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Addressing the Human Side of Safety
- 1. Human Performance Improvement (HPI) BushCoHPI@gmail.com BushCo, Inc. 1988 Stosich St Idaho Falls, Idaho 83402 208-521-5180
- 2. To proactively prevent “Unwanted Outcomes” triggered by human error. Purpose of Human Performance Improvement Unwanted Outcomes
- 4. Why a Human Performance Improvement Approach? 80% Human Error 30% Individual 20% Equipment Failures Human Errors Unwanted Outcomes 70% Latent Organization Weaknesses
- 5. Industry Event Causes due to human performance 1,676 = Org behavior (68%) 806 = Individual behavior (32%)
- 6. Three Most Applied Corrective Actions: More Policies & Procedures Training Behavior Modification
- 7. This version of Human Performance is based the airline industry Commercial nuclear power plants, United States Navy and others.
- 9. Error: Unintentional deviation from a preferred behavior
- 10. Error: Something you didn’t intend to do.
- 11. So what is an error? Most people associate an error with a bad outcome! Accident, incident, incorrect answer, etc.
- 12. Good - rare (serendipity) sticky notes? Bad - an outcome that causes you grief Benign - little to no consequences (most) Error: Can have one of three outcomes….
- 14. But there is one small problem: The quote actually originated not with the late poet and civil rights champion, but with a children' book author Joan Walsh
- 15. Error Precursors (short list)
- 17. Error Precursors (short list)
- 18. Critical Step: a procedure step or action that is within the control of the worker(s), typically irreversible, and when performed incorrectly could result in an unwanted outcome. Risk Important Step: a procedure step or action that when performed incorrectly could have a negative impact on the overall success of the process. Unwanted Outcomes: Errors that result in injury, mission interruption, or damage.
- 19. Improved Capacity to Manage Human Error at Critical/Risk Important Steps Increasing Resiliency depends on people not making errors, regardless of knowledge, skills, and ability, to perform the critical step error free (e.g. self-checks, memory requirements, Simple/Routine Communications). provides personnel with job aids such as checklist(s), labels, signs, procedures (?) that communicates the behavior expectations at the critical step. integrates safety tools such as: sensory warning devices, visual delineated boundaries, or other specialized tools that cue individuals they are in a hazardous area or zone. integrates temporary barrier(s) intended to prevent specific errors and/or the consequence of error for a specific critical step. integrates permanent barriers intended to permanently prevent error and/or the consequences of error for a specific critical step. Failing Safely “Building a Capacity for Resiliency” 1 2 3 4 5
- 20. egrates manent riers ended to manently vent error 4 Integrates temporary barrier(s) intended to prevent specific errors 3 Integrates safety tools such as: sensory warning devices 2 Provides personnel with job aids such as checklist(s), labels, signs, procedures 1 Depends on people not making errors REDUCED Human Error & IN Capacity for Resilien Peer Check Place- holders Stop When Unsure Detect Defend Control Mitigate AL/Risk STEP 2 Dimensions of “The Resiliency Scale” Best HPI Tools Concurrent Verification Self Check 3-Way Communication Pre-Job Brief Procedure Use Adam C T
- 21. “The significant problems we face cannot be solved at the same level of thinking we were at when we created them.” Albert Einstein
- 22. Does an HPI Approach Make Sense? U.S. Nuclear Industry Performance 1985-2015 HPI Initiated
- 23. Error precursors Latent Conditions Performance Mode Corrective Actions
- 32. Example of Forcing Function
- 33. Reducing Errors should not be the primary focus …… It should be reducing the consequences of errors.
- 34. To proactively prevent “Unwanted Outcomes” triggered by human error. Purpose of Human Performance Improvement Unwanted Outcomes
- 35. Principles 1. People are fallible, and even the best 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 based largely on the encouragement and reinforcement received from leaders, peers, and subordinates. 5. Events can be avoided by understanding the reasons mistakes occur and applying the lessons learned from past events.
- 36. Finished Files are the Result of Years of Scientific Study Combined With the Experience of Many Years.
