human performance, the event free clock & breaking the safety cycle introducing leading...
TRANSCRIPT
Human Performance, the Event Free Clock & Breaking the Safety Cycle
Introducing Leading Indicators to Break The “Safety Cycle”
How To Measure Safety Performance?
Where to Focus Safety Efforts?
The Safety Cycle
Injuries
Time
Upper Limit
Lower Limit
TrainingRules
Discipline
Regulations
Safety Meetings
Pre-Job Brief
AwardsFewer
Accidents?
Safety Initiatives
Five Basic Facts
1. People are fallible and even the best will make mistakes.
2. All consequential errors that could lead to injuries are preventable.
3. No worker would intentionally injure themselves.4. If there is a method that could free a worker from
being injured without undue burden, they would adopt it.
5. Fast improvement can only be achieved in an open, non-punitive, and constant learning workplace.
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
Layers of Protection
Unwanted Outcomes (Events)
Equipment Failure – 20%
Human Errors - 80%
Individual Errors – 30%
Latent Organizational Weaknesses – 70%
Human Performance
• What is Human Performance? – A series of behaviors executed to accomplish specific tasks.
Human Performance
Improve Human Performance
&
YOU WILL
Improve Operational Performance
THE THREE TYPES OF HUMAN ERRORS ARE:
1. 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”
THE THREE TYPES OF BEHAVIOR BASED ERRORS ARE:
2. 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
3. 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
THE THREE TYPES OF BEHAVIOR BASED ERRORS ARE:
Task Error Model
Knowledge based – Rule based – Skill based
Error Mode:
Inaccurate Mental Model
Error Rate 1:10Error Mode:
Misinterpretation
Error Rate 1:100
Error Mode:
Inattention
Error Rate 1:1,000
Rules, Standards, Checklist,Written Procedures
Memorization, Practice
Error Traps
Error Trap Recognition (TAPE Method)
Time Specific Error Traps Activity Specific Error Traps
Daily Cycle (time of day) Inadequate Layers of Protection
Weekly Cycle (day of week) Time Pressure Task
Monthly Cycle (summer effects, etc.) Distractive Task
Holiday Effects First Time or Infrequent Task
Person Specific Error Traps Environment Specific Error Traps
Compromised Physical & Mental Conditions
Weather Conditions
Negative Personal & Age Effects Unproven, Unseen, & Unauthorized Walk Paths
Inexperience Sloping Footing/Terrain
Not Understanding or Complying with the Rules
Low Visibility
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
Some Human Performance Tools for Teams
• Pre-job briefing (Tailboard)• Peer check• Flagging• Turnover• Post-job review• Concurrent Verification
Some Human Performance Tools for Leaders and Management
• Observations & Feedback• Self-Assessments• Operating experience
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.
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
Event Clock Resetting Types
Avoidable: Total # Events
FatalitiesLost Times 5
Fractures 2Amputations
Loss of ConsciousnessElectrical Contacts w/ Injury
Arc Flashes w/ InjurySwitching & Clearance Events 3
Motor Vehicle Accidents >$5,000 3
Unplanned Feeder Outages (@ Sub Breaker)
6
Events with OSHA Violations 1Total Event Clock Resets 20
ED/CS/RR Event Clock
Organization 2012 Resets 2012 Incentive Threshold
Energy Delivery 19
Customer Service 1
Rates & Regulatory 0
Total 20 32
Days Since Last Reset 44
Average Days Between Resets 18
Organization Days Since Last Reset
# 2012 EFC Resets
Last Resetting Event
Last Reset Date
Atwell - Tot Transmission Construction 70 3 32603 7/13/2012Lucas/Tetlow - Total ED Power Ops & Maint 68 11 32596 7/15/2012
Easterly - Total Rural AZ Delivery 37 3 32701 8/15/2012Smith - Total ED Asset Mgmt & Plng 1856 0 26223 8/23/2007McElmury - Total Safety&Perf Excellence 331 0 31796 10/26/2011
Daniel - Total Distribution Constr 60 2 32628 7/23/2012Froetscher - Total Energy Delivery 37 19 32701 8/15/2012Orlick - Marketing None 0 None None Goguen - Total Cust Svc Ops 795 0 30350 7/19/2010Loveridge - Total Meter Operations 146 1 32381 4/28/2012Casuga - Total Cmty Dev/Cust Offices 780 0 30393 8/3/2010
McLeod - Total Customer Service 146 1 32381 4/28/2012
Guldner - Total Rates & Regulation 1134 0 29162 8/14/2009Total ED/CS/RR 37 20 32701 8/15/2012
Breaking the “Safety Cycle”
Injuries
Time
Trend
Close Calls are a gift from God
Presented by: Chuck Thomack, CSP
Section Leader, Safety
(602) 371-7873
Date: September 28, 2012