1. Keys to Improving Work Methods and Instructions Rob Fisher President, Fisher IT, Inc. 802-233-0760Rob@fisherit.com Copyright, Fisher IT, Inc.

2. At a Glance… Establish / reestablish some definitions Error traps in procedures and processes – Top 5 error traps – Deviation potentials and drift Using HPI concepts in instructions – Focus on the system – HP models Copyright, Fisher IT, Inc.

3. HP Defined Copyright, Fisher IT, Inc.

5. HP RE-Defined? Copyright, Fisher IT, Inc. X XX

6. Some Things to Remember 90% of events are caused by something OTHER THAN JUST the individual 95% of people respond very similarly to the same stimuli People do what they do at the time that they do it for reasons that make sense to them at the time Human Performance is NOT Common Sense Copyright 2010, Fisher IT, Inc.

7. Know the Definitions – and Use Them Error – an action or inaction that unintentionally: – Results in an undesired condition OR – Leads a task outside of limits OR – Deviates from a set of rules Violation – an action or inaction that intentionally deviates from a set of rules Error Traps - An unfavorable condition that increases the probability for error during a specific action Error-Likely Situation - A work situation in which there is a greater opportunity for error when performing a specific action or task due to error precursors. Organizational weakness – weaknesses in the processes or values that allow the existence of an error trap or WITH model characteristic to progress to an event Copyright, Fisher IT, Inc.

8. Copyright 2012, Fisher IT, Inc. We are hired to do an OCCUPATION ( operator, mechanic, mobile equipment operator, janitor) These occupations require us to do JOBS These jobs contain TASKS These tasks contain ACTIONS (Steps) Lock-out-tag-out THIS pump Hang locks on each electrical supply Hang locks on each water supply Drive Mobile Equipment, Perform Lock-out-tag-out Operate equipment, Weld Drive fork lift into THIS tight place to handle THIS load THIS way Lift load up to see tight space Load goes into area in truck

9. Top 5 Procedure Traps to Watch For Field Decisions Difficulty Vagueness and Misleading Information Multiple Actions Conflicting Information, Actions & Formats

10. Trap 1 - Field Decisions The procedure user must make a decision with little or no guidance for making that decision. For example if the user has to: – Decide what to do out of multiple options without guidance – Determine if certain conditions exist – Determine if certain sections of procedure are applicable – Determine if the task is completed – Determine if certain requirements are met Decisions made in error prone situations have a field error rate 11 times higher than that of a well written step!

11. Field Decisions (cont.) Conditions affecting the quality of Field Decisions are: – The number of aspects to be considered – Existence of a decision aid – Readiness of the information – Decision maker’s experience and personality

12. Trap 2 - Difficulty Mental Difficulty Told once (in training, memo, OJT, etc.) and now the individual must remember to use it and how to use it Told earlier (in precautions, limitations, procedure step) and now the individual has to figure out when to apply it Physical Difficulty Difficult tasks Unnecessary or unreasonable tasks Easy to shortcut Contact with other organization Has to stop and do something else

13. Trap 3 – Multiple Actions (& embedded actions) 3 or more actions in the same step Actions in a NOTE, CAUTION or WARNING (real or embedded) Actions in Precautions, Limitations, and Pre- requisites

14. Trap 4 – Vague Terms and Misleading Information Vague Terms Abstract verbs like: Impact, Affect, Analyze, Determine, Review, Check, Ensure, Verify Abstract adjectives like: Slow, Fast, Sufficient, Normal, All, Periodically, Routinely Abstract phrases like: When Directed, As Soon As Management …., May be, Should

15. Misleading Information Misleading information is incorrect, but it’s not easy to detect and avoid the error traps it creates and may involve: – Missing critical steps to carry out a task – Missing critical data – Missing critical references – Missing critical scopes The most effective ways of discovery of misleading information are walk-through and full scope verification

16. Trap 5 – Conflicting Instructions Actions that are required by procedural steps but are contrary to the normal actions expected by the workers or formats that are “different” to the user: – Inconsistent actions – Inconsistent words – Inconsistent expressions – Inconsistent format Note: Use of double-negative statements in procedure steps increases the error rate of the step by 280%

17. www.fisherit.com Copyright, 2012 Fisher IT, Inc. Deviation Potential © Simplified Deviation Potential = Difficulty Risk+ Observation

18. www.fisherit.com Copyright, 2012Fisher IT, Inc. Deviation Potential – Simplified Deviation Potential © = Difficulty Perceived Risk + Observation Conscious Unconscious Errors Just don’t comply Accountability issue personal compliance issue Usually a single individual Wrong rule Misapply rule Trying to comply and taking a shortcut Often tribal (a group) Drift Rule Based - 3 General Categories Wrong Rule - Rule problem Misapplication - Information problem Just Don’t comply Personal compliance issue PhysicalMental Peer Supervisor Corporate Personal Intent to Violate No Intent to Violate Violations (<10%) Errors (>90%)

19. Rule Requirements (Believed Norm) Standards Time (years) Deviation Drift (New Norm) Safety Threat Incident Performance Gap (discovered by investigation) Investigation T1T2Incident Date Deviation Drift

20. www.fisherit.com Copyright, 2012Fisher IT, Inc. Deviation Potential – Simplified Deviation Potential © = Difficulty Perceived Risk + Observation Conscious Unconscious Errors Just don’t comply Accountability issue personal compliance issue Usually a single individual Wrong rule Misapply rule Trying to comply and taking a shortcut Often tribal (a group) Drift Rule Based - 3 General Categories Wrong Rule - Rule problem Misapplication - Information problem Just Don’t comply Personal compliance issue PhysicalMental Peer Supervisor Corporate Personal Difficult tasks Unnecessary tasks Unreasonable tasks Easy to shortcut Contact with other organization Has to stop and do something else Taught once - must remember now Stated earlier - must remember now Injury Personal financial loss if caught Equipment damage Corporate financial loss if caught Equipment damage Root Cause & Corrective actions Verbal reminders (or underling) Intent to Violate No Intent to Violate Violations (<10%) Errors (>90%)

21. WITH Model Work Environment Individual Capabilities Task Demands Human Nature General influences on task performance related to workplace, organizational and cultural conditions Unique mental, physical and emotional capabilities of an individual related to a specific task Specific mental, physical or team requirements of a task Generic characteristics of human beings that makes us more vulnerable to errors under certain conditions Copyright 2010, Fisher IT, Inc.

22. Conclusions The fit, form and content of instructions has a marked impact on fatality prevention We have to take the WITH model into account when writing instructions Deviation probability can be predicted and avoided if we understand it We can build quality into the processes by: – Not putting the traps in and / or – Teaching people how to identify and deal with them Copyright, Fisher IT, Inc.