Pointing and Calling 指差呼稱 Reduces Human Error 減少人為失誤

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1 Pointing and Calling 指差呼稱 Reduces Human Error 減少人為失誤 Heinrich 1930 Up to 88% of accidents attributable to some degree to human failure Speaker: Yu Pak Kuen 1

2 People can cause or contribute to accidents Through a failure a person can directly cause an accident. However, people tend not to make errors deliberately. We are often set up to fail by the way our brain processes information, by our training, through the design of equipment and procedures and even through the culture of the organisation we work for. People can make disastrous decisions even when they are aware of the risks. We can also misinterpret a situation and act inappropriately as a result. Both of these can lead to the escalation of an incident. HSE (UK) have advocated that consideration of human factors is a key ingredient of effective health and safety management, and had recommended that behavioural strategies be incorporated into a general health and safety management system. 2

3 Everyone can make errors no matter how well trained and motivated they are. 人無完美 The wrong operation, judgment and other human errors caused by the characteristics of human are often considered as the main causes of industrial accidents. HUMAN ERROR IS BOTH UNIVERSAL AND INEVITABLE 3

4 Human failures are often recognised as being a contributor to incidents and accidents HAZOP guidewords Action Errors A1 Operation too long / short A2 Operation mistimed A3 Operation in wrong direction A4 Operation too little / too much A5 Operation too fast / too slow A6 Misalign A7 Right operation on wrong object A8 Wrong operation on right object A9 Operation omitted A10 Operation incomplete A11 Operation too early / late Checking Errors C1 Check omitted C2 Check incomplete C3 Right check on wrong object C4 Wrong check on right object C5 Check too early / late 4

5 Human failures are often recognised as being a contributor to incidents and accidents HAZOP guidewords Information Retrieval Errors R1 R2 R3 R4 Information not obtained Wrong information obtained Information retrieval incomplete Information incorrectly interpreted Information Communication Errors I1 I2 I3 I4 Information not communicated Wrong information communicated Information communication incomplete Information communication unclear Selection Errors S1 Selection omitted S2 Wrong selection made Planning Errors P1 Plan omitted P2 Plan incorrect Violations V1 Deliberate actions 5

6 Human Failures 人的行為引致錯誤 Errors 錯誤 Action Errors Thinking Errors Rule-based mistakes 技術上犯錯 Knowledge-based mistakes 知識上犯錯 Routine 經常性 Slips of Actions 行動上疏忽 Lapses of memory 記憶錯誤 Violations 違犯 Situational 處境性 Exceptional 異常性 Two main types of human failure: Error is an unintentional action or decision. Violations are intentional failures deliberately doing the wrong thing. 6

7 1. Errors (Action errors) Human Failure a. Not doing what you re meant to do - Slip of actions b. Forgetting to do something, or losing your place midway through a task. Lapse of memory Occurs : maintenance, adjusting, testing Reduce Errors : not successfully by training 2. Mistakes (Thinking errors) Mistakes are decision-making failures. They arise when we do the wrong thing, believing it to be right. Rule-base: based on remembered rules or familiar procedures Knowledge-base: rely on experience instead of instruments Occurs : poor judgement, misinterpreting Reduce Errors : training and information 3. Violations deliberately doing the wrong thing Occurs: rules and procedures Reduce Errors: spotting, monitoring, supervision 7

8 Classifying Human Failures A male worker, wearing arc-welding face shield, engaged in arc-welding a metal handle onto the top rim of an empty metal drum. The metal drum was a 200- litre vessel previously used hold diesel and emptied by him a day before the accident. A female casual worker without wearing the eye protector was standing nearby to assist him. During welding, a small explosion suddenly occurred and resulted in female worker were sustained burns on her face and eyes. The male worker had received all the basic and welding safety training. The female causal worker had no knowledge of arc welding and the metal drum. Please classify the human failure involved in this accident. 8

9 Action (Skill-based) error Slips occur when Eyes not on the task (Similarity) Turning in a wrong direction Pressing wrong control Mind not on the task (Familiarity) Carry out familiar tasks automatically, without thinking, and the action is not planned On line of fire (non-detection) Standing beneath a lifted objects Contact the rotating parts of a machine Lapses a lapse in attention (Input) a lapse in taking actions (output) Interference (Storage) 9

