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Human Performance Improvement

Part I Presented by

Michael L. McIntosh, CIH, CSP, CHMM Oak Ridge National Laboratory

American Chemical Society August 2010

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“… human fallibility is like gravity, weather, and terrain, just another foreseeable

hazard. Error is pervasive … What is not pervasive are well-developed skills to

detect and contain these errors at their early stages.”

-  Weick and Sutcliffe Leading with Resilience in the Face of the Unexpected

Human Fallibility

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To Err is Human

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To Error is Human (Cont.)

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To Drift is Human

Why is HPI Important

•  UCLA research assistant died from injuries sustained in a chemical fire on December 29th, 2008

•  Texas Tech University student seriously injured on January 7th, 2010 when a mixture of nickel hydrazine perchlorate exploded in chemistry building

•  SMU student burned on May 11, 2010 in chemistry lab by pouring water too quickly on sodium hydride

•  Explosion injures four people at a University of Missouri science lab on June 28, 2010

•  Chemical Safety Review Board states “it is time to begin examining these accidents to see if they can be prevented”

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80% Human Error

20% Equipment Failures

Occurrences

30% Individual

Human Errors

70% Latent Organizational Weaknesses*

(Slips, trips, lapses)

* Latent Organizational Weakness = Hidden deficiencies in management control process or values

What Cause Occurrences?

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Incident

Error Precursors

Vision, Beliefs, &

Values

Latent Organizational Weaknesses

Mission

Goals

Policies

Processes

Programs

Flawed Defenses

Initiating Action

Vision, Beliefs, &

Values

Anatomy of an Incident

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The significance (or severity) of an incident depends upon the consequences suffered, and not on the error that

initiates it. The error that triggers a serious accident … and the error that is

one of hundreds with no consequences ... can be the same error.

Significance of an Incident

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An action that unintentionally departs from an expected behavior.

What is an Error?

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Intentional acts that deviate from a policy or procedure for personal advantage, usually adopted for fun, comfort, expedience, or

convenience.

What is a Violation?

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Two Kinds of Error

Active Error

Latent Error

Immediate consequences. Know “who did it.”

Lead to latent organizational weaknesses

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1.  People are fallible - even the best people make mistakes.

2.  Error likely situations are predictable, manageable, and preventable.

3.  Individual behavior is influenced by organizational processes and values.

4.  People achieve high levels of performance largely because of the encouragement and reinforcement received from leaders, peers, and subordinates.

5.  Incidents can be avoided through an understanding of the reasons mistakes occur and the application of the lessons learned from past incidents (or errors).

Principles of Human Performance

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Common Traps - Human Information Processing

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We see the world as we are not as it is. It is the “I” behind the “eye” that does the

seeing Anais Nin

Information Processing

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Common Error Traps – At-Risk Attitudes and Behaviors

The ability to detect error-likely situations to head off preventable events depends largely on how well

these factors are understood regarding their role in human error.

James Reason - Human Error

Humans possess an innate characteristic to be imprecise (i.e., human nature)

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•  Inaccurate Risk Perspective: Guided by the heart, not by the head

•  Pride: “Don’t insult my intelligence.” •  Heroic: “I’ll get it done, by hook or by crook.”

•  Invulnerable: “That can’t happen to me.”

•  Fatalistic: “What’s the use?” or “Que será será”

•  Bald Tire: “I’ve gone 60K miles without a flat yet.” •  Summit Fever: “We’re almost done.”

•  Pollyanna: “Nothing bad will happen.”

