Management Overview on Human Performance Improvement

Facilitators:Shane Bush, INL Brian Baskette, INPO

Purpose of Workshop

• Provide an overview of the principles, concepts, and benefits of Human Performance Improvement, or HPI (morning session, 9:00-12:00 noon)

• Provide an overview of the bases of HPI, and practical tools for implementing HPI (afternoon session, 1:00-4:30 pm)

Minimize the frequency and severity of events (i.e., occurrences)

Events

Purpose of Human Performance Improvement

21 out of 26 fuel-damaging accidents due to human error

Three out of four significant events due to human error

Greatest contributor to costs ?

70 percent of causes due to weaknesses in Organization

Why HPI in commercial nuclear?

Significant Events(commercial nuclear) Annual Industry Averages

2.38

1.66

0.85 0.880.77

0.460.28

0.08 0.04 0.03

0.30 0.300.21

0.1 0.07

0.0

0.5

1.0

1.5

2.0

2.5

3.0

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Sig

nifi

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t Eve

nts

pe

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nit

Data Source: U.S. Nuclear Regulatory Commission

(Core Damage Potential)

Is 99.9% Good Enough?1 hour of unsafe drinking water per month

2 unsafe landings per day in Atlanta, GA.

50 dropped babies per day

116,000 lost pieces of mail per hour

20,000 incorrect drug prescriptions per year

22,000 checks deposited in wrong accounts per hour

0

1000

2000

3000

4000

5000

6000

1995 1996 1997 1998 1999 2000

OccurrenceReports

Occurrences

90% Involve Human Behavior(National Safety Council)

DOE Occurrence Reports and Occurrences 1995-2000.

• Dateline clip on medical mistakes

What do you Manage?

• Assets: people & the plant

• Hazard: human error

• Exposure: “People touching equipment”

• Risk: probability and consequences

• Control: error rate and defense-in-depth

Principles1. People are fallible, and even the best make mistakes.

2. Error-likely situations are predictable, manageable, and preventable.

3. Individual behavior is influenced by organizational processes and values.

4. People achieve high levels of performance based largely on the encouragement and reinforcement received from leaders, peers, and subordinates.

5. Events can be avoided by understanding the reasons mistakes occur and applying the lessons learned from past events.

Studies of Visual Awareness

[ Video Exercise ]

Defining Human Performance

5 443 32 2 11

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2

2

3

3

4

4

5 443 32 2 11

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Target No.1Target No.1 Target No.2Target No.2

Two Kinds of Error

Active Error

(leading to latent conditions)

Latent Error

Anatomy of an Event

Event

Vision, Beliefs, &

Values

LatentOrganizationalWeaknesses

Mission

Goals

Policies

Processes

Programs

FlawedDefenses

ErrorPrecursors

InitiatingAction

Vision, Beliefs, &

Values

Insert DOE Example to illustrate Anatomy

Strategic Approach

1. Anticipate and prevent active error (Re) at the job-site.

2. Identify and eliminate latent organizational weaknesses (Md).

Re + Md ØE

Examples of Error-prevention Techniques

Turnover

Supervision

Placekeeping

Questioning attitude

Self-checking

Peer-checking

Three-way communication

Procedure use & adherence

Stop when unsure

Pre-job briefing

Examples of Defenses

• Training• Self assessment• Procedures• Planning and

Scheduling• Management

oversight• Regulatory oversight• Problem reporting

• Engineered safety features

• Personnel protective equipment

• Containment• Review and

approval• Performance

indicators

1. Facilitate open communication

2. Promote teamwork

3. Reinforce desired behaviors

4. Eliminate latent organizational weaknesses

5. Value prevention of errors

Leadership Practices

Q&AWrap-up

Welcome back!

