Principles of Human Performance Improvement

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Applying Human Performance Improvement to managing safety programs

Transcript of Principles of Human Performance Improvement

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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: Dont insult my intelligence. Heroic: Ill get it done, by hook or by crook. Invulnerable: That cant happen to me. Fatalistic: Whats the use? or Que ser ser Bald Tire: Ive gone 60K miles without a flat yet. Summit Fever: Were 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

    P