case study for tpm improving operational accuracy

7/29/2019 Case Study for TPM Improving Operational Accuracy

1/69

Polaris Veritas, Inc.

Improving Operational Accuracy

A structured systems approach to

Mistake Proofing / ErrorReduction in the Process Industry

Surviving in a world dominated bylow cost Asian manufacturers


2/69

.

Improving Operational Accuracy Becoming Aware of the nature of Errors

The role of Limbic Responses and how to mitigate the effects How we can change the expectations and behaviors of the operating team

Accountability and Mutual Support Checklists & 2 nd pair of eyes Measure Results

The When, How, Why and Who of Error Proofing Identifying Bear Traps we set for the average operator The Error / Defect pyramids The Potential Error Review Technique and ABC methodology Concentrating on the three weakest areas Poke Yoke, Checklists, 2 nd Pair of Eyes

Conservative Decision Making Management of Change Non Penal Leading Indicators short term reward


3/69

.

PROGRAM JUSTIFICATION

Currently China and Asia in general havemanufacturing costs of 1/3 1/5 those ofNorth America and Europe

Hoping to survive most internationalmanufacturers have built plants thereusing the latest technology

Making the manufacturers decision tomove operations to China a difficult one


4/69

.

Typical Reliability ImprovementPrograms Involve

Condition Based Maintenance

Work Planning and Scheduling

Multilevel Root Cause Analysis

Written Management Practices

Operator Asset Care

Reliability Centered Maintenance

Operational Accuracy Improvement - Mistake

Proofing / Error Reduction

Achieving better than < 1:400 errors OperatingAccuracy


5/69

.

PROGRAM JUSTIFICATIONWorld Class Performance (


6/69

.

REACTIVE

PROACTIVE

PRECISION

WORLD CLASS

OPERATIONS

Responsive

Work

Planned

Work

Proactive & Disciplined

Routine Problem

Solving

Problem Solving

Focused

Organizational

Learning

NATURE OF BEHAVIOR

OPERATIO

NAL

PERFORMANCE

PLANN

ED

Stable

Sustainable Cultures

TYPICAL ACTIVITIES FOR THE FOUR

STABLE OPERATING STATES

Lead/Com - 0

Planned work 24/yr.

ORIGINAL MAT BYLEDET ENTERPRIZES

Error Rate1: 40

Error Rate 1 : 400 +


7/69

.

PROGRAM JUSTIFICATION

Operating Accuracy

(Responds poorly to more capital spending

and engineering)

Maintenance materials

Maintenance workmanship

Raw materials Equipment / Process Design

45% +

7%

18%

5%

25%

Published research discuss the five sources of defects :


8/69

.

AWARENESS Everyone makes mistakes - our object is to

reduce the number and their impact usingteamwork and improved methods

There are no dumb questions

What we think we know but dont is mostdangerous

What is your current operational Error Rate?Probably 1:40 but it could be 1:400

What methods do you use for improving yourown accuracy? Defensive Driving

Improving golf

Having your spouse check what you have written


9/69

.

AWARENESS In football nobody knowingly drops a pass

In life nobody knowingly makes an error

But there still are many dropped passes and errors

criticism & blame only makes matters worse

Refer to the www. Human Error. com

Professors Panko, Reppening, and Stout

www.serendip.brynmawr.edu

seeing is not believing
http://www.serendip.brynmawr.edu/http://www.serendip.brynmawr.edu/


10/69

.

AWARENESSOur (societies) negative attitude to errors:

The banana skin

Funniest home movies

= Pain, weakness, shame and embarrassment

Cover it up as quickly as possible

Punishment has no place in the error reductionprocess

Preventing small errors from becoming defects

We are not fully responsible for our own actions


11/69

.

STUDY ACTIVITY ERRORRATE

Baddeley & Longman

[1973]

Entering mail codes. Errors after correction. Per mail code. 0.5%

Chedru & Geschwind[1972]

Grammatical errors per word 1.1%

Dhillon [1986] Reading a gauge incorrectly. Per read. = 1 : 200 0.5%

Dremen and Berry [1995] Percentage error in security analysts' earnings forecasts for reporting earnings.1980 / 1985 / 1990. That is, size of error rather than frequency of error.