[Add constant sorrow clip]

Job Site and the Individual

Inattention to Detail

[ Things Made in October ]

Traps of Human Nature Stress Avoidance of mental strain Inaccurate mental models Limited working memory Limited attention resources Mind set Difficulty seeing own errors Limited perspective Susceptible to emotion Focus on goal Fatigue

PARISIN THE

THE SPRING

BIRDIN THE

THE HAND

ONCEIN A

A LIFETIME

Phrase Recall Exercise

Source: Swain & Guttmann. Handbook of Human ReliabilityAnalysis with Emphasis on Nuclear Power Plant Applications.U.S. Nuclear Regulatory Commission (NUREG/CR-1278), 1983.

Error-likely Situation The Devil in the Details

Degree of mismatch due to:

Error likely Situation

Unintentionaldeviation frompreferred behavior

Job-Site Conditions:• Task• Individual

error precursors

Error Precursors

Task DemandsTask Demands

Individual Individual CapabilitiesCapabilities

Work Work EnvironmentEnvironment

Human NatureHuman Nature

• Limited short-term memory• Personality conflicts

• Mental shortcuts (biases)• Lack of alternative indication

• Inaccurate risk perception• Unexpected equipment conditions

• Mind-set• Hidden system response

• Complacency / Overconfidence• Workarounds / OOS instruments

• Assumptions• Confusing displays or controls

• Habit patterns• Changes / Departures from routine

• Stress• Distractions / Interruptions

Human NatureWork Environment

• Illness / Fatigue• Lack of or unclear standards

• “Unsafe” attitude for critical tasks• Unclear goals, roles, & responsibilities

• Indistinct problem-solving skills• Interpretation requirements

• Lack of proficiency / Inexperience• Irrecoverable acts

• Imprecise communication habits• Repetitive actions / Monotony

• New technique not used before• Simultaneous, multiple tasks

• Lack of knowledge (mental model)• High Workload (high memory requirements)

• Unfamiliarity w/ task / First time• Time pressure (in a hurry)

Individual CapabilitiesTask Demands

Error Precursors

OOS – out of service

Hazardous Attitudes

Pride - “Don’t insult my intelligence.”

Heroic - “I’ll get it done, hook or by crook.”

Invulnerable - “That can’t happen to me.”

Fatalistic - “What’s the use?”

Bald Tire - “Got 60K miles and haven’t had a flat yet.”

Summit Fever - “We’re almost done.”

Pollyanna - “Nothing bad will happen.”

Performance Modes

KBPatterns

RBIf - Then

SBAuto

Familiarity (w/ task)Low High

High

Low

Att

enti

on

(to

task

)

Inattention

Misinterpretation

Inaccurate Mental Picture

Sou

rce:

Jam

es R

easo

n. M

anag

ing

the

Ris

ks

of O

rgan

izat

iona

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iden

ts,

1998

.

Error-prevention TechniquesFlagging

Concurrent verification

Independent verification

Problem-solving

Conservative decision-making

Two-minute rule

Turnover

Supervision

Self-checking

Peer-checking

Three-way communication

Procedure use & adherence

Stop when unsure

Pre-job briefing

Questioning attitude

Placekeeping

Engineer Human Performance Techniques

Pre-job briefing / Task Assignment

Procedure use & adherence

Questioning attitude

Review and Verification

Problem-solving & Decision-making

Design review meetings

Signature

Supervisor Techniques

• Work planning

• Walkdown

• Task assignment

• Pre-job briefing

• Observation

• Performance management

• Post-job review

Team Errors “social loafing”

Halo Effect

Pilot / Co-pilot

Free Riding

Groupthink

Risky Shift

The Organization

To facilitate the accomplishment of the organization’s missionmission in accordance with its norms, values, and strategies.

SafetyTo consistently searchsearch for and eliminateeliminate conditions that provoke human error while reinforcing defenses.

