Presentation on theme: "Elements of an Effective HPI Program Rob Fisher President, Fisher IT, Inc. Copyright, Fisher IT, Inc. October 9, 2013 HPWG."— Presentation transcript:
Elements of an Effective HPI Program Rob Fisher President, Fisher IT, Inc. 802-233-0760Rob@fisherit.com Copyright, Fisher IT, Inc. October 9, 2013 HPWG
Copyright, Fisher IT, Inc. Charles F. Kettering – Inventor & Philosopher 1876- 1958 “A problem thoroughly understood is always fairly simple.” “Found your opinions on facts, not prejudices. We know too many things that are not true.” “Why is the human skull as dense as it is? Nowadays we can send a message around the world in one-seventh of a second, but it takes years to drive an idea through a quarter-inch of human skull.”
Understanding Human Performance Systems model – Interconnectivity – Latent conditions – Need for multiple feedback loops Need a systems approach to Human Performance Copyright, Fisher IT, Inc.
The Program MUST be based on… 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, Fisher IT, Inc.
Definitions Error: An action or inaction that unintentionally: Results in an undesirable or unwanted condition OR Leads a task or system outside of limits OR Deviates from a set of rules Event (or incident): The undesirable result of an error, a set of errors or a set of conditions Deviation:Not strictly complying with a rule, standard or expectation Violation:Intentionally not complying with a rule, standard or expectation Active Error: An action or inaction that results in immediate consequence Latent Error: An action or inaction that results in consequences that are delayed or create latent conditions Copyright, Fisher IT, Inc.
The Three Legged Stool Prevention – How much emphasis do we put on keeping bad things from happening? Detection – Are we looking at the right threshold to identify problems? Correction – Do the things we do to fix problems: – Match the significance of the problem? – Take other, similar but worse problems into account? – Not cause problems of a different type? 8 Copyright, 2013, Fisher IT, Inc.
Three Key Indicators… Prevention – The number and quality of Pre-Task briefs should increase Detection – The number and quality of MANAGEMENT observations should increase Correction – The number and quality of non-injury (near miss, close call, etc.) should increase Copyright, Fisher IT, Inc.
Copyright 2013, 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 (sections in a procedure or checklist) These tasks contain ACTIONS or Steps (lock -out- tag-out THIS pump Hang tags on each electrical supply 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
Pre-Task Brief Measures Number – Count them all – Segregate those with high risk and / or fatality-serious injury potential Quality – Capability of supervisors to perform PTBs – Effectiveness of PTB in the field Copyright, Fisher IT, Inc.
Near Miss Measures (and root cause measures) Number – Do I need to say it again? – Ratio of near miss report to events Quality – Event investigation tool checklist (or equivalent) – Do cause analyses follow the process? – Root Cause Corrective Action Reviews Copyright, Fisher IT, Inc.
Rule Requirements (Believed Norm) Standards Time (years) Deviation Drift (New Norm) Safety Threat Incident Performance Gap (discovered by investigation) Investigation T1T2Incident Date Deviation Drift
Deviation Analysis Copyright, Fisher IT, Inc. Was a safety rule or operating procedure knowingly violated? Would other similarly qualified people have done the same thing in the situation? Were the rules available, workable, intelligible, correct and consistently reinforced? YES NO Use this path to determine system failures NO Are there deficiencies in: Knowledge/skill Training Experience Selection ? NO YES Does the individual have a history of unsafe acts? YES NO Yes NO Use Deviation Potential Model To determine whether “knowingly violated” Violation – An action or inaction that intentionally deviates from a rule or standard Error – An action or inaction that unintentionally creates a problem or deviates from a rule or standard AND Use Performance Mode Model to assist Use Performance Mode Model to assist Individual Driven Violations Individual & System Driven Violations & Errors System Driven Errors
Root Cause Analysis Should NOT be based on failed barriers Should always analyze the WITH model Should look for the REASON for a deviation using the models Should determine the LATENT drivers (or causes) Should not focus on the individual but on why the individual did what they did, and what systemic drivers made it feel right Copyright, Fisher IT, Inc.
Copyright, 2012, Fisher IT, Inc. 23 Closing Summary Use the new language to describe errors, events, deviations and violations Use the new knowledge to analyze problems Recognize the performance mode you are in to minimize the error potential Recognize the triggers that tell you a trap exists that increases the probability and potential for errors Use the tools to avoid or minimize the impact of the traps