Purpose of this Training To reduce the frequency and severity of events and improve operational performance. 4 Senior Management Quote Here
At (your company name here), we value safety 5 HP Tools and Concepts Error free = event free Event-Free Clocks Goal is ZERO accidents
Why 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 6
Training Objectives Describe the types and causes of human error Describe human performance concepts and principles Apply the principles of human performance in a case study Identify the human performance tools Apply the appropriate tools in work situations 7
Module 1 Types and Causes of Human Error 8
Defining Human Performance Department of Energy (DOE) Concepts Principles System – Not step-by step process Behaviors 9
Little Things Lead to Big Things!
Layers of Responsibility Contributing to Human Performance 11
It is a system of interdependencies The Elements that Impact Human Performance 12
Read the following sentence and count the number of F’s you find. 13 Counting Exercise
FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF YEARS. 14 Counting Exercise
FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF YEARS. 15 Did you find six? Counting Exercise
Reading Exercise Clearly read the following paragraphs. 16
Aoccdrnig 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? 17 Reading Exercise
Types of Errors: 18 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)
How we commit errors 19 Human Error Unintended Action Intended Action Slip Lapse Mistake Attention Failure Intrusion, Omission, Misorder, Mistiming Planning Failure Misapplication of good rule Application of bad rule Violation Memory Failure Forgetting intention Lost place Omitting planned item Human Error Unintended Action Slip Lapse Attention Failure Intrusion, Omission, Mis-order, Mistiming Shortcuts Memory Failure Forgetting intention Lost place Omitting planned item
Human Information Processing 20 Source: Wickens, 1992 Thinking Sensing Acting Information Flow Path Shared Attention Resources
Performance Modes 21 Knowledge Based Patterns Rules Based If - Then Skills Based Auto Familiarity (w/ task) LowHigh Low Attention (to task) Inattention Misinterpretation Inaccurate Mental Picture Source: James Reason. Managing the Risks of Organization a l Accidents, in 1,000 1 in in 10 Error Rate Reduction
Error Traps produce an error-likely situation 22 Task Demands Error Traps Individual Capabilities Error Traps Work Environment Error Traps Human Nature Error Traps
Sometimes we’re up and sometimes we’re down! Recognize and work with it. 23
Event Causation 24
Module 2 Human Performance Concepts and Principles 25
Five Principles of Human Performance People are fallible. 2. Error situations are predictable. 3. Organization influences behavior. 4. Reinforcement effects performance. 5. Understanding the past helps avoid events.
Layers of Responsibility Contributing to Human Performance 27
Behavior vs. Result 28 Which shooter had better “results”?
Performance Formula 29
Functions of Defenses 30 Create Awareness Detect and Warn Protect Recover Contain Enable Escape
Defense in Depth 31
Sources of Latent Organizational Weakness 32 Processes Control of work Training Accountability policy Equipment design Process development Use of work force Values Priorities Measures & controls Coaching & teamwork Rewards & sanctions Reinforcement
Module 3 Applying the Principles 33
34 Develop Case Study/Video for your Organization
Questions on the Case Study 1. What were the consequences of this event, short and long range, and what was their significance? 2. What were some of the latent organizational weaknesses? 3. What defenses were removed or flawed? 4. What values or organizational beliefs may have contributed to the event? 5. What were some of the error traps? 6. What can we learn from this case study? 35
Module 4 Human Performance Tools 36
Error-Prevention Tools Self-checking - S.T.A.R. 2. Peer-checking - Team S.T.A.R. 3. Three-Way Communication 4. Pre-Job Briefing (FKA Tailboard) 5. STOP if Unsure 6. 2-Minute Drill
Self-Checking - S.T.A.R 40 STOP – Is my attention focused on the task? THINK – What action am I about to perform? ACT – Am I performing correctly? REVIEW – Did I get the expected results? *
Peer-Checking Team S.T.A.R 41 Use a second set of eyes to detect and correct. Both individuals actively participate in task performance. Use this tool prior to the performance of critical tasks.
Sometimes we just blow it! 42
3-Way Communication 43 Helps 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 situations Critical transactions (i.e. communicating to control personnel)
What Dennis said ( as he was leaving the room): “Don, turn off the foam machine” What Don heard: “Don’t turn off the foam machine.” 3- Way Communication 44
The Result 45
Pre-Job Briefing 46 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?
STOP if Unsure 47 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!
Two-Minute Drill 48 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.
Questioning Attitude Challenges assumptions Stimulates a healthy skepticism Vigilance when things don’t seem right Being open to challenges by others Use when uncertain, confused, doubtful 49
Turnover Information/awareness continuity Accurate transfers Transferring responsibilities Over communicate – Don’t assume Record information – Ensure accuracy Ask clarifying questions 50
Place Keeping Prevents step duplication or omission Records step completed and yet to be performed Use during Switching and Clearance procedures Circle & Slash the step number, sign or initial a blank or, check a box 51
Flagging Correct equipment identification Alerts others that equipment is unavailable Shields components from inadvertent use Used on similar–looking equipment Mandates use of peer and self-checking Remains in place until work is complete 52
Phonetic Alphabet Provides understandable difference between letters Use when letters might sound alike Use in high noise areas Use at times of poor radio/telephone reception 53
Standard Phonetic Alphabet 54
Conservative Decision Making Deliberate and methodical Clarifies goals and options Planning Resources and expertise Minimize uncertainty Facts only – challenge assumptions 55
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. Procedure Use & Adherence 56
Concurrent Verification 57 Separate confirmation by two individuals Error prevention on equipment status/condition changes Independent conclusions by all parties Verifier takes no cues from performer Not Peer Checking
Post-job Review Identifies what went well Identifies potential improvements Allows feedback from active participants Identifies actual versus planned outcome Determines future changes in similar tasks Reviews lessons learned 58
Module 5 Apply the Tools 59
How valuable is good communication? 60
Objective Review Describe the types and causes of human error Describe human performance concepts and principles Apply the principles of human performance in a case study Identify the human performance tools Apply the appropriate tools in work situations 62
The Big Question Questioning Attitude 63 “What’s the worst that could happen and how am I going to prevent it?”
Your turn Questions? 64
Thank You 65
Knowledge Check 66 Complete the knowledge check on your own. XX% minimum is required. You may use your notes. Time limit: XX minutes.