1. Fundamentals for Human Performance Improvement
Sam McKenzie

3. To minimize the frequency and severity of events
Purpose of HPI
Events
To minimize the frequency and severity of events
.Note that the course is not a program.
.State course content is a way of thinking.
“Given this task to perform under these circumstances, this person will probably make errors at around this point . . .” James Reason
ASK will human performance problems ever go away? NO
INPO Strategic Goals –
Minimize the frequency and severity of plant events.

4. Course Objectives Why HPI events occur
Error-likely Situations & error precursors
HPI Models
Jobsite tools
Leadership practices
Behavior reinforcement
Mental framework
Leadership roles
Strengths, obstacles, key learnings, & actions
State the course is designed to enable participants to accomplish the following goals:
Describe job site tools to use to manage error-likely situations.
Describe the role the organization plays in achieving HPI excellence
Identify organizational tools and their use.
Describe the role of the leader in achieving HPI excellence
Identify leadership tools and their use.
Develop actions to perform your role in HPI.
Introduce “shots on goal” analogy.
Why do we have a goalie on this slide?
Last line of defense
.goalie = worker (the last defense)
.defensemen = supervisors (prevent shots on goal)
.wingers/center = management (best defense is a good offense)
State the whole team has to play together to be effective.

5. Human Performance Target No.1 Target No.2 5 4 3 2 1 5 4 3 2 1
Security guards are participating in the annual firearms re-certification. One of the tasks was to rapidly fire five shots at the bull's-eye from the prone position with a rifle supported. No additional instructions were provided. Immediate feedback on where their shots hit the target was not provided. The goal is to hit the bulls eye five times.
Based on the results of the guard's performance as shown below on the target, develop your conclusions in the following areas:
the better performance
suspected behaviors (while firing the weapon)
the better results
observed performance (target)
observable and non-observable behaviors (while firing the weapon)
potential reasons for performance
possible ways to improve performance
Who do you want working for you?
The shooter for target no.2. This person’s behavior is consistent and thus easier to modify.
Human performance is the combination of behavior and results, you need both.
Write on flip chart HPI = B + R
Note: A task is an assignment to achieve a specified result according to specified standards (quality, quantity, timeliness, limitations, or costs).
Error = Delta Behavior/ standard or expectation
Show Parking lot example
Target No.1
Target No.2

7. Significant Events Annual Industry Averages
Data Source: U.S. Nuclear Regulatory Commission
(Core Damage Potential)
This graphic shows data that supports why HPI is so important to us and our organizations. The U.S. Nuclear Regulatory Commission maintains data on significant events that occur in the U.S. commercial nuclear power industry. The data presented here relates to events involving reactor core damage potential.
We have 103 reactors in operation; however, for purposes of illustration, I’ve rounded that number to In 1985, each reactor incurred 2.38 significant events. Multiplying 100 reactors times 2.38 events equals approximately 238 incidents that resulted in potential damage to the core.
Notice how this annual industry average steadily and dramatically fell over 15 years from 2.38 average events per reactor a year to just 0.03 events per reactor a year during In 2004, the average number of events per reactor had fallen to 0.02.
Ask: How many nuclear accidents can the nuclear power industry afford to have? Considering the impact on human life and the environment as well as their political and economic consequences, the answer is zero.

8. Nuclear Industry Event Causes due to human performance
1,676 = Organizational
Behavior (68%)
806 = Individual
Behavior (32%)
This slide presents data regarding all the events in the commercial nuclear power industry during 1998 and 1999.
Ask: By looking at this graph, on which area would you focus to get results? Expected response: Work practices area
Notice that 806 events, or 32% of all events, resulted from work practices – an individual’s behavior.
The other 1,676 events, or 68%, came from weaknesses in the organization associated with change management, work planning, training and qualification, managerial methods, etc.
This slides tells us that of all the nuclear power industry events caused by human error, 2/3 of them stemmed from organizational weaknesses, while 1/3 of the events were due to an individual’s behavior.

9. Is 99.9% Good Enough? 1 hour of unsafe drinking water per month
2 unsafe landings per day in Atlanta, GA.
50 dropped babies per day
116,000 lost pieces of mail per hour
20,000 incorrect drug prescriptions per year
22,000 checks deposited in wrong accounts per hour
Would you accept 99.9%. Just as you wouldn’t accept the above, you shouldn’t accept safety and health statistics as OK. We must continually be working for continous improvement.
Sometime we jokingly accept certain stats. Finish this sentence, “You not a good carpenter until you have cut off a ……….” Answer is finger. Do we really believe this? If your son wanted to be a carpenter would you give him this advise?

10. Two Kinds of Error Active Error (leading to latent conditions)
Definition of human error: an action (behavior) that unintentionally departs from an expected behavior (see Glossary) Write on flip chart Error = Delta Behavior/standard or expectation.
A violation involves a deliberate deviation from specified behavior (management expectations). This course does not deal with violations. However, we need to ask if the observed behavior was a violation? What is the true expectation? What we always do and has been accepted maybe the true expectation, not what we say. Or what is specified in administrative or other procedure.
.Fact: Error is defined by the behavior (B) not the result (R). NOTE: The same behavior can have little or no consequences or have great consequences. Error is classified based upon result.
.Two kinds of error (based upon the kinds of results they obtain)
.Active errors – errors(delta behavior/standard) that change equipment, system, plant state, or peoples state triggering immediate undesired consequences. Latent errors (typically by management and staff) - errors resulting in undetected organization-related weaknesses or equipment flaws that lie dormant.
Latent errors create latent conditions, for example ….
.Compare and contrast the who, what, when, and visibility for these two types of error. Have chart made up on flip chart. Leave answers blank. Facilitate responses from participants.
Characteristics Active Latent
Who? front-line workers management & staff
What? change plant state change paper, policies, values
When? Immediate dormant
Visible? yes no
.Error classification sprint - HANDOUT
.Instructions:
Take one minute to check the appropriate column on the exercise sheet
Move quickly. Identify whether the action is an active or a latent error.
.Review the results of a few with the participants.
Make sure to review 4 and 10 closely. They are related. ASK: did the I&C technician in 10 make an active error. If he did what is it? Note: It depends on the expectations of the station. Strict Procedure/schedule compliance or know the system.
.Direct attention the the definition of an error. Delta behavior/standard of expectation
(leading to latent conditions)