10 Slips and Lapses -occur in very familiar tasks which we can carry out without much conscious attention Slips performing an action too soon in a procedure, or leaving it too late, eg not putting your ear protectors on before starting the drill; performing an action in the wrong direction, eg a MEWP operator pushing the joystick to the left instead of the right; doing the right thing but on the wrong object, eg selecting the wrong size nail for the job; and carrying out the wrong check but on the right item, eg checking a dial but for the wrong value. Lapse forgetting to nail down a joist; taking your mask off to talk to a colleague and then forgetting to put it back on; failing to secure scaffolding because of an interruption; and forgetting to reply an important because of too many tasks today. 10

11 Q1 Is there awareness that training can only help to prevent mistakes (thinking errors) and that training has no effect in preventing unintentional failures slips or lapses? Training will not effect the prevention of slips/lapses or violations, only mistakes 問題一 為什麽訓練不能防止行動上疏忽及記憶錯誤的人為失誤? 11

12 Problems with training programmes? Training will not effect the prevention of slips/lapses or violations, only mistakes Little consideration is given to evaluating effectiveness of training. It cannot be assumed that by simply attending a training course means that one is adequately trained. Training should concentrate on what is safe, rather than unsafe, what to do, rather than what not to do. Training is not always consistent with the rules and procedures 12

13 How to reduce slips and lapses: Q2 How can I make sure my workers understand that they are vulnerable to slips and lapses? 問題二 我如何能令工人明白他們是非常容易犯上行動上疏忽及記憶錯誤的失誤? 13

14 How to reduce slips and lapses: Q2 How can I make sure my workers understand that they are vulnerable to slips and lapses? 問題二 我如何能令工人明白他們是非常容易犯上行動上疏忽及記憶錯誤的失誤? make all workers aware that slips and lapses do happen; checklists and reminders; procedures with place markers (tick off each step); human-centred design include in procedures the setting out of equipment, site layout and methods of work to ensure there is a logical sequence; make sure checks are in place for complicated tasks; 14

15 How to reduce slips and lapses: Q2 How can I make sure my workers understand that they are vulnerable to slips and lapses? 問題二 我如何能令工人明白他們是非常容易犯上行動上疏忽及記憶錯誤的失誤? try to ensure distractions and interruptions are minimised, eg mobile phone policy. sufficient time available to complete task warnings and alarms to help detect errors 15

16 Mistakes (thinking errors) are decision-making failures. Examples of mistakes include: making a poor judgement when overtaking, leaving insufficient room to complete the manoeuvre in the face of oncoming traffic; and an operator misinterpreting the sound of a machine breakdown and failing to switch off immediately. Doing too many things at the same time. Doing too many complex tasks at once. Time pressures. 16

17 How to reduce mistakes : Q3 How can I reduce the likelihood of mistakes occurring on the workplace? 問題三 我如何能減少在工作地方犯錯誤的機會? 17

18 How to reduce mistakes : Q3 How can I reduce the likelihood of mistakes occurring on the workplace? 問題二 我如何能減少在工作地方犯錯誤的機會? To avoid rule-based mistakes, increase worker situational awareness of high-risk tasks on site and provide procedures for predictable non-routine, high-risk tasks. To avoid knowledge-based mistakes, ensure proper supervision for inexperienced workers and provide job aids and diagrams to explain procedures. plan for all relevant what ifs (procedures for upset, abnormal and emergency scenarios) 18

19 How to reduce mistakes : Q3 How can I reduce the likelihood of mistakes occurring on the workplace? 問題二 我如何能減少在工作地方犯錯誤的機會? regular drills/exercises for upsets/emergencies clear overview / mental model (clear displays; system feedback; effective shift handover etc.) diagnostic tools and decisionmaking aids (flowcharts; schematics; job-aids etc.) competence (knowledge and understanding of system; training in decision-making techniques) organisational learning (capture and share experience of unusual events) 19

20 An effective mechanism to prevent Action Errors in Human Failures: Pointing and Calling Programme 20

21 Pointing and Calling Pointing and Calling 指差呼稱 Reduces Human Error 減少人為失誤 Make all workers aware that slips and lapses do happen Increase worker situational awareness of high-risk tasks on site Reduce human action errors effectively 21

