4Purpose of this Training To reduce the frequency and severity of events and improve operational performance.Senior Management Quote Here
5At (your company name here), we value safety HP Tools and ConceptsError free = event freeEvent-Free ClocksGoal is ZERO accidents
6Why Learn this at (your company name here)? Values: what we care about most; our beliefs.Culture: all the common values of the company. These influence everyone’s attitudes, choices, and behavior.Performance Improvement: we can anticipate an error-free workplace
7Training Objectives Describe the types and causes of human error Describe human performance concepts and principlesApply the principles of human performance in a case studyIdentify the human performance toolsApply the appropriate tools in work situations
8Types and Causes of Human Error Module 1Types and Causes of Human Error
9Defining Human Performance Department of Energy (DOE)ConceptsPrinciplesSystemNot step-by step processBehaviors
11Layers of Responsibility Contributing to Human Performance IndividualsLeadersOrganization
12The Elements that Impact Human Performance It is a system of interdependencies
13Counting ExerciseRead the following sentence and count the number of F’s you find.
14Counting ExerciseFINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF YEARS.
15Counting ExerciseFINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF YEARS.Did you find six?
16Reading ExerciseClearly read the following paragraphs.
17Reading ExerciseAoccdrnig to rscheearch at Cmabrigde Uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are wirttn, the olny iprmoetnt tihng is that the frist and lsat ltteer be at the rghit pclae.The rset can be a total mses and you can sitll raed it wouthit porbelms. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. Amzanig huh?
18Types of Errors:Active Error – An obvious mistake that has immediate, visible consequences.Latent Error –A hidden mistake that has consequences that are not immediate. *(Seat belts are a good idea)
19How we commit errors Human Error Unintended Action Intended Slip Lapse MistakeAttention FailureIntrusion, Omission,Misorder, MistimingPlanning FailureMisapplication of good ruleApplication of bad ruleViolationMemory FailureForgetting intentionLost placeOmitting planned itemMis-order, MistimingShortcuts
20Human Information Processing Shared Attention ResourcesSensingThinkingActingInformation Flow PathSource: Wickens, 1992
21Performance Modes Error Rate Reduction Attention (to task) HighLowAttention (to task)1 in 10Knowledge BasedPatternsError Rate ReductionInaccurate Mental Picture1 in 100Rules BasedIf - Then1 in 1,000MisinterpretationSource: James Reason. Managing the Risks of Organizational Accidents, 1998.Skills BasedAutoInattentionFamiliarity (w/ task)LowHigh
22Error Traps produce an error-likely situation Human NatureError TrapsTask DemandsError TrapsError Traps produce an error-likely situationWork EnvironmentError TrapsIndividual CapabilitiesError Traps
23Recognize and work with it. Sometimes we’re up andsometimes we’re down!Recognize and work with it.
25Human Performance Concepts and Principles Module 2Human Performance Concepts and Principles
26Five Principles of Human Performance People are fallible.Error situations are predictable.Organization influences behavior.Reinforcement effects performance.Understanding the past helps avoid events.
27Layers of Responsibility Contributing to Human Performance IndividualsLeadersOrganization
28Behavior vs. Result Which shooter had better “results”? 5 4 3 2 1 5 4
29Performance Formula Behavior: the way you do your job Results: getting your job donePerformance: everyone succeeding together
30Functions of Defenses Create Awareness Detect and Warn Protect Recover ContainEnable Escape
32Sources of Latent Organizational Weakness ProcessesControl of workTrainingAccountability policyEquipment designProcess developmentUse of work forceValuesPrioritiesMeasures & controlsCoaching & teamworkRewards & sanctionsReinforcement
33Applying the Principles Module 3Applying the Principles
35Questions on the Case Study What were the consequences of this event, short and long range, and what was their significance?What were some of the latent organizational weaknesses?What defenses were removed or flawed?What values or organizational beliefs may have contributed to the event?What were some of the error traps?What can we learn from this case study?
433-Way CommunicationHelps you verify that the correct information is transferred.Used during the execution of critical steps to formalize the communication.Repeat-back is required when obtaining a clearance or a switching order.Regulatory requirement in certain situationsCritical transactions (i.e. communicating to control personnel)
443- Way CommunicationWhat Dennis said (as he was leaving the room):“Don, turn off the foam machine”What Don heard:“Don’t turn off the foam machine.”
46Pre-Job Briefing What is the task to be accomplished? Who’s doing what?How will we communicate?What safety equipment do I need?What is the worst thing that could happen and how am I going to prevent it?Will add link to APS P-JB video when it is published.
47STOP if Unsure If you have a feeling something is not right – Stop! If you are not positive of the course of action or the outcome of your actions – Stop!
48Two-Minute Drill Initial worksite assessment. Use after a break or distraction.Helps to reset and verify work conditions.Provides a chance to assess changing workplace hazards at the workplace.Will add link to APS 2-Minute Drill video when it is published.
49Questioning Attitude Challenges assumptions Stimulates a healthy skepticismVigilance when things don’t seem rightBeing open to challenges by othersUse when uncertain, confused, doubtful
50Turnover Information/awareness continuity Accurate transfers Transferring responsibilitiesOver communicate – Don’t assumeRecord information – Ensure accuracyAsk clarifying questions
51Place Keeping Prevents step duplication or omission Records step completed and yet to be performedUse during Switching and Clearance proceduresCircle & Slash the step number, sign or initial a blank or, check a box
52Flagging Correct equipment identification Alerts others that equipment is unavailableShields components from inadvertent useUsed on similar–looking equipmentMandates use of peer and self-checkingRemains in place until work is complete
53Phonetic Alphabet Provides understandable difference between letters Use when letters might sound alikeUse in high noise areasUse at times of poor radio/telephone reception
55Conservative Decision Making Deliberate and methodicalClarifies goals and optionsPlanningResources and expertiseMinimize uncertaintyFacts only – challenge assumptions
56Procedure Use & Adherence Understand a procedure’s intent and purpose and follow its direction.Perform all actions as written.Stop if procedure cannot be used as written.Procedure may be corrected before continuing.Expectation: Frequent document use instead of memory and recall.
57Concurrent Verification Separate confirmation by two individualsError prevention on equipment status/condition changesIndependent conclusions by all partiesVerifier takes no cues from performerNot Peer Checking
58Post-job Review Identifies what went well Identifies potential improvementsAllows feedback from active participantsIdentifies actual versus planned outcomeDetermines future changes in similar tasksReviews lessons learned
62Objective Review Describe the types and causes of human error Describe human performance concepts and principlesApply the principles of human performance in a case studyIdentify the human performance toolsApply the appropriate tools in work situations
63“What’s the worst that could happen and how am I going to prevent it?” The Big QuestionQuestioning Attitude“What’s the worst that could happenand how am I going to prevent it?”