11. Principles of Human Performance Management
Humans are fallible . . .
Error is predictable. . .
Organization influences behavior.
Behaviors are reinforced.
Events are avoidable.
Excellence in human performance is more likely if front-line workers, support staff, and managers embrace the following underlying truths, or principles, that provide the bases for the behaviors promoted in this course.
People are fallible, and even the best people make mistakes. Neither manager nor worker is immune. It is human nature to be imprecise, to err. Consequently, error is inevitable. No amount of counseling, training, or punishment, or exhortation will change a person’s future fallibility. Are the “best” people in this room? Who is more likely to err, manager or worker? (prelude to performance modes discussion later) (Reason, Human Error, 1990)
Error-likely situations are predictable, manageable, and preventable. Can predict that a person writing a personal check at the beginning of new year stands a good chance of writing the previous year on the check; same concept applied to context of work at the jobsite. Recognizing the likelihood of such an error permits us to manage the situation proactively and prevent its occurrence. Situations are easier to manage than people’s intentions. (Chemical Manufacturers Association, A Manager’s Guide to Reducing Human Errors, 1990)
Individual behavior is influenced by organizational processes and values. Traditionally focused on the “individual error-prone or apathetic worker.” Most events can be attributed to error-prone tasks or error-prone work environments. (Reason) All work done within the context of the organizational processes, culture, and management control system; contributes the lion share (80 to 90%) of causes of human error and resulting events. Events are not typically the outcome of one individual’s action. They are more commonly the result of a combination of faults which indicate weaknesses in management and organizational activities. (Turner & Pidgeon, Man-Made Disasters, p.89) It’s difficult to avoid what you did not intend to do in the first place. (Reaon. Managing the Risks of Organizational Accidents, p128)
People achieve high levels of performance due largely on the encouragement and reinforcement received from leaders, peers, and subordinates. Level of safety and reliability of the plant directly dependent on the behavior of people. Human performance - a function of behavior and the results of that behavior. Behavior mostly influenced by the consequences experienced when that behavior occurs. Consequently, what happens to workers when they exhibit certain behaviors is an important factor in improving human performance. (Daniels, Performance Management, 1989)
Events can be avoided by understanding the reasons mistakes occur and applying the lessons learned from past events (or errors). Events can be avoided reactively and proactively. Learning from our mistakes and the mistakes of others is reactive; it’s after the fact. Anticipating how the next event or error can happen by applying the fundamentals of human performance to plant work is proactive.
Do you believe the plant can be operated indefinitely without events? (Do you expect to win or lose?)
If not: Fatalistic attitude is tacitly encouraged.
If so: Creativity and innovation are explicitly encouraged.
Note: Some may not agree that events are avoidable. The definition of event continues to be progressively lowered. What is an event today was unthinkable as an event 10 years ago.
Source: INPO, Excellence in Human Performance

12. Anatomy of an Event Event Flawed Defenses Initiating Action
Vision, Beliefs, &
Values
Vision, Beliefs, &
Values
This model is one of the key aspects of human performance that describes the overall context of the initiative. (Briefly explain it. Note that precursors to error can be internal or external to the individual. It’s simply meant to provide a basic concept of the kinds of things that can lead to human error.. Everyone has an impact. We’re really talking Organizational Performance.) This model isn’t only applicable to the nuclear industry. It comes from research which examined many businesses that focus on human performance. Work Through a traffic accident to point out the pieces of the model.
Discuss visions, values and beliefs.
. Ask what an event is. an undesirable consequence to the plant generally in terms of reduced safety margin.
. Ask what initiates a human performance event. initiating action
Emphasize the aspect of human involvement. Action may be exactly what procedure calls for, yet it is inappropriate because of plant conditions.
Define error precursors and flawed defenses. Emphasize that precursors provoke error while flawed defenses allow the consequences of the act to propagate. ERROR PRECURSORS Unfavorable factors embedded in the job site that increase the chances of error during the performance of a specific task by a particular individual. (See also human nature, individual capabilities, task demands, and work environment)
FLAWED DEFENSES Defects with administrative or physical defensive measures that, under the right circumstances, may fail to:
·        Protect plant equipment or people against hazards
·        Prevent the occurrence of active errors
·        Mitigate the consequences of error
. Ask what causes or creates these precursors and flawed defenses? latent organizational weaknesses
NOTE: The values of the individual need to match the values of the organization.
Latent Organizational Weaknesses
Mission
Goals
Policies
Processes
Programs
Event
Initiating Action
Error Precursors
Ask will time pressure ever go away?
Event - an undesirable consequence (change in state of structures, systems, and components) to the plant generally in terms of reduced safety margin; Other definitions: an outcome that must be undone; any plant condition that does not achieve its goals; a difference between what is and what ought to be
Initiating Action - an action (behavior) by an individual, either correct or in error, that results in a plant event (includes active errors that have immediate, observable, undesirable outcomes in the physical plant)
Error Precursors – (direct attention to yellow cards) undesirable conditions, prior to the action, that reduce the opportunity for successful behavior at the jobsite, prompting behavior different than intended or required, i.e., provoke or drive errant behaviors; usually embedded in task demands, work environment, individual capabilities, and human nature. Ask which of these can we effect or change?
Flawed Defenses - defects with defensive measures that, under the right circumstances, may fail to protect plant equipment or people against hazards, and fail to prevent the occurrence of active errors, violations, or at-risk behaviors.
Latent Organizational Weaknesses - undetected deficiencies in the management control processes (e.g., strategy, policies, work control, training, and resource allocation) or values (shared beliefs, attitudes, norms, and assumptions) creating workplace conditions that either provoke error (precursors) or degrade the integrity of defenses (flawed defenses)
Dual Strategy
1) Anticipate and prevent active errors (reduce number of shots on goal). (Prevents one event) 2) Discover and eliminate latent organizational weaknesses (proactive and offensive). (May prevent many events)
What’s manageable? (occur before the error and event in time) “Events are not typically the outcome of one person’s action. More commonly, it is the result of a combination of faults in management and organizational activities.” (Turner & Pidgeon, Man-Made Disasters, p.89)

13. Strategic Approach
Anticipate and prevent active error at the job-site.
Identify and eliminate latent organizational weaknesses.
These statements represent the goals we are headed for in this industry and with this training.

14. Essential Elements for Achieving Reliable Human Performance
Organizational Attributes
Process Contributors
Individual Values and Behaviors

15. The Jobsite and The Individual
Purpose of session: to recognize when you are increasing the odds (for error) against yourself.

