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

Heinrich 1930Up to 88% of accidents

attributable to some degree to

human failure

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Speaker: Yu Pak Kuen

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.

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“HUMAN ERROR IS BOTH UNIVERSAL AND INEVITABLE”

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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 failures are often recognised as being a contributor to incidents and accidents

HAZOP guidewords Action ErrorsA1 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 ErrorsC1 Check omitted

C2 Check incomplete

C3 Right check on wrong object

C4 Wrong check on right object

C5 Check too early / late

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Human failures are often recognised as being a contributor to incidents and accidents

HAZOP guidewords

Information Retrieval Errors

R1 Information not obtained

R2 Wrong information obtained

R3 Information retrieval incomplete

R4 Information incorrectly interpreted

Information Communication ErrorsI1 Information not communicated

I2 Wrong information communicated

I3 Information communication incomplete

I4 Information communication unclear

Selection Errors S1 Selection omitted

S2 Wrong selection made

Planning ErrorsP1 Plan omitted

P2 Plan incorrect

ViolationsV1 Deliberate actions

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Human Failures人的行為引致

錯誤

Errors錯誤

Violations

違犯

Situational

處境性

Exceptional

異常性

Routine

經常性

Knowledge-based mistakes

知識上犯錯

Rule-based mistakes

技術上犯錯

Lapses

of memory

記憶錯誤

Slips of

Actions

行動上疏忽Action

Errors

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Thinking

Errors

Two main types of human failure:

■ Error is an unintentional action or decision.

■ Violations are intentional failures – deliberately doing the wrong thing.

Human Failure

1. Errors (Action errors)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

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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.

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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)

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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 email because of too many tasks today.

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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?

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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

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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?

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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;

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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, egmobile phone policy.

sufficient time available to complete task

warnings and alarms to help detect errors

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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.

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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?

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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)

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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 decision-making 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)

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An effective mechanism to prevent Action Errors in Human Failures:

‘Pointing’ and ‘Calling’ Programme

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Pointing and Calling

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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

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.

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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.

• Objectives are to enhance employees’ alertness and accuracy of operations, and reduce accidents arising from negligence, error or misunderstanding.

• 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

0.5

1

1.5

2

2.5

No pointing

and

calling

Only calling

Only pointing

Pointing and

Calling

Erro

r Pe

rcen

tage（

%）

2.38(100)

1.00(42)

0.75(32)

0.38(16)

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Including worker’s eyes, mouth, ears and arm/finger

• Eyes: firmly look at the objects to be recognizedArm and finger: stretch the arms, with the index finger points to the targetMouth: shout loudly and clearly for confirmationEars: Listen to the confirmed slogan

• 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

Enhance the awareness level of the brain

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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

Bear in mind the actions and execute carefullyStart with form, end up with form

③ Raise the right hand to the ear Keep thinking and to confirm it is

no problem

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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.

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Pointing and Calling in CLP (team)

27Point + Say Do:

Pointing and Calling in MTR (work alone)

28Point + Say Do:

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Garage Shutter Closed，

OK！

Do Point + Say :

Other…..

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Guide rope，OK！

Chain Sling，OK！Protection，

OK！

Patient’s name OK！

Yes or No?

Do Point + Say :

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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Case -7

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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

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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 -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

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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

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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

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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

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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

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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

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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

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Pointing and Calling Workshop

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?

3. Can this programme be used by other sectors to reduce human errors? Which trade is the next target?

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A. Pointing and Calling strategic team

Table 7

Table 11

Table 10

Table 14

Pointing and Calling Workshop

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?

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B. Pointing and Calling Promotion team

Table 3

Table 6

Table 9

Table 13

Pointing and Calling Workshop

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?

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C. Pointing and Calling Designing Team

Table 2

Table 5

Table 8

Pointing and Calling Workshop

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?

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D. Pointing and Calling Monitoring and Review Team

Table 1

Table 4

Table 12

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

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How to implement ‘Pointing and Calling’

2.Lead by management , worker

participation3. Promote ‘Pointing and Calling’

make it widely integrated into the site's day-to-day safety training

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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

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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

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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.

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Thank You!

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‘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.