30%

52%

65%

Edmondson [1996] Errors per medication in hospital, based on data presented in the paper.Per dose. = 1 : 60

1.6%

Grudin [1983] Error rate per keystroke for six expert typists. Told not to correct errors, althoughsome did. Per keystroke.

1%

Hotopf [1980] S sample (speech errors). Per word 0.2%

Hotopf [1980] W sample (written exam). Per word 0.9%

Hotopf [1980] 10 undergraduates write for 30 minutes, grammatical and spelling errors perword

1.6%

Klemmer [1962] Keypunch machine operators, errors per character 0.02% to0.06%

Professor - Raymond Panko - The Human Error Expert


12/69

.

Klemmer [1962] Bank machine operators, errors per check 0.03%

Kukich [1992] Nonword spelling errors in uses of telecommunication devices for the deaf. 40,000words (strings). Per string.

6%

Mathias, MacKenzie &Buxton [1996]

10 touch typists averaging 58 words per minute. No error correction. In last session. Perkeystroke.

4%

Mattson & Baars [1992] Typing study with secretaries and clerks. Nonsense words. Per nonsense word. 7.4%

Melchers & Harrington[1982]

Students performing calculator tasks and table lookup tasks. Per multipart calculation.Per table lookup. Etc.

1%-2%

Mitton [1987] Study of 170,016 errors in high-school essays, spelling errors. Per word. 2.4%

Potter [1995] Errors in making entries in an aircraft flight management system. Per keystroke. Higherif heavy workload.= 1 : 10

10.0%

Rabbit [1990] Flash one of two letters on display screen. Subject hits one of two keys in response.After correction. Per choice.

0.6%

Schoonard & Boies [1975] Line-oriented text editor. Error rate per word. 3.4% without correction, 0.52% with errorcorrection. an improvement of 500%

3.9%

Shaffer & Hardwick [1968] Residual typing errors per character. Subjects with error rates higher than 2.5% wereexcluded. All qualified touch typists, including excluded. 20 subjects finally used.

0.63%

Swain & Guttman [1983] Interpreting indication on an indicator lamp. Per interpretation. 1 : 1000 0.1%

Swain & Guttman [1983] Error reading an analog meter. Per read. = 1 : 333 0.3%

Swain & Guttman [1983] Choosing an incorrect panel control from a number of similar controls.Per choice.=1 : 333

0.3%

Swain & Guttman [1983] Error reading chart recorder. Per read. = 1 : 166 0.6%

Swain & Guttman [1983] Error reading a graph. Per read. = 1 : 100 1%

Swain & Guttman [1983] Turning control in wrong direction under extreme stress. Per turn. = 1 : 2 50%

Tsao [1990] Nonword spelling errors in uses of TDD (telecommunication devices for the deaf)130,000 strings. Per string.

5%


13/69

.

MYSTERIES OF THE HUMAN BRAIN

FRONTAL LOBE HIJACKING - some less obvious possible causes of error

YOUThe Responsible

Frontal lobes

NEO MAMMALIANOuter sections

REPTILECore

L

IMBIC

DRIVES

Our 21 st Century brains crave limbicstimulation Action Movies, Thrillers etc


14/69

.

AWARENESS The brain is essentially unchanged in 35,000 years Left Over'sCanine teeth, Tails, Sympathetic Yawning, Tonsils Limbic

responses Reptilian, Neo Mammalian These responses frequently control your mind - (cerebrum) rather than

you control it Your error prone brain uses complex task sharing and short cuts It cuts & pastes information to speed operation (schema) At any point in time it might have multiple mental processes going on

that you are not aware of We have little personal control of how and why the brain does all of

thisworry / preoccupado Even seeing shouldnt be believing Fatigue & Boredom makes the Limbic Hijacking Process more likely.

Drugs that improve itRitalin ?????


15/69

.

YOUR LIMBIC RESPONSE WILLDRIVE YOU TO -

Conform to Group Behavior - Group Conformance In a group we assume that someone else will take care of a problem

- Sociproof Dilution of responsibility in the herd - Sociproof Try to achieve the highest possible status - Power Protect possession and Defend team members -Territorialism

(The home team usually wins) Sex drive - ?????