17. Traps 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 goal
Fatigue
Here is some additional reasons why you made errors. This is some reasons why we are imprecise. (Fallible) 9

18. Phrase Recall Exercise
PARIS IN THE THE SPRING
BIRD IN THE THE HAND
ONCE IN A A LIFETIME
Phrase Recall Exercise:
In just a moment, you will see three phrases appear for five seconds on this screen. I want you to write them as quickly as you can.
Instructor:
Click the slide.
After the participants write their phrases, ask them to underline the two words in each phrase that were underlined when they appeared on the screen.
Then ask a few volunteers to read the phrases they wrote and tell which words they underlined.
Note: Most participants will not catch the underlined words. They will try to use assumptions and habits to determine those words.
Click the slide again to reshow the visual without the dark shading, busy background, and noise.

19. Phrase Recall Exercise (Cont.)
PARIS IN THE THE SPRING
BIRD IN THE THE HAND
ONCE IN A A LIFETIME
Explain that trying to remember three things at once, while under a time pressure with numerous distractions, leads to error — just as it did for many of them during this exercise.
Fortunately, your errors did not cause an adverse situation.
Of course, that is not always the case in the facility.

21. Error Precursors Task Demands Work Environment Individual Capabilities
Human Nature
TWIN - Task demands, Work environment, Individual capabilities, and human Nature; can assist in identifying ELS (using 3x5 card). Adapt to specific functional group, e.g., RO, I&C, electricians, etc. Consider developing a list unique to specific task known to be error-prone.
Another plant has changed this to WITH. ARE YOU ALL WAYS WITH-IT?? T W I N
Task
Work
Individual
Nature 2

22. Count the F’s
Finished Files are the Result of Years of Scientific Study Combined with the Experience of Many Years.
Purposes of exercise: 1) Focusing only on results misses logic. 2) People get various results for valid reasons. 3) Perceptual differences exist among people.
Part A:
Explain to the class that they will have 10 seconds to complete the exercise. Encourage them to do their best, and let them know that you are really counting on them to do well on this exercise.
Tell the participants to count the number of “F’s” as in “Frank” that they see.
Click the mouse to display the sentence.
(Custom animation will display the sentence for 10 seconds and then make it disappear.)
Ask participants for results and compare them. (One instructor may list the results on the whiteboard or flipchart and tally how many persons got each of those results.)
Lightly reprimand those who only counted 2 or 3 F’s and ask them why they weren’t able to perform as well as some others did? After all, counting F’s is pretty simple work; they should have done much better.
Part B
Click the mouse to redisplay the sentence.
Ask volunteers to explain how they arrived at their result.
Discuss that some people will only count the capital F’s, because they see a capital letter in the title and “Frank,” a capitalized word, as was stated in the instructions. Some people may include the “F” in the slide header. Others will have counted the “f” in “Scientific” but may miss the “f” in the three occurrences of the word “of” because it is a short, minor word. Others may have counted all f’s regardless of their case or the word they were in.
Explain that the purpose of the exercise is to emphasize the following points:
Focusing on the results (i.e. how many F’s someone counted) ignores the effort that individuals made based on the limited instructions given.
There are valid reasons for the results that people get.
There are perceptual differences between people that must be recognized and explored if we want to learn why we don’t always get the results we want.

24. Error-likely Situation
Work Environment
precursors
Task Demands
Human Nature
Individual Capabilities
An error about to happen due to error precursors
.Fact: Mismatches between the following elements of a task situation promote error:
task demands exceed individual capabilities (easiest to see) and/or
work environment aggravates limitations of human nature
.Fact: Mismatches are created by error precursors.
.“The ability to detect error-likely situations to headoff preventable events depends largely on the extent these factors are understood regarding their role in human error.”

25. Error Precursors short list
Performance Reliability: Probabilistic Science
increases as number of error precursors decrease
decreases as number of error precursors increase
Error Precursors short list
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
Human Nature
Work Environment
Illness / Fatigue
Lack of or unclear standards
“Unsafe” 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)
Individual Capabilities
Task Demands
Error Precursor - unfavorable prior conditions that reduce the opportunity for successful behavior at the jobsite; creates (exacerbates) the mismatch associated with task demands and the individual (error-likely situation/ELS). List derived from INPO event data base and several credible references associated with human performance.
Handout – “Lifted Leads” Newsletter
Have students read “ME- Out of Sync”
Identify error precursors (use yellow cards)
Facilitate a discussion.
Multiple error precursors - increase chances of error; change the situation
How do the above conditions change from normal on-line to outage
How many error precursors are necessary to cause error? None. Why?
Human performance is not rocket science, i.e., black and white.
Individual differences
Some people respond differently, or to a different degree, to error precursors.
You may have error prone people

26. ? D Performance Modes Attention (to task) Familiarity (w/ task) KB RB
Control Mechanisms
Performance Modes
Type of errors that usually occur at upper echelons of organization; not observable
High
Low
Attention (to task) ? KB
Patterns
Type of errors that usually occur at human-machine interface; observable
Begin Note to Facilitators: 1. The material on this slide is complex; difficult to understand and difficult to explain. Before presenting this slide as part of the Human Performance Course, please read Source: James Reason. Managing the Risks of Organizational Accidents, The information in the book is very helpful in teaching Human Performance, as is this slide Consider drawing the diagram piece-by-piece on a flip chart rather than trying to explain all sections at once from the Ppt. Slide. End Note to Facilitators.
If I know how to perform a task, and I possess the ability to perform the task, then why do I sometimes err with simple tasks? Human Nature - not an excuse, but characteristic of human beings to be imprecise (expected reliability: .995 to .997 typically or ideally). What if task must have reliability of 1?
Transitions: From SB: Delta - change in task/environment; Into KB: ? - uncertainty & doubt
Definitions of each performance mode (see Generic Error Model in HPF Desk Reference). Include examples from both every day life and plant activities. Recall example events for each mode. (Human Error, p61) Mental States: Auto, If-Then, Patterns
Reliability or Chances for error: SB - 1:10K (ideal conditions); RB - 1:1K (nominal); KB - 1:2 (urgent) (chances for success improve in KB performance mode as time to make a decision increases)
Distribution of error industry wide: SB: 25%, RB: 60%, KB: 15% (Source: PII); Describe event in each mode.
Time spent in each mode: SB: 88-90%, RB/KB: 10-12% (Source: Hypnotherapy, Atlanta Constitution, 11/22/98)
RB/KB involve conscious decision making; roughly 75% of errors made during activities that take roughly 10% of time (supposition - no empirical data to support)
Error Modes: SB – Inattention; RB – Misinterpretation; KB – Inaccurate mental model/picture
KB: unfamiliarity ­, anxiety ­, stress ­, search for patterns, ­, assumptions ­, trial & error (Easter egging) ­, panic (vagabonding or tunneling) ­, event or value-added progress. Conscious, directed thinking can exclude outside sensory information - could miss important information. (Restak, Brainscapes, p30)
Time Effects: As time to respond increases, the chance for error diminishes. Chance for error is highest when the unfamiliar situation (especially involving danger) strikes suddenly without warning and requires quick reaction. (Man Made Disasters, p33-34) WANT TO AVOID THIS!!!
Workers - SB and RB most often (prescriptive in nature); Managers - RB and KB (discretionary)
SB - Unconscious competence; RB - Conscious competence; KB - Conscious incompetence
PB - Unconscious incompetence (panic-based)
To improve importance - stimulate interest in the task; why job is critical to plant success; WIIFM
Biases take over in KB, e.g., pattern matching, frequency and confirmation biases
Review error precursors that are particularly potent for each error mode (SB - distractions, illness & fatigue, simultaneous tasks; RB - mind set, confusing procedure; KB - hidden system response, assumptions, lack of fundamental knowledge)
(see more information in Man-Made Disasters, p )
Error-Prevention Techniques: SB – self-checking, peer checking, slow down; RB – critical parameter, peer-checking, If2Then2; KB – team problem-solving, devil’s advocate, “buy time,”
Purpose of Task Preview - to identify method of best control; not to question competence
Note: After illustrating each performance mode on the flip chart, refer to the Generic Error Modeling System (GEMS) model in the student notebook to reinforce student understanding of each performance mode.
Inaccurate Mental Picture RB
If - Then D
Misinterpretation SB
Auto
Source: James Reason. Managing the Risks of Organizational Accidents, 1998.
Inattention
Familiarity (w/ task)
Low
High

