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CONTINUOUS IMPROVEMENT FOR A PROCEDURE MANAGEMENT SYSTEM TO REDUCE THE INCIDENCE OF HUMAN PROCEDURE EXECUTION FAILURES
CONTINUOUS IMPROVEMENT FOR A PROCEDURE MANAGEMENT SYSTEM TO REDUCE THE INCIDENCE OF HUMAN PROCEDURE EXECUTION FAILURES
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机译：持续改进程序管理系统以减少人为程序执行故障的发生
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摘要
A method of continuously improving a procedure management system that generates human operating procedures. At least one failure mode (“root cause”) is defined for each human procedural execution failure. The root causes are mapped to stages of human operator execution for the human operating procedures where the plurality of root causes manifest, and to human intervention activities that the human operator failed to correctly execute (“procedure deficiency”). Each root cause is mapped to one or more procedure management components that may have generated the procedure deficiency. Recorded actual incidents of human procedural execution failures are analyzed to identify at least one assignable root cause. A procedure management component is updated to mitigate the assignable root cause, and is then used to change at least one human operating procedure or to generate a new human operating procedure to reduce an incidence of the human procedural execution failures.
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