5-Human Performance Improvement-Why Is It Important.pptx

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Human Performance
Improvement
Work Group
WECC Strawman Class
Based on INPO and DOE
manuals

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Objectives
Objectives:
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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Lessons
Lessons:
 Performance Improvement Overview
 Human Performance Error Prevention Tools

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What 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 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 Environment
 Distractions
 Interruptions
 Unplanned changes
Error 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
o High workload (memory requirements) o Unfamiliarity with task / First time
o Time pressure (in a hurry) o Lack of knowledge (faulty mental model)
o Simultaneous, multiple tasks o New technique not used before
o Repetitive actions / Monotony o Imprecise communication habits
o Irrecoverable actions o Lack of proficiency; Inexperience
o Interpretation requirements o Unsystematic problem-solving skills
o Unclear goals, roles, or responsibilities o “Can do” attitude for safety-critical task
o Lack of or unclear standards o Illness or fatigue; general health
Work Environment Human Nature
o Distractions / Interruptions o Stress
o Changes / Departure from routine o Habit patterns
o Confusing procedure / Vague guidance o Assumptions
o Confusing displays / controls o Complacency / Overconfidence
o Work-arounds / OOS instrumentation o Mind set (intentions)
o Hidden system responses o Inaccurate risk perception
o Unexpected equipment conditions o Mental shortcuts or biases
o Lack of alternative indication o Limited short-term memory

Two Kinds of Errors
Active Errors
Latent
Conditions

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Employees
Events occur if all barriers and the frontline fail...
Training
Process
Oversight
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 Purpose
2. Documentation Review
3. Task Assignments
4. Safety Hazards and Mitigation
5. Human Performance
6. Special Requirements or Unusual
Conditions
7. Operating Experience
8. Stop-Work Criteria
9. Oversight
10. Questions

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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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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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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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• HOW should it be performed:

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 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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 WHEN should it be performed?
1. All work activities
2. 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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 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.

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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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Primarily
Focusing
Primarily
Scanning
Primarily
Focusing
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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 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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 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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Tool #6 – Questioning Attitude
 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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 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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 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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Perception, Comprehension, and
Projection.
SCAN
FOCUS
ACT.

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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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 The phonetic alphabet can reduce the
effects of noise, weak telephone or
radio signals, or even a person’s
accent
 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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 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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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
 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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 When manipulating, altering, monitoring, or
analyzing equipment
 When a procedure exists for a work activity
 When required

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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.
Organization
Leaders
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

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