28. Error-reduction Techniques @ jobsite
Conservative decision-making
Change management
Three-way communication
Concurrent verification
Independent verification
Meetings
Peer-checking
Placekeeping
Prejob Briefing
Problem-solving
Procedure use & adherence
Questioning attitude
Self-checking
Stop & collaborate
Two minute walkdown
Error-prevention techniques are defensive measures aimed at preventing and catching active errors. These functions are implied in the Anatomy of an Event as the causal link between “flawed defenses” and the “initiating action.”
Conservative Decision Making. Conservative decision-making is a rule-based (RB) and knowledge-based (KB) performance strategy that places the safety needs of the physical plant, in particular the reactor core, above the near-term production goals of the organization.
Change Management. Change management is typically reserved for large-scale organizational change and is usually not considered for day-to-day management activities. However, most day-to-day management involves change.
Communication. The aim of communication is to achieve mutual understanding between two or more individuals involving speaking and listening.
Concurrent (Double) Verification. Concurrent verification (CV) is the act by a second qualified individual of verifying a component's position before and during component repositioning. CV aims to prevent errors.
Independent Verification. Peer-checking and concurrent verification are designed to catch errors before they are made. Independent verification (IV), on the other hand, catches errors after they have been made.
Meetings. Meetings are conducted to solve problems that cannot be handled as well by an individual. Errors can be made during meetings (knowledge-based and rule-based) due mostly to inaccurate mental models and misinterpretation of information.
Peer Checking. Peer checking provides an individual the opportunity to get a second qualified person on an informal basis to verify the correct component is selected for manipulation before the act.
Placekeeping involves the physical act of reliably marking steps in a procedure that have been completed or not applicable (skipped).
Prejob Briefing. There are two primary purposes of the prejob briefing: 1) to prepare workers for what is to be accomplished, and 2) to sensitize them for what is to be avoided.
Problem Solving: Without guidance, human beings do not usually solve problems rigorously, methodically, and painstakingly. Consequently, the chance for error increases dramatically in a knowledge-based work situation. Therefore, people need to work with others and apply a disciplined approach to problem solving.

29. Questioning Attitude Meter
Healthy Uneasiness/
Wariness/Alertness
Uncertain/ Unsure
Too Certain/
Too Sure

30. Team Errors Social Loafing Halo Effect Pilot / Co-pilot Free Riding
Groupthink
Risky Shift
·        Halo Effect - blind trust in the “competence” of specific individuals because of their experience or position in an organization. Consequently, they drop their guard against error, and their vigilance to check the respected person's actions weakens.
·        Pilot/Co‑pilot - a subordinate person (co-pilot) is reluctant to, or does not feel it is his/her place to, challenge the opinions, decisions, or actions of a senior or more experienced person (pilot). Subordinates may also express “excessive professional courtesy” when interacting with senior managers.
·        Free Riding - If one person takes the lead in an activity, peers may tend to tag along without actively scrutinizing the intent and actions of the person doing the work.
·        Groupthink - reluctance to share contradictory information about a problem for the sake of maintaining the harmony of the work group to the detriment of critical problem-solving. Usually, this is worsened by one or more dominate team members who possess considerable influence on the group's thinking. Consequently, critical information known within the group may remain unknown. Groupthink can also occur due to the existence of too much “professional courtesy;” subordinates passing on only “good news” or “sugar coating” bad news so as to not displease their boss or higher level manager.
·        Risky Shift - the tendency to gamble with decisions more as a group than they would if they were making the decision individually on their own. If two or more people agree together that they know a “better way” to do something, there is a good chance they will take the risk and disregard established procedure or policy. This is commonly referred to as a “herd mentality.”

31. Organization ASK: What have you picked up so far that can help you??
Facilitate a short review of the following topics:
Anatomy Of Event. Ask what is the importance of understanding the model.
Human performance principles. Ask what principles we have covered thus far and what examples do we have of each one.
Error-likely situations. Ask when an error‑likely situation exists.
Job-site Tools. State a job-site tool and talk about its use. Or, ask if there are any new tools or new insights about a particular tool?
INTRODUCTION
State that this module shifts in perspective from near-term (prior to work) to long-term prevention. (The emphasis shifts to making latent conditions visible.)
Goal. Influencing organizational improvement (learning) to eliminate conditions that provoke human error while reinforcing defenses.
Make a point that the hockey player is not a goalie(last line of defense) but is a defenseman or winger/center.
Workers are not free agents. Procedures, policies, programs, training, and even the culture direct their behavior. All of these are outgrowths of organization.