At-Risk Attitudes

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An error about to happen: •  Typically exists when task-related factors exceed

the capabilities of the individual (a mismatch)

Unintentional deviation from preferred behavior Jobsite conditions

Degree of mismatch due to error precursors

(also called “Error Traps”)

Error-Likely Situation

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  Limited short-term memory   Personality conflicts   Mental shortcuts (biases)   Lack of alternative indication   Inaccurate risk perception   Unexpected conditions   Mind-set   Hidden system response   Complacency / Overconfidence   Workarounds / OOS instruments   Assumptions   Confusing displays or controls   Habit patterns   Changes / Departures from routine   Stress   Distractions / Interruptions

Human Nature Work Environment   Illness / Fatigue   Lack of or unclear standards   “Unsafe” attitude for critical tasks   Unclear goals, roles, & responsibilities   Indistinct problem-solving skills   Interpretation requirements   Lack of proficiency / Inexperience   Irrecoverable acts   Imprecise communication habits   Repetitive actions / Monotony   New technique not used before   Simultaneous, multiple tasks   Lack of knowledge (mental model)   High Workload (high memory requirements)   Unfamiliarity w/ task / First time evolution   Time pressure (in a hurry)

Individual Capabilities Task Demands

(Conditions that Provoke Error)

OOS – out of service

Common Error Precursors

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Errors are for the most part unintentional. It is very hard for management to control what people did not intend to do in the first place.

- Dr. James Reason Human Error

Errors are....

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Time

Am

ount

of R

isk

Real Risk Level

Perceived Risk

Normalized Deviance

Focusing on one moment in time, you see negligence with respect to an old standard or norm.

(NASA VIDEO)

Process

Values

Normalized Deviance

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•  Excellence in Performance –  Aligns process with values –  Improved productivity, efficiency, quality, reliability, & safety –  Reduced costs (rework, lost work time, etc.) and risks –  Improved performance and effective, informed culture

Reducing Error + Managing Defenses Zero Events

Anticipate & Prevent Active Error at the Job-site

Confirm Integrity of Defenses and Identify/Eliminate Latent Organizational Weaknesses

(Unwanted Outcomes)

Goal of Human Performance Improvement

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•  Performance modes –  Skill based –  Rule based –  Knowledge based

•  Error Prevention Tools •  Just Culture

Part II

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Human Performance Improvement

Part II Presented by

Michael L. McIntosh, CIH, CSP, CHMM Oak Ridge National Laboratory

American Chemical Society August 2010

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1.  People are fallible - even the best people make mistakes.

2.  Error likely situations are predictable, manageable, and preventable.

3.  Individual behavior is influenced by organizational processes and values.

4.  People achieve high levels of performance largely because of the encouragement and reinforcement received from leaders, peers, and subordinates.

5.  Incidents can be avoided through an understanding of the reasons mistakes occur and the application of the lessons learned from past incidents (or errors).

Review of Principles of Human Performance

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1/2 to 1/10

Consider Performance Modes

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•  Chance for error is 1 in 10,000 •  Error mode is inattention •  Unintentional slips or lapses •  Intent was correct, action

inappropriate •  Skilled personnel performing

familiar tasks

Skill-Based Errors Pre-Programmed Skills or Habits

•  Normalized deviation due to familiarity is a concern

•  25% of errors are skill-based

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•  Chance for error is 1 in 1,000 •  Error mode is misinterpretation •  Conscious decision making

using stored rules •  Rules must be matched with

skills

Rule-Based Errors Selecting the Path Forward

•  Errors are made when conditions change and change is not recognized

•  60% of all errors are rule-based

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•  Chance for error is high - 1 in 2 to 1 in 10

•  Error mode is inaccurate mental picture

•  Responding to a totally unfamiliar situation

Knowledge-Based Errors Breaking New Ground

•  Uncertainty is high – added stress •  Fundamental principles and technical

understanding needed to make a decision •  15% of errors are knowledge-based

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•  Task Preview •  Job-Site Review •  Questioning Attitude •  Stop (& collaborate) when unsure •  Self-Checking •  Procedure Use and Adherence •  Validate Assumptions •  Effective Communications •  Place-Keeping •  “Do Not Disturb” Sign

Error-Prevention Tools - Individuals -

•  Questioning Attitude •  Stop (& collaborate) when unsure •  Self-Checking

•  Effective Communications

•  Procedure Use and Adherence

•  Task Preview

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Individual Capabilities

Task Demands

Human Nature

Work Environment

Error-likely Situations

Potential Consequences

Flawed Defenses

Critical Steps Task

Preview

SAFER Dialogue S – Summarize critical steps A – Anticipate error traps F – Foresee consequences E – Evaluate defenses R – Review operating experience

Work Situation Factors

Situational Awareness

Proactive Mental Framework

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•  Used along with Self-Checking •  Promotes a preference for facts over assumptions

and opinions

Fosters thought before action and helps individuals maintain an accurate understanding of work conditions.

