The document provides an overview of human performance improvement. It discusses that human error is inevitable but can be managed. It describes the significance of incidents and how the majority are caused by human error and latent organizational weaknesses. Finally, it outlines various error prevention tools that can be used at the individual and team level, such as self-checking, questioning attitudes, and peer-checking, to improve performance and safety.

1. Human Performance
Improvement
Part I
Presented by
Michael L. McIntosh, CIH, CSP, CHMM
Oak Ridge National Laboratory
1-1 American Chemical Society
August 2010

2. Human Fallibility
“… 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
1-2

3. To Err is Human
1-3

4. To Error is Human (Cont.)
1-4

5. To Drift is Human
1-5

6. 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”
I-6

7. What Cause Occurrences?
Human Errors
Occurrences
70% Latent
Organizational 30%
80% Human Error Weaknesses* Individual
(Slips, trips, lapses)
20% Equipment
Failures
* Latent Organizational Weakness = Hidden deficiencies in
management control process or values
1-7

8. Anatomy of an Incident
Flawed
Defenses
Vision,
Beliefs, &
Vision,
Values
Beliefs, &
Values
on
Missi
Goals Incident
ies
Polic ses
s
Proce s
ram
Prog
Initiating
Latent Action
Organizational
Weaknesses
Error
Precursors
1-8

9. Significance of an Incident
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.
1-9

10. What is an Error?
An action that unintentionally departs from an
expected behavior.
1 - 10

11. What is a Violation?
Intentional acts that deviate from a policy or
procedure for personal advantage, usually
adopted for fun, comfort, expedience, or
convenience.
1 - 11

12. Two Kinds of Error
Active Error
Immediate consequences.
Know “who did it.”
Latent Error
Lead to latent organizational
weaknesses
1 - 12

13. Principles of
Human Performance
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).
1 - 13

14. I - 14

15. Common Traps -
Human Information Processing
2 - 15

16. Information Processing
We see the world as we are not as it is. It
is the “I” behind the “eye” that does the
seeing
Anais Nin
1 - 16

17. Common Error Traps –
At-Risk Attitudes and Behaviors
Humans possess an innate characteristic to be
imprecise (i.e., human nature)
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
2 - 17

18. At-Risk Attitudes
• Inaccurate Risk Perspective: Guided by the
heart, not by the head
• 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?” or “Que será será”
• Bald Tire: “I’ve gone 60K miles without a flat yet.”
• Summit Fever: “We’re almost done.”
• Pollyanna: “Nothing bad will happen.”
2 - 18

19. Error-Likely Situation
An error about to happen:
• Typically exists when task-related factors exceed
the capabilities of the individual (a mismatch)
(also called “Error Traps”)
Unintentional deviation
Jobsite conditions
from preferred behavior
Degree of mismatch
due to error precursors
2 - 19

20. Common Error Precursors
(Conditions that Provoke Error)
Task Demands Individual Capabilities
 Time pressure (in a hurry)  Unfamiliarity w/ task / First time evolution
 High Workload (high memory requirements)  Lack of knowledge (mental model)
 Simultaneous, multiple tasks  New technique not used before
 Repetitive actions / Monotony  Imprecise communication habits
 Irrecoverable acts  Lack of proficiency / Inexperience
 Interpretation requirements  Indistinct problem-solving skills
 Unclear goals, roles, & responsibilities  “Unsafe” attitude for critical tasks
 Lack of or unclear standards  Illness / Fatigue
Work Environment Human Nature
 Distractions / Interruptions  Stress
 Changes / Departures from routine  Habit patterns
 Confusing displays or controls  Assumptions
 Workarounds / OOS instruments  Complacency / Overconfidence
 Hidden system response  Mind-set
 Unexpected conditions  Inaccurate risk perception
 Lack of alternative indication  Mental shortcuts (biases)
 Personality conflicts  Limited short-term memory
OOS – out of service
2 - 20

21. Errors are....
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
5 - 21

22. Normalized Deviance
Focusing on one moment in time, you see negligence
with respect to an old standard or norm.
Process
Real Risk Level
Normalized
Amount of Risk
Deviance
Perceived Risk
Values
Time
1 - 22 (NASA VIDEO)

23. Goal of Human
Performance Improvement
• 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
(Unwanted Outcomes)
Anticipate & Prevent Active Confirm Integrity of Defenses
Error at the Job-site and Identify/Eliminate Latent
Organizational Weaknesses
1 - 23

24. Part II
• Performance modes
– Skill based
– Rule based
– Knowledge based
• Error Prevention Tools
• Just Culture
1 - 24

25. Human Performance
Improvement
Part II
Presented by
Michael L. McIntosh, CIH, CSP, CHMM
Oak Ridge National Laboratory
1 - 25 American Chemical Society
August 2010

26. Review of Principles of
Human Performance
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).
1 - 26

27. Consider
Performance Modes
1/2 to 1/10
2 - 27

28. Skill-Based Errors
Pre-Programmed Skills or Habits
• 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
• Normalized deviation due to familiarity is a
concern
• 25% of errors are skill-based
2 - 28