- 37. Principles 1. People are fallible, and even the best 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 based largely on the encouragement and reinforcement received from leaders, peers, and subordinates. 5. Events can be avoided by understanding the reasons mistakes occur and applying the lessons learned from past events.
- 38. Buffalo Goring Yellowstone Park
- 39. Principles 1. People are fallible, and even the best 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 based largely on the encouragement and reinforcement received from leaders, peers, and subordinates. 5. Events can be avoided by understanding the reasons mistakes occur and applying the lessons learned from past events.
- 40. Work Location Physical Plant Touchers Paper Plant Touchers Decisions Org Processes Value s Mind the Gap 65 72 65 78
- 41. 4
- 42. Principles 1. People are fallible, and even the best 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 based largely on the encouragement and reinforcement received from leaders, peers, and subordinates. 5. Events can be avoided by understanding the reasons mistakes occur and applying the lessons learned from past events.
- 44. Principles 1. People are fallible, and even the best 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 based largely on the encouragement and reinforcement received from leaders, peers, and subordinates. 5. Events can be avoided by understanding the reasons mistakes occur and applying the lessons learned from past events.
- 47. Improved Capacity to Manage Human Error at Critical Steps Increasing Resiliency depends on people not making errors, regardless of knowledge, skills, and ability, to perform the critical step error free (e.g. self-checks, memory requirements, Simple/Routine Communications). provides personnel with job aids such as checklist(s), labels, signs, procedures (?) that communicates the behavior expectations at the critical step. integrates safety tools such as: sensory warning devices, visual delineated boundaries, or other specialized tools that cue individuals they are in a hazardous area or zone. integrates temporary barrier(s) intended to prevent specific errors and/or the consequence of error for a specific critical step. integrates permanent barriers intended to permanently prevent error and/or the consequences of error for a specific critical step. Failing Safely “Building a Capacity for Resiliency” 1 2 3 4 5
- 48. Can the Organization Create a Work Environment that Increases Employees Error Rates? 80% Human Error 30% Individual 20% Equipment Failures Human Errors Unwanted Outcomes 70% Latent Organization Weaknesses
- 52. Improved Capacity to Manage Human Error at Critical Steps Increasing Resiliency depends on people not making errors, regardless of knowledge, skills, and ability, to perform the critical step error free (e.g. self-checks, memory requirements, Simple/Routine Communications). provides personnel with job aids such as checklist(s), labels, signs, procedures (?) that communicates the behavior expectations at the critical step. integrates safety tools such as: sensory warning devices, visual delineated boundaries, or other specialized tools that cue individuals they are in a hazardous area or zone. integrates temporary barrier(s) intended to prevent specific errors and/or the consequence of error for a specific critical step. integrates permanent barriers intended to permanently prevent error and/or the consequences of error for a specific critical step. Failing Safely “Building a Capacity for Resiliency” 1 2 3 4 5
- 53. Facts vs Context
- 54. The key to understanding Errors Context !
- 55. LO/TO X Facts X
- 56. Active Errors and Latent Conditions Active Error Latent Conditions
- 58. Anatomy of an Event Event Error Precursors Vision, Beliefs, & Values Latent Organizational Weaknesses Flawed Defenses Initiating Action Vision, Beliefs, & Values
- 61. Limitations of Human Nature ❖ Avoidance of mental strain ❖ Inaccurate mental models ❖ Limited working memory ❖ Limited attention resources ❖ Pollyanna effect ❖ Mind set ❖ Difficulty seeing own errors ❖ Limited perspective ❖ Susceptible to emotion ❖ Focus on goal
- 62. If you have a topic for the new HSE news, we would like to hear from you. Contact us at jdrake@NewCompany.org Mr. Drake, I would like to submit an article about Human Performance ….. Sincerely, Timothy Shane Bush Tim, Thanks for your interest. I will forward your note to the appropriate folks. Jane MISS Drake! Miss Drake, I apologize for assuming. By the way I go by SHANE.
- 64. Bob’s Veterinarian/Taxidermist “Either Way You Get Your Dog Back”