22 An effective mechanism to prevent accidents and improve the overall safety and health standards of an enterprise Pointing refers to the action of pointing at a target by finger, while Calling refers to the firmly calling out the confirmed slogan. 22

23 Error Percentage(%) Pointing and Calling The approach of Pointing and Calling, which originated from the Zero Accident Movement in Japan, has been proved to be an effective tool in containing human errors (100) 1.00(42) Objectives are to enhance employees alertness and accuracy of operations, and reduce accidents arising from negligence, error or misunderstanding (32) 0.38(16) According to the results of the Study of the Effectiveness of Pointing and Calling in Japan, after the implementation of Pointing and Calling Human error ratio fell sharply by 84% 0 No pointing and calling Only calling Only Pointing pointing and Calling 23

24 Including worker s eyes, mouth, ears and arm/finger Eyes: firmly look at the objects to be recognized Arm and finger: stretch the arms, with the index finger points to the target Mouth: shout loudly and clearly for confirmation Ears: Listen to the confirmed slogan Enhance the awareness level of the brain Stimulus from oral muscles movement allows the brain in the correct handling status Stimulate the wrist muscles allows the brain more lively and operational Straighten your fingers to the target object look a the target object raised confirmation loudly 24

25 Bear in mind the actions and execute carefully Start with form, end up with form 1 First, look at the object to be recognized 2 Focus on the recognized object and point out with right index finger 3 Raise the right hand to the ear 4 shouting XXX Safe! OK! and pointing towards the object 3 Raise the right hand to the ear Keep thinking and to confirm it is no problem 25

26 Different models for Pointing and Calling Point + Say Do: This model is applied in verifying that conditions are safe before carrying out an operation. Do Point + Say : This model is applied in verifying that an action has just been completed safely and correctly. 26

27 Pointing and Calling in CLP (team) Point + Say Do: 27

28 Pointing and Calling in MTR (work alone) Point + Say Do: 28

29 Garage Shutter Closed, OK! Do Point + Say : 29

30 Chain Sling, OK!Protection, OK! Other.. Guide rope,ok! Yes or No? Patient s name OK! Do Point + Say : 30

31 The Approach of Pointing and Calling Reduces Human Errors When slogans for Calling are formulated, they should be simple and concise enough to express clearly the matter to be confirmed. Each company should design their slogans that meet their needs. For example, when operating a machine, after one has confirmed the machine is under safe condition, one should point at the switch of the machine and chant OK as confirmation; When one inspects a serial number, he should point at the serial number and call the number out loudly after the correct serial number is confirmed. 31

32 Case Study -01 From the photo/drawing: - Identify the major hazards - Decide which the critical points must be checked before operation - Design a pointing and calling slogan for workers 32

33 Case Study -02 From the photo/drawing: - Identify the major hazards - Decide which the critical points must be checked before operation - Design a pointing and calling slogan for workers 33

34 Case Study -03 From the photo/drawing: - Identify the major hazards - Decide which the critical points must be checked before operation - Design a pointing and calling slogan for workers 34

35 Case -1 From the photo/drawing: - Identify the major hazards - Decide which the critical points must be checked before operation - Design a pointing and calling slogan for workers 35

36 Case -2 From the photo/drawing: - Identify the major hazards - Decide which the critical points must be checked before operation - Design a pointing and calling slogan for workers 36

37 Case -3 From the photo/drawing: - Identify the major hazards - Decide which the critical points must be checked before operation - Design a pointing and calling slogan for workers 37

38 Case -4 From the photo/drawing: - Identify the major hazards - Decide which the critical points must be checked before operation - Design a pointing and calling slogan for workers 38

39 Case -5 From the photo/drawing: - Identify the major hazards - Decide which the critical points must be checked before operation - Design a pointing and calling slogan for workers 39

40 Case -6 From the photo/drawing: - Identify the major hazards - Decide which the critical points must be checked before operation - Design a pointing and calling slogan for workers 40

41 From the photo/drawing: - Identify the major hazards - Decide which the critical points must be checked before operation - Design a pointing and calling slogan for workers Case -7 41

42 From the photo/drawing: - Identify the major hazards - Decide which the critical points must be checked before operation - Design a pointing and calling slogan for workers Case -8 42