Fear and destroy anything different or that which might weaken the tribe- Security

THESE ALL HAVE NEGATIVE EFFECTS IN THE WORKPLACE


16/69

.

When, How, Why, & What you can doto reduce the number and seriousness

of errors ??? When do the errors occur ?

How do the errors occur ?

Why do the errors occur ?

What is their nature ?


17/69

.

WHENConditions for increased potential damaging event risk:Low Risk - STABLE OPERATION (95% - 5%)

Extended uneventful vigilance Getting locked into a sub routine (schema) Normal activity

High Risk - TRANSITIONAL OPERATION (5% - 95%) Start-Up and Shut-DownContinuous process plants Upset Operating Condition Emergency Operation Time of day / night High Fatigue

Overtime - extended periods without breaks

Counter progressive shift rotation Not warming up after long break

Unfamiliar Team Make Up Other High Stress

Concentrate improvement effort on transitional situations afteranalyzing error patterns


18/69

.

WHYTypes of Deviation Errors

INTENTIONAL

OMISSION

COMMISSION

UNINTENTIONAL

DELAY MOVINGTO NEXT STEP

ADDING ALITTLE EXTRA

CATALYST

FAILING TOADD ANY

CATALYST

ADDING THE

WRONG MATERIAL

Sources Analysis of hundreds ofRCAs, CMA,

HOW


19/69

.

WHEN

EXTREME STRESSAND THREAT

APPROACHINGLOSS OFOPERATING

NORMAL ACTIVITY

LOW STRESS

UNEVENTFUL

OBJECTIVE

< 1: 400WORSENING

PERFORMANCEEFFECTIVENES

S

(errorrate)

TASK LOAD

& FATIQUE

1:2 5 (ORWORSE)

CONTROL

HIGH STRESS

UPSET

CONDITIONSTART UP / SHUTDOWN

ACTUAL

< 1: 250

MODERATESTRESS

EXTENDED

VIGILANCE -

INATTENTIVE

BLINDNESS

THE FREQUENCY OF OPERATING ERROR (THERP)


20/69

.

WHEN START ++++ HIGH RISK

RELIABILITY / LIFE REDUCING STEPS


21/69

.

IMPROVING THE SITUATION


22/69

.

Operating Accuracy - Creating an Error Free

Environment

You need to learn from the mistakes of others, youllnever live long enough to make them all yourself

Maybe it was time that we stopped shouting at thedarkness and started lighting candles?

understanding the other guys problem

Nobody ever gets credit for fixing things which didnthappen!

Organizational Transparency is enough to drive theimprovements we seek?


23/69

.

FATALITIES

SERIOUS

MINORS &NEAR MISSES

UNSAFEBEHAVIOR

CATASTROPHICFAILURE

MAJOR UNPLANNED

PROCESSINTERUPTION

MINOR DEFECTS

EXTENDED PLANTS/D

SERIOUS PROCESSUPSET

MINOR DEVIATION

POTENTIAL ERRORSUNDETECTED

PRODUCT RECALL

MAJOR ISSUEBEFORE DELIVERY

ISSUE DETECTEDBUT RECOVERABLEIN PART

UNRECOGNIZEDDEFECTS

1

7

3500

35000


24/69

.

ERROR ANALYSIS - TRIANGLES

In each case, reducing the size of thetriangles base, reduces the frequency ofall the categories of defects

i.e.THE TYPES OF MINOR ISSUES ARE INDICATORS OFLARGER ISSUES

The need to permanently influence /change the behaviors causing the problem

by measuring performance and givingpositive feedback

Non penal


25/69

.

Who sees ERRORS

VISIBLE

INVISIBLE

8 of 39,000

POTENTIAL ERRORS

THE ERRORS A REGULAROPERATOR SEES

Need Root Cause Analysis$$$$$$$$$$

MINOR ERRORS

SERIOUS

MAJOR

WHAT THE TRAINED

OBSERVER SEES


26/69

.

