Unclassified Human Performance Improvement Principles for Managers.

Unclassified

Human Performance Improvement

Principles for Managers

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Course Objective

• Management will be able to create an environment where workers can make good decisions by:– Recognizing the role of the individual and

human fallibility in human performance

– Identifying how organizational systems influence human behavior

– Embracing the role of the leader to manage organizational systems and positively influence human behavior

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When Good Pets Go Bad

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Human Performance

“People do not operate in a vacuum, where they can decide and act all-powerfully. To err or not to err is not a choice. Instead, people’s

work is subject to and constrained by multiple factors”.

— Sidney Dekker

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What is Human Performance?

An individual…

working within organizational systems…

to meet expectations set by leaders.

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How to Improve Human Performance

Address limitations of human nature

Remove error traps

THIS WAY OUT

THIS W

AY OUT

Create error-tolerant systemsTHIS W

AY OUT

THIS W

AY OUT

Reinforce desired behaviors

Individual

Organization

Incentives to meet leader’s expectations

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Definitions

• Operational Upset: A condition that adversely affects, or may adversely affect, DOE or contractor personnel, the public, property, environment or the DOE mission.

• Error: An unintentional deviation from an expected behavior.

• Violation: Deliberate, intentional acts to evade a known policy or procedure requirement for personal advantage usually adopted for fun, comfort, expedience, or convenience

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HPI Principles

1. People are fallible

2. Error-likely situations are predictable

3. Individual behaviors are influenced

4. Operational upsets can be avoided

5. People achieve high levels of performance based encouragement and reinforcement.

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The Individual

HPI Principle #1:

People are fallible, and even

the best make mistakes.

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10%

90%30%

70%

Origins of Human Error

Human Error

Slip, trip or lapse

Equipment Failures

Human Errors

Operational Upsets

System Induced Error

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Basketball

• Count the number of passes between white-shirted players

• You MUST be accurate

• PAY ATTENTION!

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Limitations of Human Nature

Mistakes arise directly from the way the mind handles information, not through

stupidity or carelessness.

— Dr. Edward de Bono

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Limitations of Human Nature

• Stress• Avoidance of mental

strain• Inaccurate mental

models• Limited working

memory• Limited attention

resources

• Mind set• Difficulty seeing own

errors• Limited perspective• Susceptible to

emotion• Focus on the goal• Fatigue

See page 4 in your Concepts Guide

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Hazardous Attitudes

• 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?”• Bald Tire: “Gone 60K miles without a flat yet.”• Summit Fever: “We’re almost done.”• Pollyanna: “Nothing bad will happen.”


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Risk

“Risks that you can control are much less a source of outrage than

risks you can NOT control.”— Peter Sandman

… in other words, the risks that scare people and the risks that actually kill people are very different

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Performance ModesLo

w

Atte

ntio

n to

Tas

k

H

igh

Low Familiarity with Task High

Inattention

Misinterpretation

Inaccurate Mental Picture

Knowledge-Based

Rule-Based

Skill-Based

Patterns

If-Then

Auto

1/1,000

1/10,000

50/50 When switching from one performance mode to another a worker is presented with a new situation but has only old information on which to base decisions.


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Error Traps

HPI Principle #2:

Error-likely situations are predictable, manageable, and

preventable.

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Saw StopTM

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Error Precursors

• Limited short-term memory• Personality conflicts• Mental shortcuts (biases)• Lack of alternative indication• Inaccurate risk perception (Pollyanna)• Unexpected equipment conditions• Mindset (“tuned” to see)• Hidden system response• Complacency / Overconfidence• Workarounds / OOS instruments• Assumptions (inaccurate mental picture)• Confusing displays or controls• Habit patterns• Changes / Departures from routine• Stress (limits attention)• Distractions / Interruptions

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

Task Demands Individual Capabilities

Work Environment Human Nature


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Error Prevention Tools

• Self-checking• Peer-checking • Concurrent

verification• Independent

verification• Three-way

communication• STAR

• Pre-job briefing• Post-job briefing• Procedure use &

adherence• Problem-solving• Questioning attitude• Conservative decision

making • Stop & collaborate

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The Organization

HPI Principle #3:

Individual behavior is influenced by organizational processes and

values.

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New vs. Old View of Human Error

• Human error is a cause of accidents

• To explain failure, investigations must seek failure

• They must find people’s inaccurate assessments, wrong decisions and bad judgments

• Human error is a symptom of trouble deeper inside a system…

• To explain failure, do not try to find where people went wrong.

• Instead, find how people’s assessments and actions made sense at the time, given the circumstances that surrounded them.

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The Dryden Event

Air Ontario Flight 363 Fokker F28Dryden, CanadaMarch 10, 1989

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Types of Error

• Active Errors change equipment, system or processes that trigger immediate undesired consequences.

