over the years, we developed simple concepts and methods to assist us in performing human error investigations, risk assessments, process design, and also with the determination of suitable corrective/preventative actions. Our group had to develop concepts and methods that were 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. It was obvious to us that the very best tool for finding problems in any process is a risk assessment, but the risk assessment methods being used by our company were very time-consuming and they were not something every employee was capable of doing. We also encountered a more serious problem with these risk assessments in the fact that we could not get separate groups, even when each group was given the same exact information, to arrive at the same final risk values. You can't feel a risk assessment is reliable when one group finds the risk value to be high and another group using the same information finds the risk value to be low. The only way any company can get the thousands of necessary risk assessments performed on all processes is to have the local workgroups that actually perform these processes, the true experts on these processes, create the risk assessments themselves. Since these local workgroups still have their regular functions to perform, you can only ask them to devote a minimal amount of time to doing risk assessments. In order for local workgroups to perform their own risk assessments, the assessments had to be simple, accurate, and quick to do. The 30 Minute Risk Assessment concept came about just because it meets the basic requirements of being simple, accurate, and quick to perform. 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.
Cobra 30 Minute Risk Assessments: Control Bases Risk Analysis
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