Post on 27-Mar-2015
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Human Performance ImprovementWork Group
WECC Strawman Class
Based on INPO and DOE manuals
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ObjectivesObjectives:
Explain why human performance improvement is important to you and your Company.
Describe what can influence human performance.
Identify and apply Eight fundamental Human Performance Error Prevention Tools to improve safety and reduce errors.
Reinforce the knowledge and usage of the HP tools so that they become commonplace in the daily work environment
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LessonsLessons:
Performance Improvement Overview
Human Performance Error Prevention Tools
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What causes humans to failWhat causes humans to fail
At Risk Behaviors
Normally, humans make about ???? errors per hour.
5 errors per hour
XXX COMPANY 20,000 employees
x 5/hr
100,000 errors per hour
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What causes humans to failWhat causes humans to fail
At Risk Behaviors
This is made worse when the person: Is in a hurry Under a high workload Doing more than one thing at a time Doing the same thing over & over
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Traps in the Work Traps in the Work EnvironmentEnvironment Distractions
Interruptions
Unplanned changes
Error PrecursorsError Precursors
Those things that “set-up” a mistake to happen Task demands are greater than the worker’s abilities Confusing conditions make the job harder New techniques not used before Mental shortcuts Lack-of or unclear standards Illness / Fatigue
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Performance Improvement Overview: Common Error Precursors
Task Demands Individual Capabilities High workload (memory requirements) Unfamiliarity with task / First time
Time pressure (in a hurry) Lack of knowledge (faulty mental model)
Simultaneous, multiple tasks New technique not used before
Repetitive actions / Monotony Imprecise communication habits
Irrecoverable actions Lack of proficiency; Inexperience
Interpretation requirements Unsystematic problem-solving skills
Unclear goals, roles, or responsibilities “Can do” attitude for safety-critical task
Lack of or unclear standards Illness or fatigue; general health
Work Environment Human Nature Distractions / Interruptions Stress
Changes / Departure from routine Habit patterns
Confusing procedure / Vague guidance Assumptions
Confusing displays / controls Complacency / Overconfidence
Work-arounds / OOS instrumentation Mind set (intentions)
Hidden system responses Inaccurate risk perception
Unexpected equipment conditions Mental shortcuts or biases
Lack of alternative indication Limited short-term memory
Two Kinds of Errors
Active Errors
Latent Conditions
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EmployeesEmployees
Events occur if all barriers and the frontline fail...
TrainingTrainingProcessProcess
OversightOversight
Performance Improvement Overview: When Safety Barriers Fail
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Performance Improvement Overview: Common Error Precursors
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Human Performance Error Prevention Tools
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Human Performance Error Prevention Tools: Event Prevention
• How do We Prevent Events?
Anticipate, prevent, and catch errors at the job site: Work Preparation Work Performance Work Feedback Error Prevention Tools
Develop and Implement Defense in Depth: Process Improvement Adequate Training Oversight Teamwork
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• The Eight Human Performance Tools:
1. Tailboards (Job Briefs)
2. S.T.A.R. – Stop, Think, Act, Review Also known as “Self-Verification”
3. Three-way communication
4. Two-Minute Rule
5. Stop When Unsure
6. Questioning Attitude
7. Phonetic Alphabet
8. Procedure Use and Adherence
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Tool #1 – Tailboards:
A pre-job meeting of workers and/or supervision conducted before the performance of a job to discuss the tasks involved, hazards and related safety precautions.
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Human Performance Error Prevention Tools: TAILBOARDS
WHY: Helps personnel to better understand
what is to be accomplished and what should be avoided. They help personnel avoid surprises in the field and reinforce the idea that there are no routine tasks.
Allows an interaction between members of the crew so that there is an understanding of each members role
Designated Challenger
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TAILBOARDS WHAT should be covered:
1. Task Purpose2. Documentation Review3. Task Assignments4. Safety Hazards and Mitigation5. Human Performance6. Special Requirements or Unusual
Conditions7. Operating Experience8. Stop-Work Criteria9. Oversight10. Questions
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Human Performance Error Prevention Tools: TAILBOARDS• S.A.F.E.R
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Contractor in work area – situational awareness
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Contractor – Situational Awareness
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A tailboard in action
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How would you tailboard this situation?
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Tool #2 - STAR: (Self Checking)
WHAT: A “Self-Checking” tool where the
performer pauses to focus his/her attention, reflects on the intended action and the associated outcome.
Performer must have a sound knowledge of the task to know what to expect.
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Human Performance Error Prevention Tools: STAR
WHY: Helps the performer focus attention
on the appropriate component, think about the intended action, understand the expected outcome before acting, and verifying the results.
Boosts attention and thinking just before an action is performed.
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Human Performance Error Prevention Tools: STAR
WHEN should it be performed:
1. When operating equipment.2. When performing test programs.3. When manipulating any controls.4. When entering data into a computer.5. When revising drawings.