SOME TYPICAL OPERATIONAL DEFECTS

1. Missing a step from a procedure 2. Misreading a gage Not sealing (or reporting) process

leakages - blockage 3. Using incorrect tool or apparatus 4. Over / under fills vessel or tank 5. Not receiving or passing on a report

from interfacing shift team 6. Transposing digits in a number series 7. Incorrectly positions valves 8. . Repeatedly resetting an alarm or

other protective devices without action 9. Slow delayed required action 10. Not turning off idle equipment 11. Not making a decision when one

was required 12. Ignoring a process oscillation /

instability 13. Failure to notify others of observed

defects 14. Misunderstanding a request and not

asking the instructor to repeat request Change room shift changeovers

16. Operating equipment withoutunderstanding or authority not havingbeen trained

17. Not leaving something in a securemode

18. Operating something too fast or slow 19. Removing a safety device or

identifying tab 20. Operating equipment known to be

defective without reporting it 21. Improper feed rate or load 22. Adding wrong material to batch 23. Working on equipment while it is

running 24. Not referring to operating procedures

as required 25. Not using (and signing) the correct

checklist where one exists 26. Not preparing equipment / work

permits for repair after written request 27. Not understanding and being afraid

to ask about the chemistry or physicsinvolved

28. Interrupting another person in the

middle of a complex task


27/69

.

THE IMPROVEMENT PROCESS


28/69

.

The Process of Mistake Proofing / Error Reduction

Potential Error Review Technique

The program aims to collect Comprehensive Data provided primarily but notexclusively by operators on the potential error forms

The defect data is then analyzed and classified - ten buckets Assign a proven Resource / Technique / Technology to address each

source of the defects Using the ABC - behavioral-based safety principle of implementation

Antecedent BehaviorConsequence..C B A

i.e. Starting with consequence (the screw up) move to the behavior whichpreceded it and finally to the Antecedent .the condition whichfundamentally set it up to happen.

Only dereliction of duty will bring serious sanction sleeping on job, maliceetc. Management must be commitment to a multilevel team based non penalinitiative

The concept of taking increasingly conservative actions as stress increases is

critical


29/69

.

POTENTIAL ERROR REVIEWTECHNIQUE

Has at its core three questions:

When would a new operator be most likely to make a mistake?

What bear traps have we inadvertently created that the newoperator might step on or fall into?

What errors or potential errors have you recognized in the lastshift cycle?

With that knowledge classify the errors and act to reduce them

with specific narrowly focused techniques

STICKY LABEL


30/69

.

COLLECTING DATA - ANY OBSERVEDACTUAL SITUATION OR ACTIVITY WITH

POTENTIAL FOR ERROR

WEEK ENDINGSHIFT(Optional)

MAXIMUM OF THREE ASSOCIATED DEVIATIONS

ANALYSIS COLUMN LEAVE BLANK

DESCRIBE SITUATION OR INCIDENT (50 WORDS) DO NOT INCLUDE NAMES

Hey ! This looks like an bear trap to me ?


31/69

.

THIS IS A BEAR TRAP

WEEKENDING

SHIFT

MAXIMUM OF THREE ASSOCIATED DEVIATIONS

ANALYSIS COLUMN LEAVE BLANK

DESCRIBESITUATION OR INCIDENT (50 WORDS) DO NOT INCLUDENAMES.

The temperature gauge on the # 3 hot oil header is obscured bydirty oil on the face and is reading 50 F degrees low THIS IS A BEAR

TRAP REPORT(potential error)

# 8431

# 8431


32/69

.

ANALYTICAL METHODOLOGY

Having achieved AWARENESS we drive thechange using -

ANTECEDENT Anything which precedes andtriggers the imperfect behavior

BEHAVIOR An observable act which is error prone

CONSEQUENCE Anything which directly followsfrom the Behaviors Creates a potential for error


33/69

.


34/69

.

THE LINK BETWEEN RCA AND ABC

ABC Root Cause Analysis

(Small Issues) (Big Issues)

ANTECEDENT. LATENTCY

BEHAVIOR HUMAN FACTORS

CONSEQUENCE CAUSE

DEFECT CLASSIFICATION THE TEN BUCKETS


35/69

.