29. Rule-Based Errors
Selecting the Path Forward
• Chance for error is 1 in 1,000
• Error mode is misinterpretation
• Conscious decision making
using stored rules
• Rules must be matched with
skills
• Errors are made when conditions change and
change is not recognized
• 60% of all errors are rule-based
2 - 29

30. Knowledge-Based Errors
Breaking New Ground
• Chance for error is high - 1 in 2
to 1 in 10
• Error mode is inaccurate mental
picture
• Responding to a totally unfamiliar
situation
• Uncertainty is high – added stress
• Fundamental principles and technical
understanding needed to make a decision
• 15% of errors are knowledge-based
2 - 30

31. I - 31

32. Error-Prevention Tools
- Individuals -
• Task Preview
• Task Preview
• Job-Site Review
• Questioning Attitude
• Questioning Attitude
• Stop (& collaborate) when unsure
• Stop (& collaborate) when unsure
•
• Self-Checking
Self-Checking
•
• Procedure Use and Adherence
Procedure Use and Adherence
• Validate Assumptions
• Effective Communications
• Effective Communications
• Place-Keeping
• “Do Not Disturb” Sign
2 - 32

33. Proactive Mental Framework
Work Situation Situational
Factors Awareness
Task Critical
Demands Steps
Task
Work Preview Error-likely
Environment Situations
Individual Potential
Capabilities SAFER Dialogue Consequences
S – Summarize critical steps
Human A – Anticipate error traps Flawed
Nature F – Foresee consequences Defenses
E – Evaluate defenses
R – Review operating experience
2 - 33

34. Questioning Attitude
Fosters thought before action and helps individuals
maintain an accurate understanding of work conditions.
• Used along with Self-Checking
• Promotes a preference for facts over assumptions
and opinions
2 - 34

35. Stop When Unsure
Unsure
= unchartered territory
= knowledge-based performance mode
= High Error Rate (1/2 to 1/10)
1. Stop (pause or time-out) the activity
2. Place the equipment and the job site in a safe
condition
3. Notify your immediate supervisor
4. Get help from more knowledgeable person(s)
Stop and collaborate with an expert!
2 - 35

36. Self-Checking
Promotes a preference for facts over assumptions
and opinion.
Pause and think before acting when vital points (critical
junctures) are reached
• When to use?
• What to pay attention to?
• Where to pay attention
Promotes a
questioning attitude
2 - 36

37. Procedure Use & Adherence
Procedures - intended to direct behavior
and minimize choices the user has to make
Error can be introduced when:
• Not enough information (or too much)
• Interpretation requirements
• Procedural non-use / procedure out-dated
• Critical steps not identified
• Technical errors
• Stopping and restarting, etc….
Consider place-keeping (physically marking
completed steps) to prevent errors
2 - 37

38. Effective Communication
Goal = mutual understanding 1 Mom to Joey – “Go
walk the dog before
1 dinner.”
2 2 Joey to Mom – “I
understand that you
3
want me to walk the
dog before dinner.
Is that correct?”
3 Mom to Joey – “That
is correct” OR “That is
wrong,” and restates
original message
2 - 38

39. Team Errors
• Halo Effect: Blind trust in the competence of specific
individuals
• Pilot / Co-pilot: Subordinate reluctant to challenge
opinions, decisions, or actions of senior person
• Free Riding: One takes the lead
while others tag along without
actively scrutinizing the work.
2 - 39

40. Team Errors (Cont.)
• Groupthink: Reluctance to share contradictory
information for the sake of maintaining harmony
• Risky Shift: Tendency to gamble with decisions
more as a group than if each member was making
the decision individually – accountability is diffused
(also called “herd mentality”)
It takes a team error to
have an event.
2 - 40

41. Error-Prevention Tools
- Work Teams -
• • Pre-Job Briefings
Pre-Job Briefings
• • Peer-Checking
Peer Checking
• Verification Practices
• Flagging
• • Turnover
Turnover
• Post-Job Review
• Project Planning
• Problem Solving
• Decision Making
• Project Review Meeting
2 - 41

42. Pre-Job Briefings
To prepare for what is to be accomplished and for what
is to be avoided!
• Discuss specifics, including CRITICAL STEPS
• Discuss error traps, consequences, defenses, and
error-prevention techniques
• Encourage active engagement by all members
• Ensure key participants are present
• Discuss actions for work scope changes
• Encourage a questioning attitude and self-checking
2 - 42

43. Peer Checking
- Addresses Actions
A 2nd knowledgeable
individual verifies
that the action
planned is
appropriate and
occurs as planned.
Purpose - to
prevent errors.
2 - 43

44. Turnover
The orderly transfer of information, tasks, and
responsibilities between individuals or crews
• To establish an accurate mental model (situational
awareness)
• Thorough, accurate - may include a walk-down
• Use three-point communication
• Use written logs
2 - 44

