Human Performance

1. Human Performance P = B + R

2. What is the “Next Level” we hear so much about? “You keep using that word but I do not think it means what you think it means…” Inigo Montoya, Princess Bride Courtesy of OSHA Training Institute, Des Plaines, IL

3. Generations of Levels First Level Trailing Indicators OSHA 300 Logs EMRs Courtesy of OSHA Training Institute, Des Plaines, IL

4. 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

5. 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

6. 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

7. 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

8. Human Error is normal It is provoked by conflicting management & leadership priorities and by weakness in the organization, processes and culture.

9. Behavior can be seen and heard Results are measureable

10. Human Performance We must look at what is an accident or event . What is it? Injury? Near Miss?

11. Human Performance Cutting plastic sheeting with a knife. Standing too close. Girl Scouts Know Better! First time

12. Human Performance Cutting plastic sheeting with a knife. Standing too close. Girl Scouts Know Better! Second time

13. Human Performance Cutting plastic sheeting with a knife. Standing too close. Girl Scouts Know Better! Third time

14. 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

15. 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?

16. Human Performance How many do we make in hour? How many in a week? How many in a year? By how many employees?

17. Human Performance How many do we make in hour? How many in a week? How many in a year? By how many employees?

18. Human Performance How many, statistically, will be bad choices? (errors) How many may result in serious injury? What about acts of God?

19. Causes: Events Image courtesy of INPO

20. Reducing Error Re

21. Stress Mental Strain Avoidance Assumptions Habit Confirmation Bias Similarity Bias Frequency Bias Availability Bias Limited Perspective Fatigue Motivated Toward Goal Accomplishment Difficulty Seeing One’s Own Error Common Traps of Human Nature

22. Pride Hero Fatalistic Summit Fever Invulnerability Pollyanna Bald Tire Common Traps of Human Nature

23. 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 Slips, Lapses, Mistakes and Errors

24. Why? Low detection potential No Boss around Peer pressure Not corrected Perceived authority Boss doesn’t care Conflicting demands Competition Lack of training Precedent Emulation of role models!!!!!!! Violations

25. 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) Violations

26. 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)

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

28. Clear Expectations for HU Tools Specific Observable Objective Doable Active

29. 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

30. 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!

31. At-Risk Practices Basic Safety Risks First and Second Level Generation Items

32. Selecting and Adapting HU Tools See: Human Performance Tools, November, 2007; Department of Energy

33. Work Execution Work Preparation Work Performance Work Feedback

34. Managing Defenses Md

35. Defense-In-Depth Engineering Controls Administrative Controls Cultural Controls Oversight Controls

36. Managing Defenses Plan Do Check Adjust

37. 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

38. Self-assessments KPIs & Trending Benchmarking Independent Oversight Behavior Observations Problem Reporting Causal Analysis Management Oversight Surveys & Questionnaires Corrective Action Program Change Management Finding & Correcting Latent Weakness

39. Performance Model w/ Defenses Image courtesy of INPO

40. Results in and of a Zero Event Culture → ᴓE

41. 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. Safety Culture

42. 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.

43. Facilitate open communication Promote Team Work Reinforce desired behavior, appropriately Eliminate Latent organizational weakness Value prevention of errors Key Leadership Practices

44. People are fallible, and even the best people make mistakes • Error likely situations are predictable, manageable, and preventable • Individual behaviors are influenced by organizational processes and values • People achieve high levels of performance largely because of the encouragement received from leaders, peers, and subordinates. • Events can be avoided through an understanding of the reasons • mistakes occur and application of the reasons learned from past events (or error). HU Fundamentals

45. 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

46. Re + Md → ᴓE

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