43 Case -9 From the photo/drawing: - Identify the major hazards - Decide which the critical points must be checked before operation - Design a pointing and calling slogan for workers 43

44 Case -10 From the photo/drawing: - Identify the major hazards - Decide which the critical points must be checked before operation - Design a pointing and calling slogan for workers 44

45 Case -10 From the photo/drawing: - Identify the major hazards - Decide which the critical points must be checked before operation - Design a pointing and calling slogan for workers 45

46 Case -11 From the photo/drawing: - Identify the major hazards - Decide which the critical points must be checked before operation - Design a pointing and calling slogan for workers 46

47 Case -12 From the photo/drawing: - Identify the major hazards - Decide which the critical points must be checked before operation - Design a pointing and calling slogan for workers 47

48 Case -13 From the photo/drawing: - Identify the major hazards - Decide which the critical points must be checked before operation - Design a pointing and calling slogan for workers 48

49 Case -14 From the photo/drawing: - Identify the major hazards - Decide which the critical points must be checked before operation - Design a pointing and calling slogan for workers 49

50 Pointing and Calling Workshop A. Pointing and Calling strategic team 1. What factors are needed to cause a company/contractor practicing the point and calling programme as an integral part of safety management system? 2. Can this programme be mandated under contractual requirements of construction projects? Table 7 3. Can this programme be used by Table 11 other sectors to reduce human Table 10 errors? Which trade is the next Table 14 target? 50

51 Pointing and Calling Workshop B. Pointing and Calling Promotion team 1. What are the obstacles in adopting the point and calling programme into the safety management system of contractors? 2. How can we persuade the management to accept pointing and calling programme? 3. How can you promote and encourage workers to participate this programme? Table 3 Table 6 Table 9 Table 13 51

52 Pointing and Calling Workshop C. Pointing and Calling Designing Team 1. How can you identify the critical jobs or operations that need using pointing and calling programme to reduce the occurrence of human errors? 2. How can you design suitable slogans or headings to increase the situational awareness of the high risk activities? 3. How can you promote and encourage workers to think and design suitable slogans for their jobs? Table 2 Table 5 Table 8 52

53 Pointing and Calling Workshop D. Pointing and Calling Monitoring and Review Team 1. How can you ensure the continual running of pointing and calling programe? 2. How can you monitor the designed pointing and calling slogan and main points always appropriate to the risks of the operations? 3. How can you promote and encourage workers to conduct pointing and calling voluntarily without fear of punishment? Table 1 Table 4 Table 12 53

54 How to implement Pointing and Calling Pointing and Calling is part of the Safe Working Cycle programme 1. Comprehensive planning, promotion and training Identify the critical high risks activities and steps by management and front line In the initial stage, employees will feel not accustomed to and feel awkward Design safety slogans and training Integrate into morning safety meeting, hazard identification activity, prior-work inspection and operations if necessary, and also final check 54

55 How to implement Pointing and Calling 2.Lead by management, worker participation 3. Promote Pointing and Calling make it widely integrated into the site's day-to-day safety training 55

56 How to implement Pointing and Calling 4. Asking questions to solve problems 1. Base on existing conditions What are the potential hazards? 2. Confirmation of hazards are real These are the critical hazards. 3. Establish control strategy What should we do? 4. Setting target for pointing and calling Recognize these are the critical hazards and confirm they are under control 56

57 How to implement Pointing and Calling 5. Monitor pointing and calling practice by safety observers under Work Safe behaviour Programme 6. Review the results of pointing and calling programme in safety committee meeting 57

58 Conclusions 1. Action errors Associated with familiar tasks that require little conscious attention. These skill-based errors occur if attention is diverted, even momentarily. Pointing and calling programme is a very useful tools in reducing human action errors. 2. Training can only help to prevent mistakes (thinking errors) and that training has no effect in preventing unintentional failures slips or lapses 3. Tailor -made and integrated into normal safety management process such as safe working cycle. 4. Supported by management and participated by front-line operators. 58

59 Thank You! Pointing and Calling is a people-oriented safety management tool designed for the safe work behaviours of workers, aiming to establish an effective mechanism to prevent accidents and improve the overall safety and health standards of an enterprise. 59

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