Overview

I am writing this book with the purpose of capturing what a group of Corrective Action Engineers, of which I was a member, learned during 24 years of investigating the mistakes made by the thousands of workers who prepared the Space Shuttles for launch at the Kennedy Space Center. This book was not written for people who study human error. In fact, this book should be considered to be more of a shop manual for those individuals whose job requires them to actually deal hands on with human error on a daily basis. This book was written for managers that want to make sure their processes will be performed correctly and their people are working safely with no one at risk of being hurt as a result of a human error. This book was written for people who get handed a human error incident and told to investigate it, find out the real reason for why it happened, and make sure it never happens again. This book was written for the person whose management tells him that the workforce is making far too many mistakes and they expect him to find out why and do something about it. This book was written for the engineer who is responsible for some critical process and wants to limit the possibility of a human error occurring while the process is being worked. Over the years, we developed simple concepts and methods to assist us in performing human error investigations, risk assessments, process design, as well as the determination of suitable corrective/preventative actions. These concepts and methods that we developed had to be quick and easy to use since we dealt with a workforce of several thousand and our NASA counterparts expected some level of preliminary investigation and understanding of every workforce error within hours of the occurrence. NASA also expected the fixes for any human error issue to be implemented in a timely manner and be effective. What my group learned applies to a workforce of 2 or even 20,000. This book explains how the 30 Minute Risk Assessment concept came about, the basis on why it works, and how any organization can use it to assure all of their processes can be counted upon when needed. I am completely confident that anyone having read this book will look at workforce error differently. A reader will be able to recognize those processes where errors are likely to occur that they would not have identified previously. A reader will understand how risk assessments can be performed that are quick, simple, repeatable, and capable of identifying high-risk situations correctly. These risk assessments will also be suitable for clearly identifying exactly what actions need to be taken to reduce the risk identified and assist in prioritizing the order for addressing the required actions.

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9781500131517

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Author was born in 1954 and raised in Cocoa Beach, Florida where his father worked at Cape Canaveral on the first manned launches during the early Mercury program. After finishing high school, the author wanted to get into the oil industry and moved to Lafayette, Louisiana to attend college. At the time, Lafayette was the hub of the offshore oil industry. Upon graduation from the University of Southwestern Louisiana in Lafayette, the author took a position as a Reservoir/Production Engineer with Texas Pacific Oil Company. A few years later the author went to join Getty Oil Company managing an offshore production facility. Later the author went on to Texaco Oil Company to be an on-site drilling supervisor. Eventually the author went to work on the Alaskan North Slope at Prudhoe Bay doing Directional Drilling for Atlantic Richfield Oil Company. On a visit back to Florida, the author was offered a position at the Kennedy Space Center as a member of a new Corrective Action Engineering group. This new group was to be part of the workforce that was presently processing the Space Shuttles for each launch. This group was being developed per a new NASA requirement as a result of the Challenger disaster to more closely monitor workforce problems. The author joined this group and remained a member for 24 years. The author retired when the group was disbanded at the end of the Shuttle Program. Every position the author has ever held, whether in the oil industry or the Shuttle Program, involved working in situations where workforce human error always had the potential for catastrophic consequences.

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