• Latent Errors result in undetected organization-related weaknesses or equipment flaws that lie dormant.


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Understanding Events

• Incentives are the cornerstone of human behavior

• Dramatic events often have distant even subtle causes

• Conventional wisdom is often wrong

• Knowing what to measure and how to measure it makes a complex world much less complicated

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Organizational Processes

Workplaces and organizations are easier to manage than the minds of

individual workers. You cannot change the human condition, but you can change the conditions

under which people work.

— Dr. James Reason

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The Value of Error Tolerance

Error without consequence is a good thing — it shows that our systems are error-tolerant and

that they are working.

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Defenses in Depth

• Redundancy: many layers of protection.

• Diversity: many different varieties of protection.

• Independence: separate/autonomous layers of protection.


Operational Upset

Active Error

Verbal & Written Communication and

Procedures

Equipment Design

Training & Work Practices

Protective Equipment & Shielding

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Traditional Heisenberg Model

• Number of errors is relative to the severity of consequences

• For every major accident there are many errors

• Leads us to assume that driving down errors will eliminate major accidents

600

30

10

1Major Accidents

Near Misses

Significant Events

Nonconsequential Errors


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New View of Heisenberg Model

Major Accidents

Significant Events

Near Misses

Nonconsequential Errors

Proactive

Reactive• The consequence of

error has no relationship to the number of errors

• It is related to the number and integrity of defenses

• Any error can lead to a major accident if defenses fail

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Zero Operational Upsets

Re + Md Re + Md → → OOUUReducing Error AND Managing Defenses

leads to Zero Operational Upsets


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Medical Mistakes

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Organizational Values

HPI Principle #4:

Operational upsets can be avoided by understanding the reasons

mistakes occur and applying the lessons learned from past events.

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Blame Cycle

Reduced trustLatent

organizational weaknesses persist

Management less aware of

jobsite conditions

Less Communication

Individual counseled and/or disciplined

Human Error

More flawed defenses and

error precursors


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Culpability Decision TreeWas the behavior

intended?

YES

Did the employee have

medical restrictions?

Were the consequences

intended?

Intentional sabotage

YESNO

Were restrictions communicated

and clearly understood?

YESDid the employee knowingly violate a requirement?

NO

Possible intentional violation

System-induced violation

YES NO

NO

Were the requirements

available, workable, intelligible, and

correct?

YES

Did the employee pass the

substitution test?

NO

Were there deficiencies in

training, selection or inexperience?

YES NO

Negligent error or intentional

violation

System-induced error

Possible intentional violation

System-induced violation

YES NO

YES NO

Did the employee have a history of

unsafe acts?

Corrective measures indicated

System-induced error or

blameless error

YES NO


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Accountability vs. Culpability

Accountability Culpability

The power to accomplish performance objectives

The blame for failure vs.

A starting point for improvements

A dead end that discourages reportingvs.

Arises from empowerment and partnership

Is disempowering and divisivevs.


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Performance Culture

• Encourage Reporting: Value errors as leading safety data

• Create a Just Work Environment: Don’t try and punish errors out of the system

• Flexibility: Prepare workers to adapt effectively to changing demands

• Learning: Create opportunities for observation, reflection and feedback


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Barriers to a Learning Organization

• 20 years of experience = 1 year of learning repeated 20 times

• Experts use their informational advantage to reinforce their biases

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Human to Systems Interface

Organizational Systems:

Values

Systems in PracticeSystems in Practice Organizational Systems:

Processes


Processes


Values

• People will never perform better than what the organization will allow

• If a system relies on people doing the right thing every time, it will fail

• No working system remains in stasis

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The Leader

HPI Principle #5:

People achieve high levels of performance based largely on the encouragement and reinforcement received from peers, leaders, and

subordinates.

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Fallacy of Competing Resources

BANKRUPTCY

CATASTR

OPHE

PR

OT

EC

TIO

N

PRODUCTION

Unrealized Potential

Optimization

Better defenses

converted into increased production

Operat

ional

Upset


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How Leaders Influence Protection vs. Production

• What they pay attention to, measure, and control• Their reactions to critical incidents or crises• The allocation of resources• Their criteria for allocation of rewards and

punishment• Their criteria for selection, advancement, and

termination• Their deliberate attempts to coach or model

behaviors.


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Reality Check

• Safety values express how you desire safety to be in your organization.

• Safety systems are real defenses and actionable programs that provide measurable safety data sets.

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Implementing HPI

• HPI is not just training• It is a way of doing business that includes:

– Behavioral observation and walk-arounds– Conduct of operations and work management – Systems development and re-engineering– Issues reporting, management and corrective

actions– Event investigation and lessons learned– Performance management and assurance– Simulations and training

Unclassified Human Performance Improvement Principles for Managers.

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