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Human Performance Error Prevention Tools: STAR
• HOW should it be performed:
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Human Performance Error Prevention Tools: STAR
How: Halt conversation prior to performing
action. Perform one action at a time. Pause and self check between actions
when performing multiple actions. Recognize when uncertainties or
discrepancies exist and STOP. Personnel are alert and un-fatigued. Re-perform self check after loosing
visual of physical contact.
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Human Performance Error Prevention Tools: Tool #3
Tool #3 – Three Way Communication: Fundamental Human Performance Error
Prevention Tool where the communication originator (SENDER) verifies that the RECEIVER understands the message as intended. The RECEIVER ensures he/she understands what the sender is saying.
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Human Performance Error Prevention Tools: 3-Way Communication
WHAT: Fundamental Human
Performance Error Prevention Tool where the communication originator (SENDER) verifies that the RECEIVER understands the message as intended. The RECEIVER ensures he/she understands what the sender is saying.
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Human Performance Error Prevention Tools: 3-Way Communication
WHY: Promotes reliable transfer of information
and understanding, which ensures correct subsequent action.
WHEN should it be applied:
1. When providing critical information.2. When providing equipment status.3. When directing operation of equipment.4. When directing others to perform a task.
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1. The initiator makes a statement.
2. The participator repeats the statement in confirmation.
3. The initiator confirms back that the statement is correct.
3 Way Communication
The Message
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Human Performance Error Prevention Tools: 2-Minute Rule
Tool #4 – Two Minute Rule:
WHAT: A fundamental HP EPT that helps the worker
develop an accurate understanding of the work environment, associated hazards, equipment condition/status, and other critical work site attributes.
WHY is it important?: Improves situational awareness of the job site.
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Human Performance Error Prevention Tools: 2-Minute Rule
WHEN should it be performed?
1. All work activities2. Upon arriving at the work location.3. During job walk down.4. After breaks, lunch, or other
interruptions.5. Anytime conditions change.
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Human Performance Error Prevention Tools: 2-Minute Rule
HOW:
1. Explore the job site and adjacent areas.
2. Talk with co-workers
3. Mitigate hazards
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Tuned out - Unaware of surroundings. Mental Radar is off. OK at home, or on brief breaks at work when resting safely outside workzone away from all hazards.
Scanning – Mental Radar is actively scanning 360° for hazards and anomalies and visualizing likely outcomes. Aim to spend most of your time in this state.
Focused – You notice something, but may not know if it’s a hazard or not. You assess it, then either avoid it, or control it safely. Beware tunnel vision here.
Red Alert – You’re aware of an imminent hazard. You’ve already prepped safe, decisive actions and back up plans. You control the hazard safely. No surprises.
Four Mental States of Situational Awareness
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Photo by isafmedia. Used with permission.
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Photo by isafmedia. Used with permission.
Primarily Scanning
Primarily Focusing
The sniper’s mental state is Focused. The spotter’s mental state is Scanning. Both communicate effectively with each other. The result? Situational Awareness that you can bet your life on.
Comm
unicating
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We spend perhaps 95%+ of each typical day in only two of these mental states – Scanning and Focusing.
One “secret” to Situational Awareness is to alternate between these two mental states when you work alone, and to ensure that team members coordinate the two states effectively when working on a team.
Scanning – Mental Radar is actively scanning 360° for hazards and anomalies and visualizing likely outcomes. Aim to spend most of your time in this state.
Focused – You notice something, but may not know if it’s a hazard or not. You assess it, then either avoid it, or control it safely. Beware tunnel vision here.
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PrimarilyFocusing
Communicating
Primarily Scanning
PrimarilyFocusing
Communicating
Primarily Scanning
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Neither Scanning nor Focusing
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Human Performance Error Prevention Tools: Stop When Unsure
Tool #5 – Stop When Unsure
WHAT: When confronted with confusion or uncertainty, a
person is in unfamiliar territory. Given that the chance for error is particularly high in such situations, the best course of action, when unsure, is to stop and get help from other people.
WHY is it important? When confronted with confusion or uncertainty, a
person is in unfamiliar territory. Given that the chance for error is particularly high in such situations, the best course of action, when unsure, is to stop and get help from other people.
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Human Performance Error Prevention Tools: Stop When Unsure
WHEN should it be performed? When uncertainty, doubt, confusion, or questions
persist When encountering conditions inconsistent with
the procedure If beyond the scope of the plan or process When feeling distrustful of another individual When unexpected results or unfamiliar situations
are encountered When something expected does not happen When uncertain regarding compliance with
expectations or procedures When unfamiliar with an important work situation When inexperienced or lacking knowledge with a
task When someone else expresses doubt or concern
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Human Performance Error Prevention Tools: Stop When Unsure
HOW:
Stop the activity. Place the equipment and the job site in a safe
condition. Notify your immediate supervisor.