32. Terry Tate Clip

33. Breaking The Human Performance Paradigm
Minimum frequency and severity of plant events, with high safety margins and reliability and no fuel-damaging events.
Re + Md → ØE
[reducing error AND managing defenses leads to zero events]
Meeting the intent of INPO’s 2nd strategic objective-we focus on zero events. We could also equate this to performance improvement and it uses the same components. As such, Working toward performance improvmeent by focusing on Individual behaviors, organization and processes also gets you better performance as well as drives toward zero events!
First part is focused toward individual-key part of this is error reduction/prevention tools-share recent survey results
Md part focuses on Engineering controls, Admin controls, mgmt controls and oversight controls
[Aka: Individual Organization & Processes >>>> Performance Improvement]

34. Organizational Processes & Values
The Performance Model
A mental framework (mental model) to aid management in thinking about HPI
Job-Site Conditions
Worker Behavior
This model is the reverse of the “Anatomy of an Even”’.
The Performance Model is a system-level framework that attempts to model the prevalent factors that influence plant performance through people.
Why the focus on plant results? Events and economic performance in a deregulated economic environment
Behaviors that “alter” the state of plant “structures, systems, or components” are those that occur at the “job-site.” In this case job-site is wherever people can potentially change plant state either directly or indirectly. Operators and craft touch the plant directly. Engineers and support staff touch the plant indirectly through modifications of design bases, procedures, and other documentation.
Job-site behaviors are, in turn, influenced by conditions present in the work situation, I.e. job-site conditions. Among many other influences, error precursors exist here. Whenever a particular individual is assigned a specific task, a unique set of conditions that exist come to bear on the performance of that individual. That’s why I think there is no such thing as a “routine” task. Workers touch the physical plant.
Organizational processes and values set the stage for job-site performance. Whatever flaws exist with programs, processes, training, procedures, supervision, etc., will become embedded in the job-site once a particular individual is assigned a specific task.
Organization’s purpose is to direct people’s behavior in a predictable fashion in accomplishing the business goals of the utility.
Process – set of activities to accomplish a desired outcome; training program, tagout program, human resources, work management, engineering modification process, etc. Directed via “paper-based” procedures.
Values – shared assumptions about what is important; beliefs about conduct of work and interrelationships; I.e., “don’t embarrass the boss,” “do things right,” schedule adherence, “don’t ask dumb questions,” (contrast “espoused” values with actual values). Influence via “relationships.”
Case Study:?
Organizational Processes & Values
Plant Results

35. A lot of organizations are wrestling with this same issue and are trying their best not to get bit. Let’s take a look at one of those businesses.
Show Alligator Video Watch videotape and ask the group to share their feelings about the tape. Ask the class what parallels they can draw between this tape and our nuclear environment. The most obvious parallels are the fact that we too have alligators in our plants (energized circuits, steam, rotating equipment, high radiation areas, combustible, toxic, or inert atmospheres, high energy radioactive nuclear core) and we also tend to focus heavily on the Kennys in our plant. Another parallel is that this initiative seeks to instill in us an uneasiness toward human fallibility and vulnerability.

36. Dual Purposes
To consistently search for and eliminate conditions that provoke human error while reinforcing defenses.
Safety
To facilitate the accomplishment of the organization’s mission in accordance with its norms, values, and strategies.
If an organization only sees its purpose as production then what is its priority? What will it focus on?
In a business like commercial nuclear power where error can have significant consequences what must the purpose of the organization also be? Answer: Safety
Is safety complementary to or in conflict with production? Answer: A properly focused safety purpose is a long range production attitude. If an organization does not have significant events it will be a production success, assuming that it is producing (e.g. a dead man is pretty safe but he is not producing). The two purposes work together for success.
____________________________________________________________________________________
Activity:
Flip chart the production/protection “ROAD”

37. Competing Resources Prevention Production tn Bankruptcy Accident t0
Defenses
Bankruptcy
Prevention
Production
Just Do It!
Why aren’t there “Think Megawatts” or “Think Schedule Adherence” signs in the plant or on the plant access road?
Illustration shows what may happen if distribution of resources (priority) is too much in one or the other basket.
Production - positive reinforcer; temptation to make production-oriented decisions over safety in the near term; when you do production you get $, schedule adherence, etc. (tangible)
Prevention is a negative reinforcer, punisher, or ignored; complacency builds in when nothing bad happens after taking short cuts; people do prevention, such as self-checking, and OE, to avoid undesirable outcomes like events; when you do prevention, you get nothing (no error or events). (intangible)
Long-term vs. Near-term: The temptation is in the near-term when people are tempted to take shortcuts to achieve due dates or the work schedule. Prevention will in the long-term enhance the productivity of the plant.
C.    Emphasize the concept of an unrocked boat (no events) and its relationship to the current environment in the nuclear industry. Ask who should artificially rock the boat and how?
Incubation of Disasters (Man-Made Disasters, Turner & Pidgeon, p88)
I. Existing set of beliefs and attitudes (shared?) about hazards and safe practices degraded (Pollyanna) II. Accumulation of unnoticed mishaps (unreported errors) and low-level events (at odds with original beliefs above; perceptions about safe practice and hazards depart from reality; values become differentiated through the workforce and management; complacency and shortcuts) III. Precipitating Event (outcomes that reveal true latent condition organization) IV. Immediate consequences of the event become evident. V. Rescue and salvage (first stage of readjustment in values due to shock of experience) VI. Full cultural readjustment (second stage involving review and revision of existing ideas about hazards and safe practices to avoid them)
For in-depth information, see Managing the Risks of Organizational Accidents by James Reason (1998), pp. 3-7.
new plant state
plant event
Accident t0
Source: James Reason. Managing the Risks of Organizational Accidents, 1997 (in press).

38. Defenses Physical Administrative Functions: Create Awareness
Flawed defenses allow active errors or their consequences to occur.
Physical Administrative
Functions:
Create Awareness
Detect and Warn
Protect
Recover
Contain
Enable Escape
State that we talked yesterday about conditions provoking human error but what about defenses? If an organization is going to reinforce defenses, we need to know a little bit about them. If we are going to keep ourselves in the parity zone of protection vs. production, we need to periodically check and reinforce our defenses (rock the boat).
State that defenses fulfill the following functions:
to create awareness and understanding of the risks and hazards
to detect and warn of the presence of off-normal conditions or imminent dangers
to protect people and the environment from injury and damage
to recover from off-normal conditions and restore the system to a safe state
to contain the accidental release of harmful energy or substances
to enable potential victims to escape out-of-control hazards
.Fact: Defenses are both physical and administrative.
Ask for examples of physical defenses: engineered safety features,personal protective equipment
Ask for examples of administrative defenses. supervision,procedures, instructions, policies, standards,training, briefings
Defense Function Sprint - HANDOUT
Direct students take a minute to mark the defense function and mode of application for the items listed. (More than one box may be checked.)
Ask are there any defenses you want to review or discuss? Pick a few at random to promote discussion if the class does not respond.
Source: Maurino, Beyond Aviation Human Factors, 1995