DEFECT CLASSIFICATION THE TEN BUCKETS

1. Not understanding or participating in structured defect recognition & elimination

2. Lack of clear work instructions Cluttered Presentation Confused Priorities

3. Inadequate person to person & person to group communication

4. Insufficient individual knowledge, accountability & skills training

5. Inadequate tools & equipment

6. Lack of a well defined standard of performance

7. Lack of personal capability / attention / attitude / hurry / overload

8. Lack of understanding of the risk of and management of change

9. Insufficient recognition of appropriate effort *

10. Lack of Tactical Administration, Conservative Decision Making & Leadership (vision) *

* These are linked


36/69

.

IMPLEMENT PROGRAMS IN COMBINATION1. Structured defect recognition & elimination (Counter Intuitive Aspects)

2. Write clear work instructions Remove cluttered presentation and confused priorities

Look for Poke Yoke opportunities

3. Create written standards for person to person & person to group communication

4. Assign accountability, provide appropriate training and testing

5. Asses the need and provide tools & equipment

6. Write a series of defined operating standards incorporating the 2 nd pair of eyesconcept

7. Minimize periods of / hurry / overload by improved planning and seek ways to showthat changes in individual and group attitude can improve job satisfaction

8. Educate the team in the risks of Management of Change and Conservative DecisionMaking

9. Educate the supervisors and team members how to recognize and reward appropriateeffort *

10. Educate the team so that they can positively influence the Leadership Vision: andday to day - Tactical Administration *

h l d l


37/69

.

The Role Model Operator Has early recognition of small but abnormal

incongruous conditions

Routinely checks himself and others

Takes appropriate action based on aConservative Decision Making Process

Is comfortable with the consequences of acting

more slowly when fatigued or under stress

Communicates critical information in writing


38/69

.

A FEW EXAMPLES


39/69

.

Consequence Operator misses a step in aninfrequently practiced procedure

Behavior He never refers to the out-of-date SOPs and hasno consideration of Self Checks or 2 nd pair of eyes

AntecedentThe SOPs are inaccurate + I know the job.

(Added to much or too little, didnt understand consequence of increased volume)

DEFECT CLASSIFICATION Primary Defect - Lack of available clear work instruction (5)

Secondary Defect - Lack of positive attitude and personalattention (3)

Contributory defect - Insufficient individual knowledge (1)

OLD STYLE OPERATING PROCEDURE


40/69

.

OLD STYLE OPERATING PROCEDURE

IF THIS WAS A HIGH SCORING DEFECT


41/69

.

IF THIS WAS A HIGH SCORING DEFECT

Have operators rewrite the operating procedures in TabularSimplified Pictorial format

Simplified using road signs

TabloidT bar Pictorial pictures and diagrams

These would incorporate extensive use of OperatingChecklists during the periods of greatest risk

Write separate sections in procedure documents dedicatedto dealing with Transitional Difficulties and Troubleshooting written by operators for operators

PICTORIAL TABLOID PROCEDURE FORMAT


42/69

.

PICTORIAL TABLOID PROCEDURE FORMAT

STEPS DETAILS

CONSEQUENCES OF

DEVIATION

IF: An overcharge occursTHEN: temperature control can

be lost

1. Open water charge valve and add100 gallons of water

2. Open acid valve and add 5gallons of 30% acid over 5minutes

3. Charge 80 lbs of catalyst throughman way

4. Start Agitator

The water valve number V-132 , turn onefull turn clockwise to ensure that

it is fully closed after chargingWATER

The acid valve is a quarter turn ballvalve. It must be fully open ( handle isin-line with the pipe)

DO NOT: Delay starting the agitator itmust be started within one minute ofcharging catalystCONSEQUENCE: The vessel outlet willbe plugged and an uncontrolled reactioncould occur

w

CHECKLIST

PLUS DIAGRAMS

B OPERATOR


43/69

.

STEPS

1. Open water charge valve and add 100gallons of water

2. Open acid valve and add 5 gallonsof 30% acid over 5 minutes

3. Charge 80 lbs of catalyst throughman way

4. Start Agitator

* Step doesnt say start immediately


44/69

.

