MODULE 1

Error Prevention Basics

BASIC TOOLS FOR REDUCING MISTAKES

Objective:

Become more aware of our interactions and learn to improve those interactions.

Quick Video Links:

The Pinch

AESOP

Definitions

PIC- Person In Charge
Usually in any situation someone is in charge. This person may not actually have a specific title, or may be referred to as supervisor, team leader, manager, director, chief, captain, etc. In our seminar, PIC is a generic term to indicate the person or persons in charge.

Team

Any group of two or more people working on a common project or task, even though they may not necessarily always be called a team.

Trap

A weakness inherent in human nature that reduces our effectiveness and can lead us to take actions contrary to policy, procedures and simple common sense - putting people, equipment and projects at risk.

Tool

A simple, practical method used in Error Prevention to detect and avoid or deal with one or more Traps.

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We all make mistakes...

Balancing Risk and Safety

Risk Assessment

Risk assessment is inherent in the decision-making process. Unfortunately, people may not be aware of all the risks involved in a particular decision, or they may tend to minimize risks, especially risks they deal with every day.

TOOL

Standard Operating Procedures (SOP)

These are specific written instructions on how to do all phases of our jobs, and how to handle anticipated critical situations. A good SOP can help overcome the temptation to operate in an unwise manner, whether it is coming from ourselves or others. Even someone in a one person department can benefit from putting specific operating procedures they intend to follow down on paper. The Traps and Tools™ you are learning about in this seminar should be in your SOP.

TOOL

The PINCH

If the PIC has not succeeded in establishing a comfortable atmosphere of open participation, other team members may not verbally communicate their feelings. However, they will still communicate their feelings nonverbally. When we sense that someone is upset about something, we call that a "pinch." It is important to "address the pinch" as soon as you are aware of it. If this is not done, the pinch may grow into a disruption. While it is possible to resolve a disruption, it is much easier to handle at the pinch stage.

TOOL

AESOP

The AESOP™ Model is very effective as a mind-jogger to ensure that important factors are not inadvertently overlooked. Use AESOP™ at each stage of planning or completing a task to make sure you take into account each factor.

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AESOP-simplegraphic.png

What is AESOP?

A simple yet powerful method to maintain our focus and awareness when everything seems to be spinning out of control around us. It is especially helpful in alerting us to the one thing we may have missed.

 

How to Use AESOP
 

To use AESOP, you simply go step by step through the 5 items, asking if there are any problems or “pinches” in that area. Let’s explore these 5 items in detail here.

Assignment (What are we doing)

 

In the Assignment step, you should ask:

  • Is the assignment clear?

  • Is there any missing or confusing information?

  • Does anyone see any risks in accomplishing this assignment?

 

Equipment (How are we doing it)

 

In the Equipment step, you should ask:

  • What resources do we need to accomplish this assignment?

  • Are these resources available?

  • Are they correct and/or working right?

  • Are there any risk factors with these resources?

 

Obstacles (Wait…lets pause and make sure)

 

In the Obstacles step, you should ask:

  • Does anyone see anything that could keep us from successfully completing this assignment with these resources?

 

Personnel (Who will be doing it)

 

In the Personnel step, you should ask:

  • Who do we need for this job?

  • Are they available?

  • Do they have the training and certification necessary to do this job?

  • How long has it been since they did the same or a similar job?

  • Is anyone not feeling well, or not alert enough for this task?

Situation (Go forward, proceed with caution, or abort mission?)

 

Evaluate the situation: Even though S is the middle letter in AESOP, you will do this step last so summarize your overall Situation by determining if you are:

 

  • Green – Good to go: Everything is ready and there are no risk factors that have not been addressed.

  • Yellow – Ragged edge: There are some risk factors or uncertainties, but we can proceed while working to reduce or clarify those issues.

  • Red – STOP: There are too many or too serious of risk factors that we can’t even start. If already underway, we need to stop until we can ensure everything is under control and we are not taking any more unnecessary risks.

AESOP Resources

TOOL

Conservative Response Rule

One thing the PIC can do to encourage feedback and open discussion of problems and concerns is to institute the Conservative Response Rule™, which dictates a conservative response to any ambiguity.

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