Human Performance, the Event Free Clock & Breaking the Safety Cycle

1. Human Performance, the Event Free Clock & Breaking the Safety Cycle Introducing Leading Indicators to Break The “Safety Cycle”

2. How To Measure Safety Performance? Where to Focus Safety Efforts?

3. Injuries The Safety Cycle Upper Limit Lower Limit Time

4. Safety Initiatives Rules Discipline Training Fewer Accidents? Regulations Awards Safety Meetings Pre-Job Brief

6. Five Basic Facts • People are fallible and even the best will make mistakes. • All consequential errors that could lead to injuries are preventable. • No worker would intentionally injure themselves. • If there is a method that could free a worker from being injured without undue burden, they would adopt it. • Fast improvement can only be achieved in an open, non-punitive, and constant learning workplace.

7. Human Performance Basic Human Performance concepts focus on identifying and improving: • Human Errors • Reduce the chances of errors occurring, and • Reduce the effects of errors resulting in injury and/or system disturbances • Failed or Insufficient Layers of Protection • Latent Organizational Weaknesses

8. Layers of Protection

9. Unwanted Outcomes (Events) EquipmentFailure – 20% Individual Errors – 30% Human Errors - 80% Latent Organizational Weaknesses – 70%

10. Human Performance • What is Human Performance? • A series of behaviors executed to accomplish specific tasks.

11. Human Performance Improve Human Performance & YOU WILL Improve Operational Performance

16. THE THREE TYPES OF HUMAN ERRORS ARE: • Knowledge-based Errors • These tasks are new, unfamiliar or unique to the performer • They depend heavily upon the performer’s fundamental knowledge, diagnosis, and analysis skills • Best described as trial and error or literally “I don’t know”

17. THE THREE TYPES OF BEHAVIOR BASED ERRORS ARE: • Rule-based Errors • These tasks are familiar to the performer • Upon correct recognition of a situation or condition, the performer can apply a stored rule to steer towards a known end goal • Tasks in this domain tend to follow if-then logic

18. THE THREE TYPES OF BEHAVIOR BASED ERRORS ARE: • Skill-based Errors • These tasks are comprised of very familiar actions • Performed in comfortable surroundings • The human being is, or is close to, being on autopilot

19. Error Mode: Inaccurate Mental Model Error Rate 1:10 Error Mode: Misinterpretation Error Rate 1:100 Error Mode: Inattention Error Rate 1:1,000 Task Error Model Rules, Standards, Checklist, Written Procedures Memorization, Practice High – Attention - Low Knowledge based – Rule based – Skill based Low - Familiarity - High

23. Error Traps

24. Some Human Performance Tools for Individuals • Questioning attitude • Stop when unsure • Self-checking • Procedure use and adherence • Three-way communication • Phonetic alphabet • Place-keeping • Two Minute Drill • Conservative Decision Making

25. Some Human Performance Tools for Teams • Pre-job briefing (Tailboard) • Peer check • Flagging • Turnover • Post-job review • Concurrent Verification

26. Some Human Performance Tools for Leaders and Management • Observations & Feedback • Self-Assessments • Operating experience

27. What is an Event Clock? • A real time Human Performance tool to effectively communicate current human performance status relating to safety and reliability. • Qualifying Events reset the clock to zero • Helps improve safety and reliability by being a vehicle to share lessons learned following Qualifying Events so that we engrain the HP tools into how we do business.

28. 2012 Event Clock Criteria • Fatalities • Amputations • Loss of Consciousness • Electrical Contacts with Injury • Arc Flashes with Injury • Fractures (non-dental) • Lost-time Injuries • Switching Order & Clearance Errors (resulting in an event) • Motor Vehicle Accidents greater than $5K damage • Unplanned Significant Outages (with feeder breaker trip) • OSHA Violations with an event

33. Breaking the “Safety Cycle” Injuries Trend Time

34. Close Calls are a gift from God

35. Presented by: Chuck Thomack, CSP • Section Leader, Safety • (602) 371-7873 • Charles.Thomack@aps.com • Date: September 28, 2012