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Human Performance Error Prevention Tools: Questioning Attitude
Tool #6 – Questioning Attitude
WHAT: Attitude is a state of mind or a feeling toward a subject or object of interest.
A questioning attitude promotes a preference for facts over assumptions and opinion. Questions such as “What if…,” or “Why is this acceptable?”
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Human Performance Error Prevention Tools: Tool #6
Tool #6 – Questioning Attitude
WHY is it important?:
A questioning attitude fosters situational awareness, promotes a preference for facts over submission and opinion, and encourages thought about safety BEFORE action is taken. Without sufficient facts or verification, the performer stops the activity to address unexpected work situations that could lead to either a serious mistake or a significant event.
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Human Performance Error Prevention Tools: Questioning Attitude
WHEN should it be performed? During self-checking (Think step of STAR) Before performing an important step or phase of an
activity When making a decision about an important activity When experiencing uncertainty, confusion, or doubt When experiencing a “gut feeling” that “something is
not right” When encountering unanticipated changes in
conditions When conflicts or inconsistencies exist between plans,
procedures and actual conditions After encountering unexpected results After discovering missing information or resources Upon hearing danger words: “I assume,” “probably,” “I
think,” “maybe,” “should be,”
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Human Performance Error Prevention Tools: Questioning Attitude
HOW: Stop, Look, and Listen – Ask questions – Gather relevant
information. Proceed if sure – Continue the activity if
the uncertainty has been resolved with facts. Otherwise, do not proceed in the face of uncertainty!
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Human Performance Error Prevention Tools: Questioning Attitude
Perception, Comprehension, and Projection.
SCAN FOCUS ACT.
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Situational awareness
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Human Performance Error Prevention Tools: Phonetic Alphabet
Tool #7 – Phonetic Alphabet
WHAT: Several letters in the English language sound
alike and can be confused in stressful or noisy situations. The Phonetic alphabet specifies a word for each letter of the alphabet reducing the likelihood that the letters will be confused.
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Human Performance Error Prevention Tools: Phonetic Alphabet
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Human Performance Error Prevention Tools: Phonetic Alphabet
WHY is it important?: The phonetic alphabet can reduce the
effects of noise, weak telephone or radio signals, or even a person’s accent
WHEN should it be performed? When communicating alpha numeric
information When specifying phase or channel
designations When a sender or receiver may
misunderstand the designations of an order
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Human Performance Error Prevention Tools: Phonetic Alphabet
HOW to use the Phonetic Alphabet?:
Speak distinctly and slowly Use terms like “Stop” , “Correct”, “Wrong” Do Not use Slang Terms
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Human Performance Error Prevention Tools: Tool #8
Tool #8 – Procedure Use and Adherence
WHAT: Understanding the overall purpose and strategy of
approved procedures, promotes a safe reliable outcome. Adhering to approved procedures helps to dispel doubt and provides clarification regarding questions in the execution of various tasks and duties
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Human Performance Error Prevention Tools: Procedure Use and Adherence
WHY is it important?:
Procedure quality is paramount to safety and reliability. The completeness, accuracy, and internal consistency of the instructions, and its usability (easy to understand and follow) all impact the user. Procedures have been written over the years based on experience and proven uses of equipment. Procedures MUST be followed. Short cuts are often precursors of error
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Human Performance Error Prevention Tools: Procedure Use and Adherence
WHEN should it be performed?
When manipulating, altering, monitoring, or analyzing equipment
When a procedure exists for a work activity When required
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Human Performance Error Prevention Tools: Procedure Use and Adherence
HOW: Make sure you have the correct
procedure or SW log and it has been checked
Review the procedure or SW log before starting work, confirming understanding of the procedure’s overall purpose and expected outcome. Make any changes/revisions before you start switching.
Follow the procedure as written without deviation being aware of the potential impact the action can have on equipment.
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Human Performance Error Prevention Tools: The Four Tools
• The Eight Human Performance Tools:
1. Tailboards (Job Briefs)
2. S.T.A.R. – Stop, Think, Act, Review Also known as “Self-Verification”
3. Three-way communication
4. Two-Minute Rule
5. Stop When Unsure
6. Questioning Attitude
7. Phonetic Alphabet
8. Procedure Use and Adherence
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Individuals
Each employee has a role and a responsibility in error prevention, at all levels in an organization.
OrganizationLeaders
Human Performance Error Prevention Tools: The Working Connection
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Human Performance Error Prevention Tools: Individuals
Role of the Individual:
Apply and use Error Prevention Tools.
Coach and reinforce use of EPTs with others.
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Human Performance Error Prevention Tools: Visibility
Role of Visibility between Peers and Leaders:
Observations Role modeling Reinforcing expectations Coaching Recognition Brother’s Keeper
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Human Performance
Make it a Habit