Questioning Attitude

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Unsure = unchartered territory = knowledge-based performance mode = High Error Rate (1/2 to 1/10)

1. Stop (pause or time-out) the activity 2. Place the equipment and the job site in a safe

condition 3. Notify your immediate supervisor 4. Get help from more knowledgeable person(s)

Stop When Unsure

Stop and collaborate with an expert!

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•  When to use? •  What to pay attention to? •  Where to pay attention

Promotes a preference for facts over assumptions and opinion.

Promotes a questioning attitude

Self-Checking

Pause and think before acting when vital points (critical junctures) are reached

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•  Not enough information (or too much) •  Interpretation requirements •  Procedural non-use / procedure out-dated •  Critical steps not identified •  Technical errors •  Stopping and restarting, etc….

Procedure Use & Adherence

Procedures - intended to direct behavior and minimize choices the user has to make Error can be introduced when:

Consider place-keeping (physically marking completed steps) to prevent errors

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Goal = mutual understanding

1

1 Mom to Joey – “Go walk the dog before dinner.”

2 2 Joey to Mom – “I understand that you want me to walk the dog before dinner. Is that correct?”

3

3 Mom to Joey – “That is correct” OR “That is wrong,” and restates original message

Effective Communication

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•  Halo Effect: Blind trust in the competence of specific individuals

•  Pilot / Co-pilot: Subordinate reluctant to challenge opinions, decisions, or actions of senior person

•  Free Riding: One takes the lead while others tag along without actively scrutinizing the work.

Team Errors

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•  Groupthink: Reluctance to share contradictory information for the sake of maintaining harmony

•  Risky Shift: Tendency to gamble with decisions more as a group than if each member was making the decision individually – accountability is diffused (also called “herd mentality”)

It takes a team error to have an event.

Team Errors (Cont.)

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•  Pre-Job Briefings •  Peer-Checking •  Verification Practices •  Flagging •  Turnover •  Post-Job Review •  Project Planning •  Problem Solving •  Decision Making •  Project Review Meeting

Error-Prevention Tools - Work Teams -

•  Pre-Job Briefings •  Peer Checking

•  Turnover

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•  Discuss specifics, including CRITICAL STEPS •  Discuss error traps, consequences, defenses, and

error-prevention techniques •  Encourage active engagement by all members •  Ensure key participants are present •  Discuss actions for work scope changes •  Encourage a questioning attitude and self-checking

To prepare for what is to be accomplished and for what is to be avoided!

Pre-Job Briefings

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A 2nd knowledgeable individual verifies that the action planned is appropriate and occurs as planned. Purpose - to prevent errors.

Peer Checking - Addresses Actions

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•  To establish an accurate mental model (situational awareness)

•  Thorough, accurate - may include a walk-down •  Use three-point communication •  Use written logs

The orderly transfer of information, tasks, and responsibilities between individuals or crews

Turnover

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•  Understand error-provoking factors and human fallibility & vulnerabilities

•  Anticipate error-likely situations •  Apply error-prevention tools & techniques •  Improve personal capabilities •  Use the proactive mental framework and S-A-F-E-R

dialog

What Individuals can do……

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HIGH

Rel

iabi

lity

of D

efen

se

Degree of Human Control

Self-Checking

Supervision/Qualifications

Caution Tags

Procedure Use

Document Reviews

Personal Protective Equipment

Interlocks

Engineered Safeguards

Containment Structures (e.g., shield walls)

Dependability of Defenses

Reliability of the defense/control is inversely proportional to the amount of human intervention required

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Weakness in defenses may not be detected and repaired … because the people involved often

forget to be afraid.