45. What Individuals can do……
• Understand error-provoking factors and human
fallibility & vulnerabilities
• Anticipate error-likely situations
• Apply error-prevention tools & techniques
• Improve personal capabilities
• Use the proactive mental framework and S-A-F-E-R
dialog
2 - 45

46. Dependability of Defenses
HIGH
Containment Structures (e.g., shield walls)
Engineered Safeguards
Reliability of Defense
Interlocks
Personal Protective Equipment
Document Reviews
Reliability of the defense/ Procedure Use
control is inversely
proportional to the amount of
human intervention required Caution Tags
Supervision/Qualifications
Self-Checking
LOW Degree of Human Control HIGH
3 - 46

47. Dependability of Defenses (Cont.)
WARNING: Defense-in-depth can be a two-edged
sword.
• Redundant defenses improve safety margins but
also increase complexity.
• Flaws, traps, flawed defenses, and safety hazards
can become more difficult to detect.
– Latent conditions allowed to persist
Weakness in defenses may not be detected and
repaired … because the people involved often
forget to be afraid.
3 - 47

48. Organizational Values
- Error Tolerance -
Error Tolerance:
• Design processes, tasks, equipment, etc., such that
the inevitable human error will not result in an event
of consequence.
Error without consequence shows that our systems
are error-tolerant and that they are working.
4 - 48

49. What Organizations can do….
• Foster a culture that values the prevention of errors
and mishaps
• Preclude the development of error-likely situations
• Eliminate latent organizational weaknesses that
provoke error
• Create a “Learning” environment that promotes
continuous improvement
• Value error tolerance
• Report all errors and near misses
• Expect the unexpected, and have appropriate
contingency plans in place
4 - 49

50. Errors are....
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
5 - 50

51. Value Prevention of Errors
“If error-free performance (avoiding active
errors) is not held up as an important value
or is not expected for daily work, then people
may adopt unsafe practices to get their work
done, possibly placing themselves, others, or
the facility at risk of an event.”
Human Performance Reference Manual
INPO 06-003
5 - 51

52. Value Prevention of Errors
Understanding human fallibility encourages a proactive
perspective toward work:
• It is easy to err, and a person may not even know it
• Workers should possess a keen - and healthy -
sense of uneasiness toward any activity
– prompts the mindset: “expect success but
anticipate failure”
– fosters intolerance for error traps / precursors
5 - 52

53. Human Performance
“Workplaces and organizations are easier
to manage than the minds of individual
workers. You can not change the
human condition, but you can change
the conditions under which people
work.”
- Dr. James Reason
5 - 53

54. A Just Culture
Atmosphere of trust in which people are encouraged,
even rewarded, for providing essential information – but
in which they are also clear about where the line is
drawn between acceptable and unacceptable behavior.
• It is unacceptable to punish all errors and unsafe acts
regardless of origins and circumstances;
• It is equally unacceptable to give blanket immunity
from sanctions to all actions that could, or did,
contribute to organizational accidents.
6 - 54

55. Benefits of a Just Culture
• Promotes a reporting and learning culture & honest
investigation of true organizational weaknesses
• Provides forward-looking accountability
• Builds Trust … what’s said gets done by management
• Ensures respect for the individual
• Instills belief that discipline is fairly administered
• Maintains zero tolerance for harassment/retaliation
• Provides multiple avenues of communication
• Builds confidence in broader organizational cause
investigations
6 - 55

56. Human
“Success”
Flawed defenses &
Individual recognized
error precursors
or rewarded
eliminated
Praise
Latent organizational
Cycle
Increased trust
weaknesses identified
Management more
aware of jobsite Effective
conditions communication
6 - 56

57. HROs
Cultures of Mindfulness
High Reliability Organizations (HROs):
Diverse organizations that share a
singular demand: They have no
choice but to function reliably. If
reliability is compromised, severe
harm results.
1. Healthy preoccupation with failure
2. Reluctance to oversimplify
3. Sensitivity to operations
4. Maintain capabilities for resilience
5. Deference to expertise
Adapted from “Managing the Unexpected,” by Karl Weick and Kathleen Sutcliffe
6 - 57

58. References
• Managing the Risks of Organizational Accidents, James Reason,
Ashgate, 2006
• Managing Maintenance Error, James Reason and Alan Hobbs,
Ashgate, 2003
• The Field Guide to Understanding Human Error, Ashgate, 2006
• Just Culture, Sidney Dekker, Ashgate, 2007
• The Design of Everyday Things, Donald Norman, Basic Book, 1988
• Blink, Malcolm Gladwell, Back Bay Books, 2005
• The Human Contribution, James Reason, Ashgate, 2008
• The Challenger Launch Decision, Diane Vaughan, University of
Chicago Press, 1997
• Why Hospitals Should Fly, John J. Nance, JD, Second River
Healthcare Press, 2008
I - 58