Upon completion of this course, participants will be able to:

• Differentiate between active failures (errors, violations) and latent conditions in the workplace.
• Apply **Reason's Swiss Cheese Model** to analyze the systemic nature of failures and incidents.
• Identify cognitive and organizational factors that reliably predict and contribute to human error.
• Design and implement **Error Reduction Techniques** (e.g., forcing functions, checklists, simplification) into processes.
• Establish a **Just Culture** that balances accountability with a focus on system improvement.
• Conduct thorough, non-punitive incident investigations using structured Human Factors methodologies.
• Develop targeted training and communication strategies based on error patterns and cognitive science.
• Measure and monitor the effectiveness of error prevention interventions in operational settings.

• HSE and Quality Assurance Professionals
• Process Engineers and Business Process Owners
• Operations Managers and Supervisors
• Internal Audit and Risk Assurance Specialists
• Training and Organizational Development Staff

• Group Incident Analysis Workshop using the Swiss Cheese Model
• Case Studies on Accidents where Human Error was the Stated vs. Systemic Cause
• Individual Exercise: Redesigning a Flawed Procedure using Error Reduction Techniques
• Role-Playing Non-Punitive Incident Debriefings with an Employee
• Discussions on the Ethical Implications of Systemic Blame vs. Individual Blame

Unit 1: The Science of Human Error

• Defining human error: slips, lapses, mistakes, and violations.
• Introduction to **Reason's Swiss Cheese Model** of systemic accidents and failures.
• Differentiating between **Active Failures** (direct actions) and **Latent Conditions** (system design flaws).
• Understanding the cognitive limitations that lead to common errors (memory, attention, confirmation bias).
• The role of the operational environment (noise, fatigue, time pressure) on human performance.

Unit 2: Systemic Analysis and Root Cause

• Conducting non-punitive incident investigations focused on system, not person, failure.
• Applying **Human Factors** tools to map the sequence of events and decision points.
• Identifying the specific latent conditions that led to the breakdown of defenses.
• Using techniques (e.g., 5 Whys, Fishbone Diagrams) to determine the deepest organizational root causes.
• The importance of collecting data on near-misses and minor errors for proactive analysis.

Unit 3: Error-Proofing and Process Design

• Applying the hierarchy of human error controls (from elimination to administrative controls).
• Designing for error reduction: simplification, standardization, and visual management.
• Implementing **Forcing Functions** and interlocks to make incorrect actions physically impossible.
• Developing effective checklists, protocols, and cognitive aids to support decision-making.
• The role of technology (automation, interfaces) in mitigating human error and its potential side effects.

Unit 4: Developing a Just Culture

• Defining a **Just Culture**: differentiating between acceptable human error, negligence, and willful misconduct.
• Establishing clear rules and boundaries for accountability and disciplinary action.
• Training managers to conduct supportive and system-focused error debriefings.
• Encouraging the voluntary reporting of errors and system flaws without fear of retribution.
• The critical role of leadership in modeling the principles of a just culture.

Unit 5: Organizational and Cultural Mitigation

• Managing risks associated with fatigue, excessive workload, and low staffing levels.
• Designing effective, scenario-based training that focuses on known error traps.
• Implementing organizational learning mechanisms to share error data and best practices across departments.
• Measuring the effectiveness of human error prevention initiatives and process changes.
• Integrating human factors analysis into the design of new systems and procedures.