Recommended
Recommended
More Related Content
Similar to C6-Human-Performance-Hydro.pptx
Similar to C6-Human-Performance-Hydro.pptx (20)
Recently uploaded
Recently uploaded (20)
C6-Human-Performance-Hydro.pptx
- 1. Human Performance & Human Error Reduction at Manitoba Hydro
- 2. • History of Human Performance • Human performance & brain activities • Latent Organization Weakness (LOW) • Error precursors • Maintaining positive control • Which HER tools & why Human Performance & Human Error Reduction at Manitoba Hydro
- 3. • These concepts originated with nuclear industry History of Human Performance
- 4. • Humans in the workplace • Errors in the workplace
- 5. • People are fallible and all make mistakes • Error likely situations are predictable, manageable and preventable • Individual behaviours are influenced by organizational processes and values • People achieve high levels of performance based largely on the encouragement and reinforcement received by leaders, peers and subordinates • Events can be avoided by an understanding of the reason mistakes occur and lessons learned from past events • Your brain & your eyes sometimes are not helpful Principles of Human Performance
- 6. Get a some paper and count the changes • Count the money https://www.youtube.com/watch?v=14Nb45CS9og A few brain activities
- 7. A few brain activities
- 8. A few brain activities
- 9. Latent Organizational Weakness (LOW) 80% 20% Equipment Failure Human Error Latent Organizational Weaknesses Individual Errors
- 10. Error = slip, lapse or mistake • Slip = physical action fails to achieve immediate objective • Lapse = failure of one’s memory of recall • Mistake = inadequate plan to achieve intended outcome; can be active or latent • Violation = intentional disregard of known rule or policy (deliberate deviation) What's an error
- 11. From Tim Autrey’s book are his terms skills, rules and knowledge. These are summarized below: 1. Skills – based most reliable / low error opportunity / low brain reliability 2. Rule – based less reliable then skills based / following a process or procedure / what’s the quality of that process or procedure / are you required to interpret at some level 3. Knowledge – based least reliable / solving the “New Riddle” / new and or unfamiliar task / not planned / environmental factors beyond your control Skills / Rule / Knowledge
- 12. Error Precursors
- 14. Five Tools: 1. Questioning attitude 2. Procedure use and adherence 3. Self checking STAR 4. Effective communication 5. Stop when unsure / Know when to stop Human Error Reduction Tools
- 16. Procedure use and adherence
- 17. Self checking STAR Stop – Think – Act – Review
- 19. Stop when unsure / Know when to stop
- 20. • Human Error Reduction tools should be used when engaging in critical steps • A critical step is a procedure step, series of steps or action that if performed improperly will cause irreversible harm to people or equipment etc. Critical Steps
- 21. • Improve our overall safety & quality • Reduce our “re-work” • Encourage open and honest communication • Assist fellow employees Why do we use HER tools
Editor's Notes
- This is the Pickering Nuclear Generation Station in Ontario For Manitoba hydro it started in 2013 with an engineering group and the concept with a few pilot projects & work areas Then there was a management working group that looked at several different venders PPC Practicing Perfection Canada was selected and I was assigned this in early 2018 Training executive / trainers / stakeholders / others that were missed Know I'm started to do site safety assessments to verify application
- One side is a duck & rabbit the second one is a silowet of a woman and a saxophone player
- 80% of errors are human related, 20% are equipment related. Of the 80% of errors that are human related, 85% of these are attributable to Latent Organizational weaknesses, and 15% are attributable to human failure. Human Error Reduction tools are designed to mitigate both Latent Organizational weaknesses and human failings. Provide a local area example of a Latent Organizational weakness which led to an error. Provide a local area example of a Latent Organizational weakness which led to an error. Write Management Control on the flip chart or board, then underneath draw a table with two headings – Process and Value. Ask the group to brainstorm where errors can lie dormant, waiting to get you when you least expect it at work. If they are struggling to come up with answers, ask them if all their procedures are up to date and written perfectly without error. Then write procedures under process. Other examples of process LOWS are strategy, policy, work control, training, resource allocation. Examples of value LOWS are shared beliefs, attitudes, norms, assumptions. Management decisions about expectations, resources, and rewards, as well as their personal style determine what is done, where it is done, how well it is done, and when it is done – either contributing to the health of the organization or further weakening it’s resistance to error and events. The organization plays a much larger role in the overall performance than the workforce. When managers understand how their organizations work, they are better able to identify and eliminate latent conditions that either promote error or worsen the events triggered by the error. Rather than getting stuck over terminology such as “Latent Organizational Weakness”, we can consider these hidden conditions to be like landmines that have been lost or forgotten over time, waiting to blow up when we step on them. By simplifying the term of Latent Organizational Weakness to landmine, we offer language that is memorable and meaningful, rather than “management speak”.
- This is key material as there is a need for the organization to recognize the difference between an error and a violation. Take the time to develop this out. May be most effective to develop it out on a board or flipchart. Use examples such as those listed in the guide which are practical and relevant to the work group. Example of willful violation: “better to seek forgiveness later than ask permission now”, or getting an attaboy for ‘getting it done’. Use of Human Error Reduction Tools will mitigate Slips, Lapses, Mistakes and Errors. Now let’s look at the tools . . .
- Skills - Example driving - little to no traffic / good roads / you know the area & where you are going / good weather / nice music on radio / enjoying your favorite coffee Rules - Example driving - more traffic / some road construction / have been there before but still need GPS or map/ light rain / you turned off your radio / not sipping on your coffee Knowledge - Example driving - lots of traffic / given unclear direction (wrong or no street names) / don’t know the area / storming weather / significant time restraint / unfamiliar vehicle
- Ask what intolerance for error or error precursors looks like at Manitoba Hydro (ie, reporting broken equipment, cleaning up oil spills, calling in replacement workers when a co-worker is ill etc) What might it look like after this training? Write examples given on flip chart or white board. This is another that should be brought back to the work area in the room.
- Option: refer to pre-work, ask were you able to use the tools Critical point: each manager needs to work with FSO to develop own list of critical points and determine how to apply tools Hand out student package
- The second of the two most powerful tools. It is conscious, deliberate thought prior to, during performance of an action ensuring the desired response is achieved. It is the last barrier between you and a mistake. Exposing and resolving questions and issues before any work activity is the most effective way to avert errors. Critical Thinking followed by Action - Dali Lama A technique whereby the individual performing a task can ensure that they do the right thing. Used with the other tools helps to keep the mind engaged. Never hesitate to STOP a task in progress, if there is questions/concerns. Resolve before proceeding.
- Describe the events of pulling a trigger on a rifle / Hanging ground chains / closing a knife switch / dumping a load from a dump truck / opening a 4 inch valve / pulling a disconnect For the gun example - hunter safety course / select a gun / do provincial paper work for purchase / purchase gun and understand required maintenance / purchase rifle range club pass / purchase appropriate shells / book a time at the range / set up mentally & physically / then if all is good pull the trigger
- Some ideas are: WIIFM employees: They go home at the end of the work day happy and healthy. They don’t have to re-do work that was completed wrongly the first time. There is trust and integrity in my work place and is a welcoming workplace. WIIFM managers and supervisor: My employees go home at the end of the day happy and healthy. Employees don’t have to re-do work that was completed wrongly the first time. With the help from my employees there is trust and integrity in my work place and is a welcoming workplace. Safety measures in the long run will decrease (near misses may increase in the short term if they are not currently being reported). I like the quote “We are borrowing you from your family & fiends during the work day. Its our responsibility to help get you back home safe.”