39. Defense -in- Depth Challenges To the Plant EVENTS VERBAL
COMMUNICATIONS
MANAGERIAL METHODS
DESIGN
WRITTEN COMMUNICATIONS
TRAINING
WORK
PRACTICES
CHANGE
IMPLEMENTATION
WORK SCHEDULE
WORK ORGANIZATION OR
SUPERVISORY METHODS
ENVIRONMENTAL
FACTORS
One great thing about our business is that we have lots of protective layers. This means that some of these barriers can erode or break down and another layer in the chain can prevent an event from occurring. Other industries with defense in depth have this same benefit. The common problem we have with this is that since events are few and far between and since our organizations can tolerate erosion in some of our defenses without resulting in events, this is exactly what happens -- unless we’re proactive and vigilant. What happens when these defenses begin to erode is that we wind up thinking we have defense in depth when in fact we really have flawed defenses and broken barriers.
This is why it is important to examine near misses and keep an open mind about what may be flawed.
EVENTS

40. Performance Model w/ example defenses (10-08-02)
Equipment Ergonomics & Human Factors
Pre-job Briefing
Just-in-time Operating Experience
Task Preview
Turnover
Clearance Walkdown
Flagging
Environmental Conditions
Work-arounds & Inconveniences
Housekeeping
Challenge
Questioning Attitude
RWPs
Critical Parameters
3-Part Communication
Worker Knowledge, Skill, & Proficiency
Procedure / Work Package Quality
Equipment Labeling & Condition
Procedure Use & Adherence
Conservative Decision-Making
Management Monitoring
Personal Motives
Morale
Lockout / Tagout
Tool Quality & Availability
Intolerance for Error Traps
Self-Checking
Place-Keeping
Problem-solving
Methodology
Values & Beliefs
Foreign Material Exclusion
Fitness- for-Duty
Leadership
PLANT
RESULTS
JOB-SITE
CONDITIONS
ORGANIZATION
PROCESSES
& VALUES
WORKER
BEHAVIOR
Double (dual) Verification
Supervision
Uneasy Attitude
Rigor of Execution
Roles & Responsibilities
Peer-Checking
Recognizing Error Traps
Team Skills
Stop When Uncertain
Proper Reactions
High Standards
Reinforcement
Coaching
Questioning Attitude
Respect for Others
Open & Honest Communication
Compelling Vision
Healthy Relationships
Courage & Integrity
Motivation
Example
Walkdowns
Performance Feedback
Task Assignment
HP Surveys
Task Qualification
QC Hold Points
Independent Verification
Forcing Functions
Personal Protective Equipment
Interlocks
FME
Alarms
Handoffs
Training
Procedure Revisions
Rewards & Reinforcement
Meetings
Compatible Goals & Priorities
Reviews & Approvals
Reactor Protection Systems
Role Models
Safety Philosophy
Strategic HPI Plans
Design & Configuration Control
Equipment Reliability
Post-job Critiques
Staffing OE
Work Planning
Simple / Effective Processes
Problem- Solving
Safeguards Equipment
Root Cause Analysis
Problem Reporting
Containment
Task Allocation
Clear Expectations
Self-Assessment
Accountability
Independent Oversight
Scheduling / Sequencing
Change Mgmt.
Benchmarking
Socialization
Performance Indicators
Performance Model w/ example defenses ( )
Labor Relations
Corrective Action Program
Communication Practices & Plan
Management Practices
Trend Analysis

41. Latent Organizational Weaknesses (sources)
A.    Precursor Review
1.     Refer to Common Error-Provoking Precursors in Individual Section of "Student Notebook."
2.     Ask what causes or creates (insert a precursor). Pick several precursors and ask for a similar response from the class. Expected response is some element of the organization.
3.     Facilitate discussion leading to the conclusion that many precursors are created by organizational weaknesses in policies, processes, practices, and procedures.
Latent Organizational Weaknesses (sources)
Processes (structure)
Work control
Training
Accountability policy
Reviews & approvals
Equipment design
Procedure development
Human resources
Values (relationships)
Priorities
Measures & controls
Critical incidents
Coaching & teamwork
Rewards & sanctions
Reinforcement
Promotions & terminations
VII.        Note: Students will necessarily need to speculate. There are many organizational flaws that could create the conditions listed in the precursor chart. Verify the logic of their suggestions (no leaps in logic)
B. Give examples of categories of organizational weaknesses found in the "Student Notebook."
Note these organizational functions are all subsets of design, construction, operation and maintenance.
Discuss differences between processes and values.
Handout - Latent organizational weaknesses.
expect discussion
1.     Take a moment to emphasize the reality of the propagation of these weaknesses by providing the following information to the participants:
·        B" resulted in electricians unknowingly working on energized equipment and electric shock to one of the workers (without serious injury).
·        "C" resulted in loss of control of a ground buggy and significant damage to a station auxiliary transformer.
·        "E" contributed to a rod manipulation error.
·       In the case of "F," see SOER 94-1.  
VIII. PLANT‑SPECIFIC EVENTS EXERCISE Note: Allow about one hour. 
(The events should be fairly recent, include organizational, contributors or causes, and be simple enough to be presented in just a few paragraphs.) 
A.    Divide the class according to the number of events to be reviewed. Assign a breakout area to each group.
B.    Assign one event to each group.
C.    Provide the following exercise instructions:
For example, four groups of five for a class of twenty can be used for two events. One event can be given to two groups and the other event to the other two groups.
1.     Working individually, highlight the initiating action that caused the event, error precursors, flawed defenses, and underlying organizational weaknesses. Allow 5 minutes.
2.     Gather into groups and summarize your input on a flip chart under the four headings of initiating action, flawed defenses, error precursors, and organizational weaknesses. Select a spokesperson. Allow 15 minutes.
3.     Review results; ensure participants identify organizational weaknesses. Allow 20 minutes.
4.     Emphasize the following key points:
·        latent weakness manageability ‑‑ In most cases the latent conditions and their associated organizational weaknesses existed long before the event. If they can be discovered, they can be corrected.
Ask what could have been changed organizationally to avoid the event.
Note: While emphasizing these points, you should maintain the balance portrayed by the team (whether hockey, soccer, or what) analogy.
·        impact an organization has on individual performance -- The organization has a great deal of influence on the work environment, task demands, individual capability, and defense‑in‑depth.
The best defense is a good offense (organization), but the goalie (individual) must still be there to deflect shots on goal. (not overlooking individual responsibility)

42. Finding Latent Organizational Weaknesses
Self-Assessments
Benchmarking
Post-job Critiques
Trending
Surveys and Questionnaires
Observations
Root Cause Analysis

43. Air Ontario Flight 363 Fokker F28 Dryden, Canada March 10, 1989
Announce the case study title.
Show video.
Assign each table to identify answers to one of the following aspects of the Anatomy: flawed defense, initiating act, error precursors, and latent organizational weaknesses. (5 minutes)
Each table reports results (10 minutes).

