Joel E. Heim Manager, Training & Development

Human Performance Improvement

Through a Just Culture

Moving from a Reactive Safety Culture

Principles of Human Performance

• People are fallible, and even the best people make

mistakes

• Error-likely situations are predictable, manageable,

and preventable

• Individual behavior is influenced by organizational

processes and values

• People achieve high levels of performance because

of the encouragement and reinforcement received

from leaders, peers, and subordinates

• Events can be avoided through an understanding of

the reasons mistakes occur and application of the

lessons learned from past events or errors

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12 Most Common Causes of Human Error

• Lack of Communication

• Lack of Teamwork (No Peer Caring)

• Norms (Culture)

• Pressure (Shortcuts)

• Complacency

• Lack of Knowledge (Unconscious Incompetence)

• Lack of Awareness

• Lack of Resources

• Distraction

• Lack of Assertiveness (Courage to speak up)

• Fatigue

• Stress

Information Word Game

✓ Bed

✓ Rest

✓ Awake

✓ Snooze

✓ Nap

✓ Drowsy

✓ Pillow

✓ Wake

✓ Tired

✓ Blanket

✓ Slumber

✓ Peace

✓ Yawn

✓ Doze

Error Precursors (Error Traps)

• Task Demands

– Time pressure

– High workload

– Simultaneous tasks

– Repetitive tasks

– Monotony

– Unclear goals

– Unclear standards

• Individual Capabilities

– Unfamiliarity with task

– Lack of knowledge

– Poor communication

– Inexperience

– Illness / Fatigue

– Unsafe attitude

– Major life event

Error Precursors (Error Traps)

• Work Environment

– Distractions

– Interruptions

– Departure from routine

– Work-arounds

– Personality conflicts

– Shift changes

– Production

overemphasis

– Physical climate

• Human Nature

– Stress / Mental strain

– Habits / Biases

– Assumptions / Mindset

– Complacency

– Overconfidence

– Inaccurate risk

perception

– Limited memory

– Circadian rhythm

Unsafe Attitudes / At-Risk Behaviors

• Pride

– “Don’t tell me what to do”

• Heroic

– Custer at Little Big Horn, “Here I come to save the day”

• Fatalistic

– Predetermined, Inevitable, “Let the chips fall where they may”

• Invulnerability

– “Nothing will happen to me”

• Pollyanna

– “All is well”, “What can go wrong”, “It’s routine”

• Bald Tire

– “We’ve always done it this way”

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Team Errors

• Halo Effect

– Blind trust due to experience or education

• Pilot / Co-pilot

– Reluctance of subordinate to question senior person

• Free Riding

– Taking passive role

• Groupthink

– Reluctance to question group opinion

• Diffusion of Responsibility

– Spread the blame

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Error Likely Situations

Moving to a Just Culture

• Manage your state and habits of mind

• Pay attention to what stories you tell yourself

• Be aware of your mental biases

– Invincibility / Invulnerability

– Fundamental Attribution Error

– Outcome Bias

– Hindsight Bias

– Confirmation Bias

Why We Do What We Do

• Antecedent

– Prompts a Behavior

• Behavior

– Specific muscle movement

• Consequence

– What happens to us

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Behavioral Consequences

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R+ positive reinforcement

R- negative reinforcement

P+ Punishment

P- Penalty

Behavioral Consequences

• Determine the probability of a behavior re-occurring

• Will be either:

– Positive or Negative

– Immediate or Future

– Certain or Uncertain

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Establish and Maintain a Just Culture

• An open, honest, reporting culture

• Look at the intent, not just the consequence

– Get away from fault and blame

• Recognize the difference between errors and

violations

– Errors are unintentional slips or lapses

– Violations are intentional

• Balanced accountability is the key

• Just Culture begins with Trust

Five Dysfunctions of a Team

• Inattention to Results

• Avoidance of Accountability

• Lack of Commitment

• Fear of Conflict

• Absence of Trust

23From “The Five Dysfunctions of a Team” – Patrick Lencioni

Strategic Approach for Human Performance

• Anticipate, prevent, catch, and recover from active

errors at the job site

– Preparation

– Performance

– Feedback

• Identify and eliminate latent organizational

weaknesses that provoke human error and degrade

controls against error and consequences of error

– Control hazards by elimination or substitution

– Engineered Features

– Administrative Provisions

– Cultural “Norms”

– Oversight

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Human Performance Tools

• Task Preview

• Job-site Review

• Questioning Attitude

• Stop when Unsure

• Procedure Use and

Adherence

• 3-way Communication

• Phonetic Alphabet

• Pre-job Briefing

• Post job Review

• Concurrent Verification

• Independent Verification

• Place-keeping

• Validating Assumptions

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Principles of Human Performance

• People are fallible, and even the best people make

mistakes

• Error-likely situations are predictable, manageable,

and preventable

• Individual behavior is influenced by organizational

processes and values

• People achieve high levels of performance because

of the encouragement and reinforcement received

from leaders, peers, and subordinates

• Events can be avoided through an understanding of

the reasons mistakes occur and application of the

lessons learned from past events or errors

26

Universal Sign of Commitment

References

• DOE Human Performance Improvement Handbook

Vol. 1

• DOE human Performance Improvement Handbook

Vol. 2

• Crucial Conversations – Joseph Grenny, David

Maxfield, Kerry Patterson

• The Five Dysfunctions of a Team – Patrick Lencioni

• Bringing Out the Best in People – Aubrey Daniels

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