HUMAN PERFORMANCE FUNDAMENTALS

Turning Defense into Offense

Introductions

• Name• Position• Location• Time on job• Expectations

2

Housekeeping

• Restrooms• Exits (fire assembly area)• Breaks• Cell Phones• Parking Lot• Safety Note

3

Purpose of this Training

To reduce the frequency and severity of events and improve operational performance.

4

Senior Management Quote Here

At (your company name here), we value safety

5

• HP Tools and Concepts• Error free = event free

• Event-Free Clocks• Goal is ZERO accidents

Why Learn this at (your company name here)?

• Values: what we care about most; our beliefs.

• Culture: all the common values of the company. These influence everyone’s attitudes, choices, and behavior.

• Performance Improvement: we can anticipate an error-free workplace

6

Training Objectives

• Describe the types and causes of human error

• Describe human performance concepts and principles

• Apply the principles of human performance in a case study

• Identify the human performance tools• Apply the appropriate tools in work

situations

7

Module 1

Types and Causes of Human Error

8

Defining Human Performance

• Department of Energy (DOE)• Concepts• Principles• System

– Not step-by step process

• Behaviors

9

Little Things Lead to Big Things!

10

600

1

3010

Layers of Responsibility Contributing to Human Performance

11

It is a system of interdependencies

The Elements that Impact Human Performance

12

Read the following sentence and count the number of F’s you find.

13

Counting Exercise

FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF YEARS.

14

Counting Exercise

FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF YEARS.

15

Did you find six?

Counting Exercise

Reading Exercise

Clearly read the following paragraphs.

16

Aoccdrnig to rscheearch at Cmabrigde Uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are wirttn, the olny iprmoetnt tihng is that the frist and lsat ltteer be at the rghit pclae.

The rset can be a total mses and you can sitll raed it wouthit porbelms. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. Amzanig huh?

17

Reading Exercise

Types of Errors:

18

• Active Error – An obvious mistake that has immediate, visible consequences.

• Latent Error – A hidden mistake that

has consequences that

are not immediate. *(Seat belts are a good idea)

How we commit errors

19

HumanError

UnintendedAction

IntendedAction

Slip

Lapse

Mistake

Attention FailureIntrusion, Omission,

Misorder, Mistiming

Planning FailureMisapplication of good ruleApplication of bad rule

Violation

Memory FailureForgetting intention

Lost placeOmitting planned item

HumanError

UnintendedAction

Slip

Lapse

Attention FailureIntrusion, Omission,

Mis-order, Mistiming

Shortcuts

Memory FailureForgetting intention

Lost placeOmitting planned item

Human Information Processing

20

Source: Wickens, 1992

ThinkingThinkingSensingSensing ActingActing

InformationFlow Path

SharedAttentionResources

Performance Modes

21

Knowledge BasedPatterns

Rules BasedIf - Then

Skills BasedAuto

Familiarity (w/ task)Low High

High

Low

Atten

tion

(to

task

)

Inattention

Misinterpretation

Inaccurate Mental Picture

Sour

ce: J

ames

Rea

son.

Man

agin

g th

e Ri

sks

of O

rgan

izati

onal

Acc

iden

ts, 1

998.

1 in 1,000

1 in 100

1 in 10

Error Rate Reduction

Error Traps produce anerror-likely situation

22

TaskDemands

Erro

r Tra

ps

Individual

Capabilities

Erro

r Tra

ps

Work

Environment

Error Traps

Human

NatureError Traps

Sometimes we’re up and sometimes we’re down!

Recognize and work with it.

23

Event Causation

24

Module 2

Human Performance Concepts and Principles

25

Five Principlesof Human Performance

26

1. People are fallible.

2. Error situations are predictable.

3. Organization influences behavior.

4. Reinforcement effects performance.

5. Understanding the past helps avoid events.

Layers of Responsibility Contributing to Human Performance

27

5 443 32 2 11

1

1

2

2

3

3

4

4

Behavior vs. Result

28

Which shooter had better “results”?

5 443 32 2 11

1

1

2

2

3

3

4

4

Performance Formula

29

Functions of Defenses

30

• Create Awareness

• Detect and Warn

• Protect

• Recover

• Contain

• Enable Escape

Defense in Depth

31

Sources of Latent Organizational Weakness

32

Processes

• Control of work• Training• Accountability

policy• Equipment design• Process

development• Use of work force

Values

• Priorities• Measures &

controls• Coaching &

teamwork• Rewards &

sanctions• Reinforcement

Module 3

Applying the Principles

33

34

Develop Case Study/Video for your

Organization

Develop Case Study/Video for your

Organization

Questions on the Case Study

1. What were the consequences of this event, short and long range, and what was their significance?

2. What were some of the latent organizational weaknesses?

3. What defenses were removed or flawed?

4. What values or organizational beliefs may have contributed to the event?

5. What were some of the error traps?

6. What can we learn from this case study?

35

Module 4

Human Performance Tools

36

Error-Prevention Tools

37

1. Self-checking - S.T.A.R.

2. Peer-checking - Team S.T.A.R.

3. Three-Way Communication

4. Pre-Job Briefing (FKA Tailboard)

5. STOP if Unsure

6. 2-Minute Drill

7. Questioning Attitude

8. Turnover

9. Place Keeping

10. Flagging

11. Phonetic Alphabet

12. Conservative Decision Making

Error-Prevention Tools (continued)