44. Leadership
Leaders can be supervisors and managers.

45. Relationships Leadership Practices 1. Facilitate open communication
2. Promote teamwork
3. Reinforce desired behaviors
4. Eliminate latent organizational weaknesses
5. Value prevention of errors
Relationships
Behaviors that support these opportunities can set example and help prevent errors.
Facilitate communication efforts - communication blockages, the prevalent flawed defense in major disasters; blame-free atmosphere (Allinson)
Promote Teamwork
Reinforce desired job-site behaviors - using performance management techniques (Daniels)
Identify & eliminate latent organizational flaws - revise policies, practices, & processes to proactively eliminate latent organizational errors that:
inhibit desired job-site behavior (individual)
establish conditions that promote error or violation (individual)
inhibit effectiveness of defenses (against the consequences of error)
Promote a sense of vulnerability & need for interdependency - due to the following:
human fallibility - we will make mistakes; every task is opportunity for error
complex technological environment - tight coupling & opaque systems
fast-paced operational tempo - time pressure
latent organizational flaws - even managers & engineers make mistakes
Ongoing basis - as or more important than production efforts; high-level attention vs. assumed (Embrey) .
BREAKOUT SESSION - ENABLER BEHAVIORS
Divide the class into five groups and assign each group a particular enabler.
Ask each group to identify what a leader could be seen doing or heard saying for the specific enabler.
Also report how behaviors relate to the human performance system. Pretend you are a video camera with audio. Tell exactly what you see and hear the person doing. Use the desk reference and the Excellence in Human Performance to help.
.Follow the format below for each group’s report:
Present ideas to class one group at a time.
Discuss concepts (specified in remainder of this lesson plan) associated with specific enabler.
Relate enabler to human performance system.

46. Consequences that Increase Consequences that Decrease Behavior
Reinforcement
Behavior
BEHAVIOR INCREASES
Consequences that Increase
1. GET SOMETHING YOU WANT
2. AVOID SOMETHING YOU DON’T WANT
Consequences that Decrease Behavior
1. GET SOMETHING YOU DON’T WANT
2 . LOSE SOMETHING THAT YOU HAVE
BEHAVIOR DECREASES
Source: Daniels, Bringing Out the Best in People, 1989.
.Ask: What is human performance? B + R
How can a leader get someone to do the desired behavior once?; quick change (for example, directives, verbal orders, training, signs, procedures, messages, or threats)
How can a leader can get someone to repeat the desired behavior (for example, positive consequences, graphs of results, rewards, threat of punishment, or recognition)
.Law of Human Nature: People tend to seek things they like (pleasure, rewards) and avoid things they don’t like (punishment, negative situations, being ignored)
.Effect of consequences on behavior [9]
positive reinforcement (R+) - personal satisfaction after successfully troubleshooting and repairing a failed instrument
negative reinforcement (R-) - taking foot off the accelerator of your car when you see a highway patrolman
punishment (P) - burning your finger when touching a hot stove top
extinction (X) - not receiving a snack after inserting 50 cents into a vending machine .

47. Individual Capabilities Error-likely Situations Potential Consequences
Task Preview
SAFER Dialogue
S – Summarize critical steps
A – Anticipate error traps
F – Foresee consequences
E – Evaluate defenses
R – Review operating experience
Individual Capabilities
Task Demands
Human Nature
Work Environment
Error-likely Situations
Potential Consequences
Flawed Defenses
Critical Steps
Task Preview
A task preview attempts to improve a worker's situational awareness of job site conditions that could provoke error before work is done.
This is the context for performance, the set of antecedent conditions that shape the worker's behavior. They are unique to a specific task and a particular individual assigned to perform that task. There is no such thing as a “routine job.” In every case, despite the same task, the environment and/or the individual can change in some fashion since the last time the task was performed, even if it was just yesterday. Either the task or the person can change from one hour to the next. And, the inherent unreliability of human nature should add a degree of uneasiness toward the job especially if it is risk‑significant.
Safe - Summarize critical steps, anticipate errors, Foresee consequences and evaluate defenses
What to Accomplish and What to Avoid. A pre-job briefing helps all those involved to understand the scope of what is to be accomplished (big picture), limits and precautions, task sequences, and roles and responsibilities for a task. An effective pre-job briefing requires an intelligent conversation—a dialogue among all participants—about a specific task to prepare workers for not only desired accomplishments, but also to address what to avoid. The “avoid” dialogue should sensitize workers to “see” error-likely situations, especially at critical steps or phases of the activity. Although not specifically addressed in the framework, the framework’s ability to identify problems is enhanced by using pertinent operating experience—how mistakes have been made before. Conduct pre-job briefings for not only infrequently performed or complex tasks, but also for the so-called routine jobs. Experience reveals that most events occur during routine activities.

48. Guidance for Level of Pre-job Briefing
Low-Risk
High-Risk
Simple or Repetitive
SAFER Dialogue
Preplanned Prejob Briefing Forms
Plus SAFER
Complex or Infrequent
Generic Prejob
Briefing Checklist
Infrequently Performed Test or Evolution
Extensive pre-job briefings do not have to be performed for every activity. Tasks are simple or complex, repetitive or infrequent, low or high risk. Obviously, there are variations even among simple tasks. However, how much of a pre-job briefing should be conducted? A simple task is one that involves few interactions with plant equipment, indications, or other individuals. A repetitive task is one that involves repeated actions. A complex task involves multiple interactions with plant equipment, indications, and/or with other individuals or team members. The greater the number of interactions within a short time frame, the greater the opportunity for error becomes. An infrequent activity involves evolutions that are seldom performed even though covered by existing normal or abnormal procedures (for example, plant startup after a prolonged outage or after any outage that involves significant changes to systems, equipment, or procedures related to the core, reactivity control, or reactor protection). Low risk involves little or no consequence to either plant equipment or personnel should a mistake occur.
What to Accomplish and What to Avoid. A pre-job briefing helps all those involved to understand the scope of what is to be accomplished (big picture), limits and precautions, task sequences, and roles and responsibilities for a task. An effective pre-job briefing requires an intelligent conversation—a dialogue among all participants—about a specific task to prepare workers for not only desired accomplishments, but also to address what to avoid. The “avoid” dialogue should sensitize workers to “see” error-likely situations, especially at critical steps or phases of the activity. Although not specifically addressed in the framework, the framework’s ability to identify problems is enhanced by using pertinent operating experience—how mistakes have been made before. Conduct prejob briefings for not only infrequently performed or complex tasks, but also for the so-called routine jobs. Experience reveals that most events occur during what many consider routine activities.
Plus SAFER
Plus SAFER

