1 Human Performance Tools System Operator Conference September 11-13 and September 25-27, 2012...

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Human Performance Tools

System Operator ConferenceSeptember 11-13 and September 25-27, 2012

Memphis, TN

Sam AustinManager, System Operator Training

Tennessee Valley Authority

2012 System Operator Conference

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Learning Objectives

At the conclusion of this training session, you should be able to:• Name the 5 basic principles of human performance.• List the barriers that prevent human performance errors and

discuss how these barriers can break down to cause events.• Discuss the underlying basis for the 5 human performance

tools presented today, and when to use these tools. • Apply the 5 human performance tools to your daily job• Identify the fundamental aim of human performance tools


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Outline of Topics

• 5 basic principles of human performance• Breakdown of barriers that prevent human error• 5 human performance tools• Applying and using human performance tools• Aim of using human performance tools


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Five Basic Principles of Human Performance

• People make mistakes

• Error-likely situations are predictable and preventable

• Organizational values influence individual behavior

• High levels of performance are achieved based largely on encouragement from peers

• Events can be avoided by understanding root causes and lessons learned


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Is it a Question of Competence or Fallibility?

• Pride – an excessively high opinion of ones’ ability.

• Pride tends to blind us to the value others can provide. • Pride hinders teamwork.

• People think their competence is being questioned when they are corrected about not adhering to expectations.


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• The issue is human fallibility, NOT a human being’s competence.

• Because of the limitations of human nature, error-prevention methods should be used to control error.

Is it a Question of Competence or Fallibility?


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Barriers That Prevent Human Error Events

Individual Barriers

(Proper use of Human Performance Tools)

Programmatic Barriers

Organizational Barriers

Management BarriersInitiating Action

Poorly written procedures, failed or non-existent barriers, ineffective management

Weak skills, failed or non-existent barriers

Significant Event

Break-down of

barriers lead to error events


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NERC Industry Advisory

November 08, 2011: Reducing Human Performance Errors by the Use of Configuration Control Practices


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By developing and implementing proper

configuration control, entities can reduce exposure to

the inherent risk of human performance errors that

occur during the maintenance and testing of

protection systems.


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Some of the suggested tools to use:

• Maintenance Alteration Log – “procedure use”• Peer Review/Peer Check• Self Check• Place Keeping


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Error Prevention Methods/Human Performance Tools

• STOP when unsure

• PEER-CHECKING: Have peers check your work • PROCEDURE USE & ADHERENCE: Use and adhere to

all procedures • PLACE KEEPING: Keep your place!

• SELF-CHECKING: Check yourself and each step of your work


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Stop When Unsure

• When confronted with a situation that creates a question, a person is in uncharted (unfamiliar) territory—a knowledge-based performance situation

• Whenever a question is encountered and what to do

about it is uncertain, stop and get help.

• Given the chances for error are particularly high in a knowledge-based situation, the best course of action, when unsure, is to take a time-out and get another person’s ‘mind’ focused on the problem.


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Stop When Unsure

• When that “gut feeling” is telling you that something is not right, stop.

• Get help from those who possess the expertise, not necessarily from those of higher rank.

• Don’t be embarrassed, stop and get help!


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Stop When Unsure

When to use the tool

When……• You get unexpected results

• You are in unfamiliar situations

• You have uncertainty whether or not you are in compliance with expectations, procedures, or regulations


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Peer Checking

• Peer checking is an error-prevention technique:• a verbal agreement between two individuals prior to

a specific action and/or task• one will observe or check the behavior of the other to

prevent an error by the performer.

• One person acts as the performer, and the second person, an experienced peer familiar with the activity, acts as the checker.


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Peer Checking

• Peer-checking is merely two persons (performer and checker):

• self-checking in parallel• agreeing together that the action is the correct action to be

performed and……• on the correct component!

• Peer checking augments self-checking, but does not replace it.

• This technique takes advantage of a fresh set of eyes not trapped by the performer’s task focused mind-set. The checker may “see” hazards or potential consequences the performer does not see.


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Peer Checking

When to use the toolWhen……• You are in an error-likely situation with critical steps• There is a history of error or unfavorable operating

experience with a particular action• Mis-identification, mis-operation, or improper installation

or assembly can have undesirable impact on people’s safety or plant equipment

• The checking is requested by a peer


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Procedure Use & Adherence

• Procedures help users to perform activities correctly, safely, consistently, and in accordance with design requirements.

• Procedures direct people’s actions in a proper sequence and minimize reliance on one’s memory and the choices made in the field.

• Procedures incorporate the policies, operating experience, effective work practices and management decisions about how a task is to be performed.


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Procedure Use & Adherence

When to use the tool When…..• Your activities involve manipulation, monitoring, or

analysis of equipment or physical work in the field.


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Place Keeping

• Place keeping is used to mark the steps in a procedure or work document that have been completed or that are not applicable, so that steps are not accidentally omitted or repeated.

• Methods include circle/slash, check box, or sign – offs.


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Place Keeping

When to use the tool When…..• Using a procedure or work document to perform critical

activities.

• You are suspending performance of a procedure. Keep your place to identify the last step completed.


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Self Checking – “STAR” Stop – Think – Act – Review

• Self-checking helps prevent errors when:• “touching” plant equipment to change its status or…• even when revising a document important for plant

safety and reliability.• Self-checking is particularly effective during skill-based

tasks that could be performed without much conscious thought.

• This technique helps boosts attention at important points in an activity before an important action is performed. If attention is not focused, error is likely!


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Self Checking

When to use the tool

When…..• Critical steps must be identified• Equipment must be manipulated• You experience a time pressure, or “hurried” feeling• The task is interrupted – self check when resuming steps

CHECKCHECKCHECKAGAIN!


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Human Performance Tools in Use

Play Video


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Fundamental Aim of Using Human Performance Tools

• Help the individual maintain “positive control” of a work situation and to prevent errors that cause harm.

• Positive control means that “what is intended to happen” is what happens and that is all that happens.

• Despite rigorous use of these error-prevention tools, people will still make errors. But, rigorous application of these basic tools may eliminate “events”.

• This is accomplished by placing barriers between you and the manipulation of equipment, that if operated improperly, triggers an “event”.

• Good use of tools prevent breakdown of the barriers that will prevent error events!


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Summary

The main points of this training session are: • Humans are fallible and we all make mistakes.

• Human performance tools, such as self- and-peer checking, adherence to procedure, etc, help the system operator maintain positive control of a work situation.

• Incorporating human performance tools in the application of your job will help minimize mistakes and NOT trigger events.


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Questions?

1 Human Performance Tools System Operator Conference September 11-13 and September 25-27, 2012...

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