38

13. Procedure Use and Adherence

14. Concurrent Verification

15. Post-job Review

Error-Prevention Tools (continued)

39

Management Tools include:1. Observations2. Self-Assessments3. Operating Experience

Self-Checking - S.T.A.R

40

• STOP – Is my attention focused on the task?

• THINK – What action am I about to perform?

• ACT – Am I performing correctly?

• REVIEW – Did I get the expected results?

*

Peer-CheckingTeam S.T.A.R

41

• Use a second set of eyes to detect and correct.

• Both individuals actively participate in task performance.

• Use this tool prior to the performance of critical tasks.

Sometimes we just blow it!

42

3-Way Communication

43

• Helps you verify that the correct information is transferred.

• Used during the execution of critical steps to formalize the communication.

• Repeat-back is required when obtaining a clearance or a switching order.

• Regulatory requirement in certain situations

Critical transactions (i.e. communicating to control personnel)

What Dennis said (as he was leaving the room):

“Don, turn off the foam machine”

What Don heard:

“Don’t turn off the foam machine.”

3- Way Communication

44

The Result

45

Pre-Job Briefing

46

• What is the task to be accomplished?

• Who’s doing what?

• How will we communicate?

• What safety equipment do I need?

• What is the worst thing that could happen and how am I going to prevent it?

STOP if Unsure

47

• If you have a feeling something is not right – Stop!

• If you are not positive of the course of action or the outcome of your actions – Stop!

Two-Minute Drill

48

• Initial worksite assessment.

• Use after a break or distraction.

• Helps to reset and verify work conditions.

• Provides a chance to assess changing workplace hazards at the workplace.

Questioning Attitude

• Challenges assumptions

• Stimulates a healthy skepticism

• Vigilance when things don’t seem right

• Being open to challenges by others

• Use when uncertain, confused, doubtful

49

Turnover

• Information/awareness continuity

• Accurate transfers

• Transferring responsibilities

• Over communicate – Don’t assume

• Record information – Ensure accuracy

• Ask clarifying questions50

Place Keeping

• Prevents step duplication or omission

• Records step completed and yet to be performed

• Use during Switching and Clearance procedures

• Circle & Slash the step number, sign or initial a blank or, check a box

51

Flagging

• Correct equipment identification

• Alerts others that equipment is unavailable

• Shields components from inadvertent use

• Used on similar–looking equipment

• Mandates use of peer and self-checking

• Remains in place until work is complete

52

Phonetic Alphabet

• Provides understandable difference between letters

• Use when letters might sound alike

• Use in high noise areas

• Use at times of poor radio/telephone reception

53

Standard Phonetic Alphabet

54

Conservative Decision Making

• Deliberate and methodical

• Clarifies goals and options

• Planning

• Resources and expertise

• Minimize uncertainty

• Facts only – challenge assumptions

55

• Understand a procedure’s intent and purpose and follow its direction.

• Perform all actions as written.

• Stop if procedure cannot be used as written.

• Procedure may be corrected before continuing.

• Expectation: Frequent document use instead of memory and recall.

Procedure Use & Adherence

56

Concurrent Verification

57

• Separate confirmation by two individuals

• Error prevention on equipment status/condition changes

• Independent conclusions by all parties

• Verifier takes no cues from performer

• Not Peer Checking

Post-job Review

• Identifies what went well

• Identifies potential improvements

• Allows feedback from active participants

• Identifies actual versus planned outcome

• Determines future changes in similar tasks

• Reviews lessons learned

58

Module 5

Apply the Tools

59

How valuable is good communication?

60

61

Objective Review

• Describe the types and causes of human error

• Describe human performance concepts and principles

• Apply the principles of human performance in a case study

• Identify the human performance tools• Apply the appropriate tools in work

situations

62

The Big Question

• Questioning Attitude

63

“What’s the worst that could happen

and how am I going to prevent it?”

Your turn

Questions?

64

ThankThankYouYou

65

Knowledge Check

66

• Complete the knowledge check on your own.

• XX% minimum is required.

• You may use your notes.

• Time limit: XX minutes.