49. Post-Job Critique Purpose: Organizational improvement (OE)
Quick and easy
Production and Prevention
Management acknowledgement
Follow-through
Feedback via the post-job critique provides management with an important and fresh source of information about how well the organization supported job-site performance. The fundamental purpose of information gained from this critique is to improve the organization of work as it supports worker performance at the job site. Such information will not only improve the productivity of the job but will also help identify opportunities to strengthen defenses against error and events and eliminate error precursors embedded in the task.
Preferably, the post-job critique is structured as a simple, quick, and painless means of gathering information from workers about the work (planned versus actual) and should last only a few minutes depending upon the complexity of the job just completed. Supervisors do not necessarily have to lead this discussion; workers can be made responsible for this activity and the results provided to the supervisor along with other related paperwork. If necessary, problem reports are submitted. This information is in turn acknowledged and incorporated into organizational structures, as appropriate, to support future job performance. To reinforce the future communication of feedback, those providing feedback should be informed how their ideas were resolved. For instance, one plant posts ideas submitted and their resolution on an intranet Web page that is updated routinely. Similar to the goal of operating experience, post-job critiques attempt to get the right information to the right person(s) in time to prevent an error and ultimately an event for the next operation.

50. Blame Cycle Human Error Less communication
Management less aware of jobsite conditions
Reduced trust
Latent organizational
weaknesses persist
Individual counseled and/or disciplined
More flawed defenses & error precursors
Trust erodes.
Information flow diminishes.
Good people leave organization.
An “us vs. them” culture evolves.
People want justice, not necessarily a blame-free environment (Reason)
.Error should be seen as opportunity to learn.
.When listening, notice how people feel about something as well as what they are saying; “be here now.”
Source: Reason, Managing the Risks of Organizational Accidents, pp

51. Culpability Evaluation Flowchart
Attachment A
Culpability Evaluation Flowchart
Discipline required
Accountability PR&D
Process Issue
Were actions as intended?
Knowingly violate expectations?
Pass
substitution
test?
History of
human performance problems? No No
Yes No
Yes No
Yes No
Yes
Self reported? No
Were consequences as intended?
Were expectations reasonable, available, workable, intelligible, and correct?
Deficiencies in
training, selection, assignment, or experience?
Yes No
Yes
Yes
Yes No
Corrective
training or
other
intervention
may be warranted
Intentional Act (not an error)
Possible
reckless
violation
Organization induced violation
Have class read accountability definition from glossary.
Ask, how is accountability used here? How should it be used?
Review elements of flowchart. Ask for an example to use to ‘walk through” the flowchart.
Ask, how can this be used to strengthen or enhance a blame-free environment?
Possible
negligent
error
System induced
Blameless
error
Evaluate Organizational Processes & Management / Supervisory Methods
Diminishing
culpability

52. “The longest distance to travel in HPI is from the head to the heart
“The longest distance to travel in HPI is from the head to the heart.” -Tom Herrall, Mcguire plant manager
Purposefulness
Control
Competence
Progress

53. Error Precursors Organizational Weaknesses Root Cause Root Cause Root
HVCM
Explosions/Fires
Tunnel Fire
CMS Hydrogen
Release(s)
Rad Posting
Violations
Root
Cause
Root
Cause
Root
Cause
Root
Cause
Time Pressure
Stress
Habit Patterns
Changes
Assumptions
Repetitive Actions
Simultaneous
Hidden System Response
Workarounds
Complacency
New Technique
Hazardous Attitude
Interpretation
Unclear Goals
Error Precursors
Organizational Weaknesses

54. Implementing a “Program”
Senior Management Commitment
Steering Committee
Self-assessment
Strategy
Communicate and Empower
Implement
Evaluate
Maintain
Most attempts at error management are:
piecemeal rather than planned
reactive rather than proactive
event-driven rather than principle-driven
James Reason
Managing the Risks of Organizational Accidents, p.126
Weaknesses in the implementation of change by station management is of particular concern. Much of the problem with human performance improvement is that managers have not methodically thought it through. Improvement will not be attained by simply mandating it. It requires an organization-wide change in behaviors and associated beliefs and values. Behavior changes can be conditioned through application of appropriate rewards and sanctions. But lasting change must be embedded in the hearts and minds of the employees.
A methodical approach involving management and leadership is necessary. The following change process is one of many, but is suggested here as it specifically relates to human performance improvement:
Identify a champion - a member of the senior management team (sponsor) intimately involved in change effort, preferably someone with a passion for improving human performance; possesses authority to devote resources to change effort
Establish an informed human performance steering committee - knowledgeable and reputable members of line management and dedicated members of the workforce willing to take a leadership role; a temporary organization established in an advisory capacity; not a problem-solving committee
Create a vision and a sense of urgency - a vivid realization of what could be and the undeniable need for bold change from the present way of doing business (Operations Focus - Core Process: power block)
Develop a strategy - a vision-oriented implementation plan based on the principles of human performance, input from front-line workers, and on an accurate self-assessment of the present reality; not a cookie-cutter, program-of-the-day approach; clear goals and next steps (see next slide)
Communicate - line management's repetitive efforts to create a shared understanding of the vision, the gap between the present and the vision's future state, and the strategy using multiple forums and mediums; include active clear explanations of expectations and accountabilities
Empower - educating people and aligning organizational processes to remove barriers to implementation of the strategy
Implement - doing new leader and individual behaviors; planning without doing is a recipe for failure
Generate short-term successes - a succession of planned occasions, after implementation, that indicate the changes are working and confirms the validity of the vision; rewards those who exhibit new behaviors and builds momentum for the rest of the organization
Embed changes - consolidating gains in behavior via revisions in organizational processes and via leadership focus and attention; ongoing effort for continuous improvement
(Source: Kotter, Leading Change, 1996 and Shonk, Team-Based Organizations, 1997)