D54 - Human Factors and Root Cause Analysis
Trish Borzon
1150 Posts
This talk describes human factors in root cause analysis. A classification system for human errors is given and then converted into an Ishikawa diagram. This Ishikawa diagram can serve as a template to use when investigating failures caused by human error such as when an employee skips an assembly operation. A Swiss cheese model for human error in services and industry is also presented. Although typically used in aircraft accident investigation and medical mistakes, this model serves as a solid basis for investigating human error related failures. A list of questions to ask based on the Swiss cheese model will be provided.

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Trish Borzon
1150 Posts
Human Factors and RCA_Barsalou_D54.pdf - here are the slides to Matthew's presentation - Enjoy!
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