A SECOND EXAMPLE OF ERROR CLASSIFICATION

Consequence 2 nd shift double charged catalyst

Behavior Relying on verbal - Casual word of mouth communication

AntecedentHe thought that telling Joe was adequate

(The operator was in a hurry to get home)

DEFECT CLASSIFICATION

Primary defect - Deficient person to person & person to group

communication Secondary - Lack of a Defined Standard of Communication on Shift

Change both verbal and documentary

Contributory - Lack of positive attitude and personal attention

CORRECTIVE ACTION THE TEAM WOULD CREATE A


45/69

.

CORRECTIVE ACTION - THE TEAM WOULD CREATE ANEW PERFORMANCE STANDARD

Deficient person to person or person to groupcommunication

Remedial action write and implement new standardinvolving the following -

Person to Person Communication Standard

Formal (written) shift change communication Best Practice isadhered to

There are no change room exchanges The relief shift supervisor starts 30 Mins before his crew

Written mandatory electronic shift logs with routine review Individual operators to routinely check each other whileperforming complex tasks


46/69

.

Periodical Self Audits AgainstWritten Standards

A Performance Standard for Operations

EXAMPLE


47/69

.

OPERATIONAL ACCURACY PERFORMANCE STANDARD EXAMPLEHow will we know when we are successful?

100%100%100%100%100%100%

80%

100%100%100%100%

90%

90%90%100%80%50%

80%90%60%

1.S O Ps accuracy and claritySOPs are in Simplified /Tabular/ Pictorial format.Multiple checklist are in routine useMarking/Clarity, Accessibility and Orientation of Controls is excellent.Possibility of accidental activation is eliminatedCritical settings are secureEmergency Controls clearly markedAmount of force / effort is appropriate

Bear trap stickers are applied when potential errors are recognizedPoka Yoke techniques are used

2.Personal and group communicationGroup Communication

With the creation of Transparency rather than impose punitive disciplinereviews are made against a Formal Written standard for Groupcommunication -

Daily 24 hour operating reviewProduction/ Maintenance - daily planningMonthly defects checklists are usedMonthly issues are formally ANALYZED and reviewedPlant Managers communication

Person to Person CommunicationFormal (written) shift change communication Best Practice is adhered toThere are no Change room exchangesElectronic shift log analysisThe relief shift supervisor starts 30 Mins before his crew Individual operators routinely check each other while performing complex tasks

Observed

Level of

Success

Target

Level of

Success

Work Process Measure

SUSTAINING THE CHANGE


48/69

.

SUSTAINING THE CHANGE The Hawthorn Effect

What gets measured, most often, gets improved+ leading indicators

Monthly Data shortest practical period

Requires that feedback be

SOON - CERTAIN - POSITIVE(rather thanlate occasionalnegative)

Peer (trained observer) to Peer immediate

Kaizen Team Based approach Leading Indicators Short term reward - Points

systemgain share..

Periodic Audit

TIMING - WHEN TO ATTEMPT

OPERATIONAL ACCURACY


49/69

.

Responsive

Work

Planned

Work

Proactive & Disciplined

Routine Problem

Solving

Problem Solving

Focused

Organization

Learning

NATURE OF BEHAVIOR

OPERATIONAL

PERFORM

ANCE

REACTIVE

PLANNED

PROACTIVE

PRECISION

WORLD CLASSOPERATIONS

OPERATIONAL ACCURACY

IMPROVEMENT

OD < 100 points

Lead/Com - 0

Planned work 250 points

Lead/Com 100%Planned work >95%

PdM based >75%

BP/RCA implemented /

shared

>24/yr.

ORIGINAL MAT BY

LEDET ENTERPRIZES

REVIEW


50/69

.

REVIEW The significance of Improving / Understanding

Operating Accuracy and how it compliments overall

reliability improvement programs Having operators own the improvement process Getting rewarded for driving slower when under stress The underlying conceptsErrors are everywhere

(Panko) Who, when & why the errors are made Collecting details and classifying them by type Narrowly focusing on the most common ten

classes of defect and what we can do to reducethem

The ABC methodology: Antecedent Behavior- -Consequence

The difficulties of Implementation - Trainingoperators as observers

Provide feedback using Leading Indicators

AWARENESS

TECHNIQUE

1

TECHNIQUE2

PROGRAM SUMMARY


51/69

.

