Human Error? No Problem

  • By Staff Employee
  • 20 Mar, 2017
How procedures can help us avoid human error in the cannabis growing process. The post Human Error? No Problem appeared first on Cannabis Industry Journal.
If you are in the business of growing cannabis, you should be aware of the common reasons for production losses, how to address root causes and how to prevent future occurrences in a sustainable way. Human error is the number one root cause identified in investigations for defects in the cultivation business. Sadly, little is known about the nature of these errors, mainly because our quest for the truth ends where it should begin, once we know it was a human error or is “someone’s fault.”
Yes, human error usually explains the reason for the occurrence, but the reason for that error remains unexplained and consequently the corrective and preventive actions fail to address the underlying conditions for that failure. This, in turn, translates into ineffective action plans that result in creating non-value added activities, wasting resources and money as well as product.
Human error growing oops seeds
Human error can occur when workers are in direct contact with the plant
So after investigating thousands of human error events and establishing systems to improve human reliability in manufacturing facilities, it became even clearer to me, the need to have good, human-engineered standard operating procedures (SOPs).
In the cannabis growing process, there are different types of mistakes that, when analyzed, all can be addressed in the same manner. For example, some common errors that we see are either overwatering or nutrient burn, which can occur when the plant is overfed. The same is true in the opposite scenario; underfeeding or under watering lead to problems as well. If your process is not automated, the reason for these failures was most likely human error. Now, why did the person make that mistake? Was there a procedure in place? Was the employee trained? Is there a specific process with steps, sub-steps, quantities and measures? Were tools available to be able to do the task correctly? There is so much that can be done about these questions if we had clear, well-written and simple, but specific instructions. The benefits greatly outweigh the effort required.
Also, besides providing step-by-step instructions to avoid commission errors (to perform incorrectly as opposed to omit some step), there are other types of errors that can be avoided with SOPs.
Dirty marijuana leaves
Decision making like detecting nutrient deficiencies can lead to human error.
Decision-making is another reason why we sometimes get different results than the ones expected. If during your process there are critical, knowledge-based decisions, workers need to be able to get all the information to detect as well as correct situations. Some decisions are, for example, when (detection) and how (steps) should I remove bud rot? Is there a critical step in the process (caution) to avoid other plants from becoming affected? Any information on the what, how, when, where and why reduces the likelihood of a decision error, later described as obvious.
When we face manufacturing challenges like nutrient deficiency in a particular stage, mold, fungus, gnats or even pollination of females, we want to do whatever we can to prevent it from happening again. So consider that from avoiding to detecting errors, procedures are a critical factor when improving human performance.
Here are some guidelines when writing procedures to prevent human error.
  1. Use them. Enforce the use of procedures at all times. As humans, we overestimate our abilities and tend to see procedures as an affront to our skills.
  2. Make sure it is a helpful procedure and users are involved in the process. People that participate in writing rules are more likely to follow them.
  3. Make sure they are available for their use.
  4. All critical activities should have a procedure.
  5. The procedure needs to be clear, have a good format, clear graphics, appropriate level of detail and specific presentation of limits.
  6. Make sure that facts, sequence and other requirements are correct and all possible conditions are considered e.g. “what if analysis”.
Human error won’t be eradicated unless we are able to really identify what is causing humans to err. If eliminating or “fixing” the actual individual eliminates or potentially reduces the probabilities of making that mistake again, then addressing the employee would be effective. But if there is a chance that the next in line will be able to make the same mistakes, consider evaluating human factors and not the human. Take a closer look and your process, system and ultimately your procedures.
In sickbay, after treatment, The Doctor gives Seven a hypospray and she wakes up but is disoriented and thinks she is still in the holodeck. She finally realizes her error and The Doctor explains the situation to her. Her cortical node began to shut down, but he was able to stabilize it before any permanent damage occurred. She tries to blame him, but he just continues on with the diagnostic on her entire cortical array.

"I wish to ask you a personal question." "Shoot." "You have an appealing coiffure. What is your grooming regimen?" "You're asking me what I do with my hair?" "Yes." "Erm, well, nothing too elaborate – sonic shower, a little engine grease. Thinking about a new look?" "Perhaps. I'll keep you apprised if you'd like." "Please do."

In order to help with the diagnosis, he wonders what she was doing before she collapsed. He goes through a series of possibilities, but all she tells him is that it was "research". He tells her that the simulation of Chakotay told him they were having an argument and points out some details of the program including her gorgeous dress. She realizes she can't hide it anymore.

The technique for human error rate prediction (THERP) is a first generation methodology, which means that its procedures follow the way conventional reliability analysis models a machine. The technique was developed in the Sandia Laboratories for the US Nuclear Regulatory Commission . Its primary author is Swain, who developed the THERP methodology gradually over a lengthy period of time. . THERP relies on a large human reliability database that contains HEPs, and is based upon both plant data and expert judgments. The technique was the first approach in HRA to come into broad use and is still widely used in a range of applications even beyond its original nuclear setting.

All hope seems lost when Seven calls up from astrometrics. She believes she can disarm the warhead by extracting the detonator with the transporter. Janeway doesn't believe she can get a lock on it since it's so small and they're traveling so fast. Seven thinks that if she can use the sub-micron imager to focus the targeting scanners, she can lock on and beam it out. Janeway is running out of options, so she agrees.

When Seven responds, it is revealed that the piano playing and the baby shower were part of a holodeck program designed to help Seven of Nine become more comfortable in social situations. She ends the program and her clothes change back to normal and her ocular implant reappears. On her way out of the holodeck, she rearranges her hair back to its normal French twist coiffure.

THERP models human error probabilities (HEPs) using a fault-tree approach, in a similar way to an engineering risk assessment, but also accounts for performance shaping factors (PSFs) that may influence these probabilities. The probabilities for the human reliability analysis event tree (HRAET), which is the primary tool for assessment, are nominally calculated from the database developed by the authors Swain and Guttman; local data e.g. from simulators or accident reports may however be used instead. The resultant tree portrays a step by step account of the stages involved in a task, in a logical order. The technique is known as a total methodology as it simultaneously manages a number of different activities including task analysis, error identification, representation in form of HRAET and HEP quantification.

Recently, there has been a renewed interest in problem driving behaviors such as running traffic signals, following too closely, aggressive lane changing, driving too fast for conditions, and driving while inattentive to the driving task. However, there has been a lack of specific data necessary to identify, characterize, and categorize "crash problem types," which has restricted efforts directed at problem driving behaviors. In order to develop more effective countermeasures, specific problem behaviors that cause crashes, and the conditions and situational factors associated with those crashes, must be identified.
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