Dual Purposes

Defenses

• Create Awareness• Detect and Warn• Protect• Recover• Contain• Enable Escape

Physical Administrative

Flawed defenses allow active errors or their consequences to occur.Source: Maurino (1995)

MANAGERIAL METHODS

TRAINING

WORK SCHEDULEWORK ORGANIZATION OR

SUPERVISORY METHODS

WRITTEN COMMUNICATIONS

CHANGEIMPLEMENTATION

VERBALCOMMUNICATIONS

DESIGN

WORK PRACTICES

ChallengesChallengesTo the PlantTo the Plant

ENVIRONMENTALFACTORS

EVENTS

Defense-in-

Depth

LeadershipProper Reactions

High Standards Reinforcement

Coaching

Questioning Attitude

Respectfor Others

Open & HonestCommunication

CompellingVision

HealthyRelationships

Courage &Integrity

Motivation

Example

Communication Practices / Plan

Reviews & Approvals

Change Mgmt.

Problem Solving

Scheduling / Sequencing

Clear Expectations

Role Models

Safety Philosophy

Task Allocation

Meetings

Rewards & Reinforcement

Trend Analysis

OE

Training

Handoffs

Accountability

Simple/effective Process Philosophy

Procedure Revisions

Work Planning

Corrective Action

Self-Assessment

Benchmarking

Equipment Labeling & Condition

Procedure / Work Package Quality

Worker Knowledge,Skill, & Proficiency

Fitness-for-Duty

Wary Attitude

Equipment Ergonomics & Human Factors

Tool Quality & Availability

Roles &Responsibilities

HousekeepingEnvironmentalConditions

Foreign Material Exclusion

Lockout / Tagout

Personal Motives

Intolerance for Error Traps Self-Checking Place-Keeping

3-Part Communication

DoubleVerification

Procedure Use& Adherence

Supervision

Management Monitoring

Stop WhenUncertain

Critical Parameters

Problem-SolvingMethodology

ConservativeDecision-Making

Team Skills

Peer-Checking

Safeguards Equipment

Reactor Protection Systems

Containment

QC Hold Points

Independent Verification

InterlocksPersonal Protective Equipment Alarms

Forcing Functions

Postjob Reviews

Problem Reports

Root Cause Analysis

Performance Indicators

PLANTRESULTS

JOB-SITECONDITIONS

ORGANIZATIONPROCESSES

& VALUES

WORKERBEHAVIOR

Pre-jobBriefing

Just-in-time Operating Experience

Task Preview

Turnover

Clearance Walkdown

Walkdowns

Performance Feedback

Task Assignment

HP Surveys

Task Qualification

Performance Model

RECALL: Anatomy of an Event

Event

Vision, Beliefs, &

Values

LatentOrganizationalWeaknesses

Mission

Goals

Policies

Processes

Programs

FlawedDefenses

ErrorPrecursors

InitiatingAction

Vision, Beliefs, &

Values

Latent Organizational Weaknesses (sources)

Values (relationships) Priorities Measures & controls Critical incidents Coaching & teamwork Rewards & sanctions Reinforcement Promotions &

terminations

Processes (structure) Work control Training Accountability policy Reviews & approvals Equipment design Procedure

development Human resources

Finding Latent Organizational Weaknesses

Self-Assessments Benchmarking Post-job Reviews Trending Document Reviews Surveys and Questionnaires Observations Root Cause Analysis

Leadership

LeadershipProper Reactions

High Standards Reinforcement

Coaching

Questioning Attitude

Respectfor Others

Open & HonestCommunication

CompellingVision

HealthyRelationships

Courage &Integrity

Motivation

Example

Communication Practices / Plan

Reviews & Approvals

Change Mgmt.