PROGRAM SUMMARY Awareness Problem Prevention Understanding and dealing with your Limbic Responses

Change expectations and behaviors Accountability and Mutual Support Checklists & 2 nd pair of eyes Measure Results

Identifying Bear Traps Analytical technique - The Potential Error Review Technique - ABC Root Cause Analysis After analysis concentrate on the three weakest areas Poke Yoke, Checklists, 2 nd Pair of Eyes Management of Change Conservative Decision Making Non Penal Kaizen - Team based approach Leading Indicators short term reward 2 5 year implementation


52/69

.

AN E-MAIL SURPRISE

A Recent Message from a Christian Friend


53/69

.

A Recent Message from a Christian Friend CHRISTIAN WAYS TO REDUCE STRESS

An Angel says, "Never borrow from the future. If you worry about what may happen tomorrow and it doesn't happen, you haveworried in vain. Even if it does happen, you have to worry twice."

1. Pray

2. Go to bed on time.

3. Get up on time so you can start the day unrushed.

4. Say No to projects that won't fit into your time schedule, or that will compromise your mental health.

5. Delegate tasks to capable others.

6. Simplify and unclutter your life.

7. Less is more. (Although one is often not enough, two are often too many.)

8. Allow extra time to do things and to get to places.

9. Pace yourself. Spread out big changes and difficult projects over time; don't lump the hard things all together.

10. Take one day at a time.

11. Separate worries from concerns. If a situation is a concern, find out what God would have you do and let go of the anxiety. If youcan't do anything about a situation, forget it.

12. Live within your budget; don't use credit cards for ordinary purchases.

13. Have backups; an extra car key in your wallet, an extra house key buried in the garden, extra stamps, etc.

14. K.M.S. (Keep Mouth Shut). This single piece of advice can prevent an enormous amount of trouble.

15. Do something for the Kid in You everyday.

16. Carry a Bible with you to read while waiting in line.

17. Get enough rest.

18. Eat right.

19. Get organized so everything has its place.


54/69

.

20. Listen to a tape while driving that can help improve your quality of life.

21. Write down thoughts and inspirations.

22. Every day, find time to be alone.

23. Having problems? Talk to God on the spot. Try to nip small problems in the bud. Don't wait until it's time to go to bed to try andpray.

24. Make friends with Godly people.

25. Keep a folder of favorite scriptures on hand.

26. Remember that the shortest bridge between despair and hope is often a good "Thank you Jesus."

27. Laugh.

28. Laugh some more!

29. Take your work seriously, but not yourself at all.

30. Develop a forgiving attitude (most people are doing the best they can).

31. Be kind to unkind people (they probably need it the most.

32. Sit on your ego.

33. Talk less; listen more.

34. Slow down.

35. Remind yourself that you are not the general manager of the universe.

36 . Every night before bed, think of one thing you're grateful for that you've never been grateful for before. GOD HAS A WAY OF

TURNING THINGS AROUND FOR YOU. "If God is for us, who can be against us?" (Romans 8:31)


55/69

.

Questions ?

For a copy of the updated paper or thePowerPoint presentation please email

me at

[email protected]

A just discovered conceptA second pair of eyes

POLARIS VERITAS INC


56/69

.

POLARIS VERITAS, INC.(Stellar North)

Reliability andProcess Safety

Consultants

Houston, Texas, USA

Phone: (01) 281 280 [email protected]

Driving your Manufacturing

Efficiency to World Class


57/69

.

BACK UP SLIDES


58/69

.

SO YOU THINK SEEING IS BELIEVING


59/69

.

The Hole in the Retina


60/69

.

Going up or Down ?


61/69

.

Front or Back


62/69

.


63/69

.

Curved or Straight Lines ?


64/69

.

Gray Dots ?


65/69

.

WHO DO YOU THINK YOU ARE?


66/69

.

Brain Structure FunctionAssociated Signs and Symptoms

of Damage

YOU

The outermost layer of the cerebralhemisphere which is composed of graymatter. Cortices are asymmetrical. Bothhemispheres are able to analyze sensorydata, perform memory functions, learn newinformation, form thoughts and makedecisions.

