Human error is a significant source of risk within any organization, one that plays a large role in unintended and sometimes catastrophic events. The costs of these errors can be substantial—from financial impacts and damaged corporate reputation, to the potential shutdown of the business, or even injuries and fatalities.
Using our Human Performance Reliability (HPR) process, Kestrel works with companies to identify multiple factors contributing to human error within operations. We then develop workable solutions that strengthen the barriers to error and reduce the likelihood of recurrence.
Kestrel’s HPR process helps companies:
- Integrate human factor analyses into their incident investigation processes
- Identify the underlying factors contributing to unintended events (e.g., incidents and accidents, environmental releases, air emission events, product quality deviations, food safety events)
- Link identified human behavior to specific operational controls that are missing or need improvement to reduce the likelihood of incidents
- Reveal immediate local and systemic improvement actions
- Identify system-wide opportunities for improvement in the prevention of unintended events
Learning from the Past to Improve Future Performance
Companies use a variety of administrative and engineered controls to manage risk associated with employee behavior. Despite best efforts, however, unintended events can occur when there is a failure in one or more of these controls. Using the HPR process, Kestrel helps companies to:
- Determine where to focus improvement efforts by identifying which of the controls need to be adjusted or developed.
- Characterize what needs improvement to reduce human error by identifying the factors within the controls that are contributing to the unintended events.
Kestrel follows a systematic review process guided by our Human Factor Integration Tool (HFIT™) to collect detailed information and to identify associated (or missing) controls related to the event. HFIT™ helps to identify error patterns and the significance of behaviors and controls most often associated with those events.
Immediate and Systemic Opportunities
The HPR process provides immediate value when applied to the investigation of an individual event by identifying additional factors that may have been missed following a traditional root-cause analysis approach. It is most powerful, however, when data from multiple events are aggregated. The results of multiple investigations yield a pattern of human factor indicators that can be used to uncover systemic opportunities for operational enhancements and improved overall reliability.