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Joel E. Heim Manager, Training & Development
Human Performance Improvement
Through a Just Culture
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Moving from a Reactive Safety Culture
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Principles of Human Performance
• People are fallible, and even the best people make
mistakes
• Error-likely situations are predictable, manageable,
and preventable
• Individual behavior is influenced by organizational
processes and values
• People achieve high levels of performance because
of the encouragement and reinforcement received
from leaders, peers, and subordinates
• Events can be avoided through an understanding of
the reasons mistakes occur and application of the
lessons learned from past events or errors
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12 Most Common Causes of Human Error
• Lack of Communication
• Lack of Teamwork (No Peer Caring)
• Norms (Culture)
• Pressure (Shortcuts)
• Complacency
• Lack of Knowledge (Unconscious Incompetence)
• Lack of Awareness
• Lack of Resources
• Distraction
• Lack of Assertiveness (Courage to speak up)
• Fatigue
• Stress
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Information Word Game
✓ Bed
✓ Rest
✓ Awake
✓ Snooze
✓ Nap
✓ Drowsy
✓ Pillow
✓ Wake
✓ Tired
✓ Blanket
✓ Slumber
✓ Peace
✓ Yawn
✓ Doze
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Error Precursors (Error Traps)
• Task Demands
– Time pressure
– High workload
– Simultaneous tasks
– Repetitive tasks
– Monotony
– Unclear goals
– Unclear standards
• Individual Capabilities
– Unfamiliarity with task
– Lack of knowledge
– Poor communication
– Inexperience
– Illness / Fatigue
– Unsafe attitude
– Major life event
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Error Precursors (Error Traps)
• Work Environment
– Distractions
– Interruptions
– Departure from routine
– Work-arounds
– Personality conflicts
– Shift changes
– Production
overemphasis
– Physical climate
• Human Nature
– Stress / Mental strain
– Habits / Biases
– Assumptions / Mindset
– Complacency
– Overconfidence
– Inaccurate risk
perception
– Limited memory
– Circadian rhythm
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Unsafe Attitudes / At-Risk Behaviors
• Pride
– “Don’t tell me what to do”
• Heroic
– Custer at Little Big Horn, “Here I come to save the day”
• Fatalistic
– Predetermined, Inevitable, “Let the chips fall where they may”
• Invulnerability
– “Nothing will happen to me”
• Pollyanna
– “All is well”, “What can go wrong”, “It’s routine”
• Bald Tire
– “We’ve always done it this way”
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Team Errors
• Halo Effect
– Blind trust due to experience or education
• Pilot / Co-pilot
– Reluctance of subordinate to question senior person
• Free Riding
– Taking passive role
• Groupthink
– Reluctance to question group opinion
• Diffusion of Responsibility
– Spread the blame
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Error Likely Situations
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Moving to a Just Culture
• Manage your state and habits of mind
• Pay attention to what stories you tell yourself
• Be aware of your mental biases
– Invincibility / Invulnerability
– Fundamental Attribution Error
– Outcome Bias
– Hindsight Bias
– Confirmation Bias
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Why We Do What We Do
• Antecedent
– Prompts a Behavior
• Behavior
– Specific muscle movement
• Consequence
– What happens to us
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Behavioral Consequences
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R+ positive reinforcement
R- negative reinforcement
P+ Punishment
P- Penalty
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Behavioral Consequences
• Determine the probability of a behavior re-occurring
• Will be either:
– Positive or Negative
– Immediate or Future
– Certain or Uncertain
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Establish and Maintain a Just Culture
• An open, honest, reporting culture
• Look at the intent, not just the consequence
– Get away from fault and blame
• Recognize the difference between errors and
violations
– Errors are unintentional slips or lapses
– Violations are intentional
• Balanced accountability is the key
• Just Culture begins with Trust
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Five Dysfunctions of a Team
• Inattention to Results
• Avoidance of Accountability
• Lack of Commitment
• Fear of Conflict
• Absence of Trust
23From “The Five Dysfunctions of a Team” – Patrick Lencioni
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Strategic Approach for Human Performance
• Anticipate, prevent, catch, and recover from active
errors at the job site
– Preparation
– Performance
– Feedback
• Identify and eliminate latent organizational
weaknesses that provoke human error and degrade
controls against error and consequences of error
– Control hazards by elimination or substitution
– Engineered Features
– Administrative Provisions
– Cultural “Norms”
– Oversight
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Human Performance Tools
• Task Preview
• Job-site Review
• Questioning Attitude
• Stop when Unsure
• Procedure Use and
Adherence
• 3-way Communication
• Phonetic Alphabet
• Pre-job Briefing
• Post job Review
• Concurrent Verification
• Independent Verification
• Place-keeping
• Validating Assumptions
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Principles of Human Performance
• People are fallible, and even the best people make
mistakes
• Error-likely situations are predictable, manageable,
and preventable
• Individual behavior is influenced by organizational
processes and values
• People achieve high levels of performance because
of the encouragement and reinforcement received
from leaders, peers, and subordinates
• Events can be avoided through an understanding of
the reasons mistakes occur and application of the
lessons learned from past events or errors
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Universal Sign of Commitment
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References
• DOE Human Performance Improvement Handbook
Vol. 1
• DOE human Performance Improvement Handbook
Vol. 2
• Crucial Conversations – Joseph Grenny, David
Maxfield, Kerry Patterson
• The Five Dysfunctions of a Team – Patrick Lencioni
• Bringing Out the Best in People – Aubrey Daniels
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