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Human Performance

P = B + R

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What is the “Next Level” we hear so much about?

Courtesy of OSHA Training Institute, Des Plaines, IL

“You keep using those words but I do not think they mean what you think they mean…”

Aneigo Montoya, Princess Bride

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Generations of Levels

First Level

Trailing Indicators

OSHA 300 Logs

EMRsCourtesy of OSHA Training Institute, Des Plaines, IL

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Generations of Levels

Second Level

Weighted Audits, Surveys & Observations

Systems can be sided by their own terms

Courtesy of OSHA Training Institute, Des Plaines, IL

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Generations of Levels

Third Level

Predictive Audits (Risk Rating)

Combination of weighted audits, surveys & observations to provide a set of risks likely to result in events.

Courtesy of OSHA Training Institute, Des Plaines, IL

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Generations of Levels

Next Level

Based on Aristotle

“We are what we repeatedly do, Excellence, then, is not an act but a habit.”

Courtesy of OSHA Training Institute, Des Plaines, IL

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Generations of Levels

Next Level

To understand, we have a formula:

Given P = B + R, then Re + Md → ᴓE

Courtesy of OSHA Training Institute, Des Plaines, IL

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Human Error is normal

It is provoked by conflicting management &

leadership priorities and by weakness in the

organization, processes and culture.

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Behavior can be seen and heard

Results are measureable

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Human Performance

We must look at what is an accident or event .

What is it?

Injury?

Near Miss?

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Human Performance

Cutting plastic sheeting with a knife.

Standing too close.

Girl Scouts Know Better!

First time

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Human Performance

Cutting plastic sheeting with a knife.

Standing too close.

Girl Scouts Know Better!

Second time

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Human Performance

Cutting plastic sheeting with a knife.

Standing too close.

Girl Scouts Know Better!

Third time

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Human Performance

The Accident or Event is the action which may or may not result in injury.

The Initiating Action was based on a choice, a human choice. Choice was

manifested in Behavior. The measurable Result was observable.

P = B + R

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Human Performance

How many of these choices might be made by a human in your

organization?

How many are bad choices (errors)?

How many do we make in a minute?

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Human Performance

How many do we make in hour?

How many in a week?

How many in a year?

By how many employees?

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Human Performance

How many do we make in hour?

How many in a week?

How many in a year?

By how many employees?

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Human Performance

How many, statistically, will be bad choices?

(errors)

How many may result in serious injury?

What about acts of God?

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EventsCauses:

Image courtesy of INPO

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Reducing Error

Re

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Common Traps of Human Nature

StressMental Strain Avoidance

Assumptions HabitConfirmation BiasSimilarity

BiasFrequency Bias

Availability BiasLimited Perspective Fatigue

Motivated Toward Goal AccomplishmentDifficulty Seeing One’s Own Error

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Common Traps of Human Nature

Pride Hero

Fatalistic Summit Fever

Invulnerability Pollyanna

Bald Tire

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Slips, Lapses, Mistakes and Errors

People tend not to err intentionally.

Line employees tend to make Active Errors – have an immediate effect

Managers tend to have Latent Errors-have a delayed effect

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Violations

Why?

Low detection potential No Boss aroundPeer pressure Not correctedPerceived authority Boss doesn’t careConflicting demandsCompetitionLack of training Precedent

Emulation of role models!!!!!!!

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Violations

People sometimes violate procedures, for evil or for good.

Honest intent to deviate from procedure to achieve a greater good

Hostile acts (over time, good intentioned deviation may become hostile)

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Fundamental Prevention Tools

Situational Awareness Task Preview

Pre-job Briefing Peer-Checking

Questioning Attitude Flagging

Procedure Use Placekeeping

3-way Communication Phonetic Alphabet

Validate Assumptions Signature

Concurrent Verification (Honey Do’s)

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Positive Control

Many errors can be accounted for if an employee has positive control of their tool or work situation.

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Clear Expectations for HU Tools

Specific

Observable

Objective

Doable

Active

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Critical Steps

Used to prepare for a work activity

Summarize the critical steps

Anticipate errors for each critical step

Foresee probable results of error for each step

Evaluate controls at each critical step

Review previous experience and lessons learned to each critical step

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Competence vs. Control

Respecting Human Fallibility

Positive Control means what is intended to happen is what happens, and that is all that happens.

Built in checks are not an accusation on competence!

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At-Risk Practices

Basic Safety Risks

First and Second Level Generation Items

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Selecting and Adapting HU Tools

See:

Human Performance Tools, November, 2007; Department of Energy

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Work Execution

Work Preparation

Work Performance

Work Feedback

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Managing Defenses

Md

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Defense-In-Depth

Engineering Controls

Administrative Controls

Cultural Controls

Oversight Controls

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Managing Defenses

Plan

Do

Check

Adjust

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Beware of Latent Errors

They do not fade away, they collect!

“Liberation and mobilization of human energies-rather than symmetry and harmony-constitute the purposes of organization. Human performance is its goal and its test.”

Peter Drucker

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Finding & Correcting Latent Weakness

Self-assessmentsKPIs & TrendingBenchmarkingIndependent OversightBehavior ObservationsProblem ReportingCausal AnalysisManagement OversightSurveys & QuestionnairesCorrective Action ProgramChange Management

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Performance Model w/ Defenses

Image courtesy of INPO

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Results in and of a Zero Event Culture

→ ᴓE

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Safety Culture

Must cultivate a Questioning Attitude!

Events often result from a shared assumption, value and/or belief of the organization.

All must be watchful and question the established culture at all times.

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Leadership

ANY individual who takes personal responsibility for his or her performance as well as the organization's performance AND attempts to influence the improvement of the organization that supports that performance.

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Key Leadership Practices

Facilitate open communication

Promote Team Work

Reinforce desired behavior, appropriately

Eliminate Latent organizational weakness

Value prevention of errors

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HU Fundamentals

1. People are fallible, and even the best people make mistakes

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

3. Individual behaviors are influenced by organizational processes and values

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

5. Events can be avoided through an understanding of the reasons mistakes occur and application of the reasons learned from past

events (or error).

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Resources

Human Performance Reference Manual, Oct., 2006: Institute of Nuclear Power Operations (INPO).

Human Performance Tools: For Individuals, Work Teams, and Management, Nov., 2007: Department of Energy, Human Performance Center.

Instructor Notes

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Re + Md → ᴓE

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