Left Hemisphere Sequential Analysis: systematic, logical

interpretation of information. Interpretationand production of symbolic information:language, mathematics, abstraction andreasoning. Memory stored in a languageformat.

Right Hemisphere Holistic Functioning: processing multi-sensory input simultaneously to provide"holistic" picture of one's environment.Visual spatial skills. Holistic functions suchas dancing and gymnastics are coordinated

by the right hemisphere. Memory is storedin auditory, visual and spatial modalities.

CORPUS CALLOSUM

Connects right and left hemisphere to allowfor communication between thehemispheres. Forms roof of the lateral andthird ventricles.

Damage to the Corpus Callosum may result in "SplitBrain" syndrome.

CEREBRAL CORTEX

Cognition and memory.Prefrontal area: The ability to concentrateand attend, elaboration of thought. The"G t k " (j d t i hibiti )

Impairment of recent memory, inattentiveness,inability to concentrate, behavior disorders, difficultyi l i i f ti L k f i hibiti


67/69

.

Basal Ganglia

FRONTAL LOBE

"Gatekeeper"; (judgment, inhibition).Personality and emotional traits.Movement:Motor Cortex (Brodman's): voluntary motoractivity.Premotor Cortex: storage of motor patternsand voluntary activities.Language: motor speech

in learning new information. Lack of inhibition(inappropriate social and/or sexual behavior).Emotional liability. "Flat" affect.Contralateral plegia, paresis.Expressive/motor aphasia.

PARIETAL LOBE

Processing of sensory input, sensorydiscrimination.Body orientation.

Primary/ secondary somatic area.

Inability to discriminate between sensory stimuli.Inability to locate and recognize parts of the body(Neglect).Severe Injury: Inability to recognize self.Disorientation of environment space.Inability to write.

Primary visual reception area.

Primary visual association area: Allows for

visual interpretation.

Primary Visual Cortex: loss of vision opposite field.Visual Association Cortex: loss of ability torecognize object seen in opposite field of vision,

"flash of light", "stars".

Auditory receptive area and associationareas.Expressed behavior.Language: Receptive speech.Memory: Information retrieval.

Hearing deficits.Agitation, irritability, childish behavior.Receptive/ sensory aphasia.

THE UNDER.ESTIMATED LIMBIC YOU

Olfactory and their different pathways.Hippocampi and their different pathways.

Limbic lobes: Sex, rage, fear; emotions.Integration of recent memory, biologicalrhythms. Hypothalamus.

Loss of sense of smell.

Agitation, loss of control of emotion. Loss of recentmemory.

Sub cortical gray matter nuclei. Processinglink between thalamus and motor cortex.Initiation and direction of voluntarymovement. Balance (inhibitory), Posturalreflexes.Part of extrapyramidal system: regulation ofautomatic movement.

Movement disorders: chorea, tremors at rest andwith initiation of movement, abnormal increase inmuscle tone, difficulty initiating movement.Parkinson's.

What makes o niq e Aptit des & Attit des


68/69

.

LIMBIC

DRIVES

HIGH

MEDIUM

LOW

PURPOSE SOCIAL POWER SEXUAL TERRITORIAL SECURITY

FUNCTIONALPROGRAMS(INATEABILITIES)

PHYSICALDEXTERITY

INTELLIGENCE

MEMORY

LANGUAGE

ENERGY

SENSITIVITY

PHYSIQUE

ANGERCONTROL

What makes you unique Aptitudes & Attitudes

WHAT IS PROVIDED?


69/69

WHAT IS PROVIDED?Training and Implementation Support using proven programs

First we create awareness of an error filled environment

Describe the negative aspects of the Limbic Responses

Implement a program to recognize and remove the errors

Calculate the cost of actual and potential errors

Implement programs to address the Ten defect areas to include

1. Simplified pictorial, tabular, procedures writing

2. Coaching and checking one another in error reduction

3. Improving accurate communication both individual & group

4. Creating a 1:400 error performance standard

5. Describing appropriate decisions & leadership6. Simplifying methods and equipment marking

7. Formally solving associated problems at all levels

8. Identifying and minimizing contributory system instabilities

9. Dealing with changes in processes and people

case study for tpm improving operational accuracy

Documents