elements of an effective hpi program rob fisher president, fisher it, inc....
TRANSCRIPT
Copyright, Fisher IT, Inc.
Elements of an Effective HPI Program
Rob FisherPresident, Fisher IT, Inc.
802-233-0760 [email protected] 9, 2013
HPWG
Copyright, Fisher IT, Inc.
Charles F. Kettering – Inventor & Philosopher1876- 1958
“A problem thoroughly understood is always fairly simple.”
“Found your opinions on facts, not prejudices. We know too many things that are not true.”
“Why is the human skull as dense as it is? Nowadays we can send a message around the world in one-seventh of a second, but it takes years to drive an idea through a quarter-inch of human skull.”
Understanding Human Performance
• Systems model – Interconnectivity– Latent conditions– Need for multiple
feedback loops
• Need a systems approach to Human Performance
People
Programs
Processes
Work Environment
Organization
Equipment
Copyright, Fisher IT, Inc.
Copyright, Fisher IT, Inc.
True or False?
Most problemsin industry
are related toHuman Error…
The Program MUST be based on…90% of events are caused by something OTHER THAN JUST the individual
95% of people respond very similarly to the same stimuli
People do what they do at the time that they do it for reasons that make sense to them at the time
Human Performance is NOT Common Sense
Copyright, Fisher IT, Inc.
Definitions• Error: An action or inaction that unintentionally:
• Results in an undesirable or unwanted condition OR• Leads a task or system outside of limits OR• Deviates from a set of rules
• Event (or incident): The undesirable result of an error, a set of errors or a set of conditions
• Deviation: Not strictly complying with a rule, standard or expectation
• Violation: Intentionally not complying with a rule, standard or expectation
• Active Error: An action or inaction that results in immediate consequence
• Latent Error: An action or inaction that results in consequences that are delayed or create latent conditions
Copyright, Fisher IT, Inc.
Copyright, Fisher IT, Inc.
For Every Deviation FromA Definition…Your Program
Weakens!
The Three Legged Stool• Prevention – How much
emphasis do we put on keeping bad things from happening?
• Detection – Are we looking at the right threshold to identify problems?
• Correction – Do the things we do to fix problems:– Match the significance of the problem?– Take other, similar but worse problems
into account?– Not cause problems of a different type?
You cannot ‘correct’ your
way to excellence
8
Copyright, 2013, Fisher IT, Inc.
Copyright, Fisher IT, Inc.
Three Key Indicators…
• Prevention– The number and quality of Pre-Task briefs should
increase• Detection– The number and quality of MANAGEMENT
observations should increase• Correction– The number and quality of non-injury (near miss,
close call, etc.) should increase
Copyright 2013, Fisher IT, Inc.
We are hired to do an OCCUPATION (operator, mechanic, mobile equipment operator, janitor)
These Occupations require us to do JOBS
These jobs contain TASKS(sections in a procedure or checklist)
These tasks contain ACTIONS or Steps (lock-out-
tag-out THIS pump
Hang tags on each electrical supply
Hang locks on each electrical supply
Hang locks on each water supply
Drive Mobile Equipment, Perform Lock-out-tag-out
Operate equipment,Weld
Drive fork lift into THIS tight place to handle THIS load THIS way
Lift load up to see tight space
Load goes into area in truck
Human Performance Improvementis about improving our abilities
at the TASK and STEP level
Copyright, Fisher IT, Inc.
Pre-Task Brief Measures
• Number–Count them all– Segregate those with high risk and / or
fatality-serious injury potential• Quality–Capability of supervisors to perform PTBs– Effectiveness of PTB in the field
Copyright, Fisher IT, Inc.
True or False?
Organizational values influence
individual behaviors…
Copyright, Fisher IT, Inc.
Management Observation Measures
• Number–Again – count them all–Percentage of HRT / FSIP that get observed
• Quality–Percent that are value based– Lessons learned
Copyright, Fisher IT, Inc.
TRUE BUT….
The values of the small organization always trump the values of the big orgainzation related to individual
behaviors…
Copyright, Fisher IT, Inc.
Near Miss Measures(and root cause measures)
• Number– Do I need to say it again?– Ratio of near miss report to events
• Quality– Event investigation tool checklist (or equivalent)– Do cause analyses follow the process?– Root Cause Corrective Action Reviews
Copyright, Fisher IT, Inc.
“We have good processes…If we could just get peopleto follow them we would
be fine!”
Copyright, Fisher IT, Inc.
People
Programs
Processes
Work Environment
Organization
Equipment
www.fisherit.com Copyright, 2012 Fisher IT, Inc.
Deviation Potential © Simplified
Deviation Potential = Difficulty
Risk + Observation
Rule Requirements (Believed Norm)
Sta
nd
ard
s
Time (years)
Deviation Drift (New Norm)
Safety Threat Incident
Performance Gap(discovered byinvestigation)
Investigation
T1 T2 Incident Date
Deviation Drift
www.fisherit.com Copyright, 2012Fisher IT, Inc.
Deviation Potential – Simplified
Deviation Potential © = Difficulty
Perceived Risk + Observation
Conscious
Unconscious Errors
Just don’t complyAccountability issuepersonal compliance issueUsually a single individual
Wrong ruleMisapply ruleTrying to comply and
taking a shortcutOften tribal (a group)Drift
Rule Based - 3 General CategoriesWrong Rule - Rule problemMisapplication - Information problem
Just Don’t complyPersonal compliance issue
Physical Mental
Peer
SupervisorCorporate
Personal
Difficult tasksUnnecessary tasksUnreasonable tasksEasy to shortcutContact with
other organizationHas to stop and do
something else
Taught once - must remember nowStated earlier - must remember now
InjuryPersonal financial
loss if caughtEquipment damage
Corporate financialloss if caught
Equipment damageRoot Cause & Corrective actions
Verbal reminders
(or underling)
Intent to Violate
No Intent to Violate
Violations (<10%)
Errors (>90%)
Copyright, Fisher IT, Inc.
Deviation Analysis
Was a safety rule or operating procedure knowingly violated?
Would other similarly qualified
people have done the same thing in the
situation?
Were the rules available, workable, intelligible, correct and consistently
reinforced?
YESYES
NO
Use this path to determine system failures
NO
Are there deficiencies in:
• Knowledge/skill• Training
• Experience• Selection ?
NO
YES
Does the individual have a history of unsafe
acts?
YES
NO
Yes
NO
Use Deviation Potential ModelTo determine whether “knowingly violated”
Violation – An action or inaction that intentionally deviates from a rule
or standard
Error – An action or inaction that unintentionally creates a problem or
deviates from a rule or standard
AND
Use Performance Mode
Model to assist
Use Performance Mode Model to assist
Individual Driven
Violations
Individual & System
Driven Violations & Errors
System Driven Errors
Copyright, Fisher IT, Inc.
Root Cause Analysis
• Should NOT be based on failed barriers• Should always analyze the WITH model• Should look for the REASON for a deviation
using the models• Should determine the LATENT drivers (or
causes)• Should not focus on the individual but on why
the individual did what they did, and what systemic drivers made it feel right
Copyright, 2012, Fisher IT, Inc.
23
Closing Summary
• Use the new language to describe errors, events, deviations and violations
• Use the new knowledge to analyze problems• Recognize the performance mode you are in to
minimize the error potential• Recognize the triggers that tell you a trap exists
that increases the probability and potential for errors
• Use the tools to avoid or minimize the impact of the traps
Organizations that integrate human performance concepts into their day-to-day work improve:• Performance in safety, quality,
effectiveness & efficiency and• Communication which significantly
improves overall engagement