WARNING: Defense-in-depth can be a two-edged sword.

•  Redundant defenses improve safety margins but also increase complexity.

•  Flaws, traps, flawed defenses, and safety hazards can become more difficult to detect. –  Latent conditions allowed to persist

Dependability of Defenses (Cont.)

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Error without consequence shows that our systems are error-tolerant and that they are working.

Organizational Values - Error Tolerance -

•  Design processes, tasks, equipment, etc., such that the inevitable human error will not result in an event of consequence.

Error Tolerance:

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•  Foster a culture that values the prevention of errors and mishaps

•  Preclude the development of error-likely situations •  Eliminate latent organizational weaknesses that

provoke error •  Create a “Learning” environment that promotes

continuous improvement •  Value error tolerance •  Report all errors and near misses •  Expect the unexpected, and have appropriate

contingency plans in place

What Organizations can do….

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Errors are for the most part unintentional. It is very hard for management to control what people did not intend to do in the first place.

- Dr. James Reason Human Error

Errors are....

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“If error-free performance (avoiding active errors) is not held up as an important value

or is not expected for daily work, then people may adopt unsafe practices to get their work done, possibly placing themselves, others, or

the facility at risk of an event.” Human Performance Reference Manual

INPO 06-003

Value Prevention of Errors

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Understanding human fallibility encourages a proactive perspective toward work:

•  It is easy to err, and a person may not even know it •  Workers should possess a keen - and healthy -

sense of uneasiness toward any activity – prompts the mindset: “expect success but

anticipate failure” – fosters intolerance for error traps / precursors

Value Prevention of Errors

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“Workplaces and organizations are easier to manage than the minds of individual

workers. You can not change the human condition, but you can change

the conditions under which people work.”

- Dr. James Reason

Human Performance

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•  It is unacceptable to punish all errors and unsafe acts regardless of origins and circumstances;

•  It is equally unacceptable to give blanket immunity from sanctions to all actions that could, or did, contribute to organizational accidents.

Atmosphere of trust in which people are encouraged, even rewarded, for providing essential information – but

in which they are also clear about where the line is drawn between acceptable and unacceptable behavior.

A Just Culture

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•  Promotes a reporting and learning culture & honest investigation of true organizational weaknesses

•  Provides forward-looking accountability •  Builds Trust … what’s said gets done by management •  Ensures respect for the individual •  Instills belief that discipline is fairly administered •  Maintains zero tolerance for harassment/retaliation •  Provides multiple avenues of communication •  Builds confidence in broader organizational cause

investigations

Benefits of a Just Culture

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Human “Success”

Flawed defenses & error precursors

eliminated

Latent organizational weaknesses identified

Management more aware of jobsite

conditions Effective

communication

Increased trust

Individual recognized or rewarded

Praise Cycle

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1.  Healthy preoccupation with failure 2.  Reluctance to oversimplify 3.  Sensitivity to operations 4.  Maintain capabilities for resilience 5.  Deference to expertise

Diverse organizations that share a singular demand: They have no choice but to function reliably. If reliability is compromised, severe harm results.

HROs Cultures of Mindfulness

High Reliability Organizations (HROs):

Adapted from “Managing the Unexpected,” by Karl Weick and Kathleen Sutcliffe

References

•  Managing the Risks of Organizational Accidents, James Reason, Ashgate, 2006

•  Managing Maintenance Error, James Reason and Alan Hobbs, Ashgate, 2003

•  The Field Guide to Understanding Human Error, Ashgate, 2006 •  Just Culture, Sidney Dekker, Ashgate, 2007 •  The Design of Everyday Things, Donald Norman, Basic Book, 1988 •  Blink, Malcolm Gladwell, Back Bay Books, 2005 •  The Human Contribution, James Reason, Ashgate, 2008 •  The Challenger Launch Decision, Diane Vaughan, University of

Chicago Press, 1997 •  Why Hospitals Should Fly, John J. Nance, JD, Second River

Healthcare Press, 2008

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