Human Performance Improvement

Principles

Facilities Division Lawrence Berkeley National LaboratoryJanice Sexson

“Humans rather than technical failures now represent the greatest threat to complex and potentially hazardous systems”

James Reason, 1995

Why A Human Performance Improvement Approach?

To proactively prevent “occurrences” triggered by human error

Occurrence

A condition that adversely affects, or may

adversely affect, DOE or contractor personnel, the public, property, environment or the DOE mission

Occurrences

20% Equip-ment Failure80 % Human Error

Human Factors

70% Latent Organization Weakness

30% Individual

Facts About Human Error

• It thrives in every industry• It is a major contributor to events and

occurrences• It is costly, adverse to safety and hinders

productivity• The greatest cause of human error is

weakness in the organization not the lack of skill or knowledge

Hazardous Attitudes

• Pride-Don’t insult my intelligence• Heroic-I’ll get it done, hook or by crook• Invulnerable-That can’t happen to me• Fatalistic-what's the use• Bald Tire-Got 60 K miles and haven’t had a flat tire

yet• Summit Fever-We’re almost done• Pollyanna-Nothing bad will happen

Human Error

Individual Error-reduction tools

• Discussing Lessons Learned• Behavior based safety• Error-Precursor• Peer-Check• Enhanced Pre-Job Briefing• 3 way communication

Principles

• People are fallible, and even the best make mistakes

• Error-likely situations are predictable, manageable, and preventable

• Individual behavior is influenced by organization processes and values

Principles

• People achieve high levels of performance based largely on the encouragement and reinforcement received from leaders, peers, and subordinates

• An understanding of the reasons mistakes occur, and application of the lessons learned from past events can avoid future events

Blame CycleA Human Error

Happens

Worker is counseled

and/or disciplined

Trust levels reduced

because of managements

actions

Worker no longer feels

safe to communicate

Management is less aware of

working conditions

Latent organization

weakness persist

Error likely workplace

exists

Human Performance

“Event are not so much the result of error-prone

workers as they are the outcome of error-prone tasks and error-prone work environments, which are controlled by the organization.”

Human Beings

• http://www.youtube.com/watch?feature=player_embedded&v=8V2hhtNw8vU

Notable Organizational Behaviors

• Managers foster a culture that values prevention of events

• Managers strengthen the integrity of defenses to prevent or mitigate the consequences

• Managers preclude the development of error-likely situations

• Managers create a learning environment that promotes continuous improvement

Leadership Behavior

•Facilitate open communication

•Promote teamwork to eliminate error-likely situations and strengthen defenses

•Search for and eliminate organizational weaknesses that create error-likely situations

•Reinforce jobsite behaviors

•Value the prevention of errors

Individual Tools

• Questioning attitude

• Clear communication techniques

• Stop when unsure

Management Tools

• Solicit and act on feedback from worker

• Determine fundamental causes

• Monitor trends • Self-Assessment• Process mapping• Task Analysis• Benchmarking

Summary

• Question

• Communicate

• Stop