Problem Solving

Scheduling / Sequencing

Clear Expectations

Role Models

Safety Philosophy

Task Allocation

Meetings

Rewards & Reinforcement

Trend Analysis

OE

Training

Handoffs

Accountability

Simple/effective Process Philosophy

Procedure Revisions

Work Planning

Corrective Action

Self-Assessment

Benchmarking

Equipment Labeling & Condition

Procedure / Work Package Quality

Worker Knowledge,Skill, & Proficiency

Fitness-for-Duty

Wary Attitude

Equipment Ergonomics & Human Factors

Tool Quality & Availability

Roles &Responsibilities

HousekeepingEnvironmentalConditions

Foreign Material Exclusion

Lockout / Tagout

Personal Motives

Intolerance for Error Traps Self-Checking Place-Keeping

3-Part Communication

DoubleVerification

Procedure Use& Adherence

Supervision

Management Monitoring

Stop WhenUncertain

Critical Parameters

Problem-SolvingMethodology

ConservativeDecision-Making

Team Skills

Peer-Checking

Safeguards Equipment

Reactor Protection Systems

Containment

QC Hold Points

Independent Verification

InterlocksPersonal Protective Equipment Alarms

Forcing Functions

Postjob Reviews

Problem Reports

Root Cause Analysis

Performance Indicators

PLANTRESULTS

JOB-SITECONDITIONS

ORGANIZATIONPROCESSES

& VALUES

WORKERBEHAVIOR

Pre-jobBriefing

Just-in-time Operating Experience

Task Preview

Turnover

Clearance Walkdown

Walkdowns

Performance Feedback

Task Assignment

HP Surveys

Task Qualification

Leader’s Role

Competing Resources

Source: James Reason. Managing the Risks of Organizational Accidents, 1997 (in press).

Pre

ven

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Productiont0

tn

new plant state

plant eventAcc

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uptcy

1. Facilitate open communication

2. Promote teamwork

3. Reinforce desired behaviors

4. Eliminate latent organizational weaknesses

5. Value prevention of errors

Leadership Practices

Challenge to Communicate

Managers:

“Ask for what you need to hear, not for what you want to hear.”

Subordinates:

“Tell your boss what they need to hear, not what you think they want to hear.”

--Roger BoisjolyFormer chief engineer for Morton-Thiokol, Inc.

Four goals in any communication:• Have the message received.

• Have the message understood.

• To initiate action.

• To maintain or enhance the relationship.

“ I didn’t say she stole the money.”

Team Skills Ladder

Inquiry

Advocacy

Leadership

Conflict Management

Critique Performance

Difficulty increases as you “climb” the ladder!

TRUSTCOM

MUNIC

ATION

Reinforcement

Source: Daniels, Bringing Out the Best in People, 1989.

Consequences that Decrease Behavior

Behavior

BEHAVIOR INCREASES

Consequences that Increase

Behavior

1. GET SOMETHING YOU WANT1. GET SOMETHING YOU WANT

2. AVOID SOMETHING YOU DON’T 2. AVOID SOMETHING YOU DON’T WANTWANT

1. GET SOMETHING YOU DON’T 1. GET SOMETHING YOU DON’T WANTWANT

2 . LOSE SOMETHING THAT YOU 2 . LOSE SOMETHING THAT YOU HAVEHAVEBEHAVIOR DECREASES

Insert Terry Tate clip

Behavior can be:

• Desirable; want more of it – the Good

• Acceptable or unacceptable; improvement is wanted – the Badthe Bad

• Unsafe, at-risk, or unsatisfactory; want it to stop now – the Ugly

What does excellence require?

BlameCycle

HumanError

Lesscommunication

Management lessaware of jobsiteconditions

Reduced trustLatent organizationalweaknesses persist

Individual counseled and/or disciplined

More flawed defenses& error precursors

Source: Reason, Managing the Risks ofOrganizational Accidents, pp.127-129.

Eliminating Latent Organizational Weaknesses

Solicit and act on feedback from workers

Determine fundamental causes

Monitor trends

Observe work in the field

Conduct surveys and use questionnaires

Perform process mapping

Conduct task analysis

Perform benchmarking

Behaviors that influence values & beliefs

1. What leaders pay attention to, measure, or control

2. Reactions to critical incidents or crisis

3. Criteria used to allocate scarce resources

4. Deliberate attempts at role modeling, teaching, and coaching

5. Criteria for reinforcement and discipline

6. Criteria used to select, promote, or terminate employees

Source: Schein, Edgar H. Organizational Culture andLeadership, Jossey-Bass, 1992, p231.

Q&A Wrap-up

Thanks!