Presentation on theme: "Elements of an Effective HPI Program"— Presentation transcript:
1 Elements of an Effective HPI Program HPWGElements of an Effective HPI ProgramRob FisherPresident, Fisher IT, Inc.October 9, 2013Copyright, Fisher IT, Inc.
2 Charles F. Kettering – Inventor & Philosopher “A problem thoroughly understood is always fairly simple.”“Found your opinions on facts, not prejudices. We know too many things that are not true.”Charles F. Kettering – Inventor & Philosopher“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.”Copyright, Fisher IT, Inc.
3 Understanding Human Performance Systems modelInterconnectivityLatent conditionsNeed for multiple feedback loopsNeed a systems approach to Human PerformanceCopyright, Fisher IT, Inc.
4 Most problems in industry are related to Human Error… True or False?Most problems in industry are related to Human Error…Copyright, Fisher IT, Inc.
5 The Program MUST be based on… 90% of events are caused by something OTHER THAN JUST the individual95% of people respond very similarly to the same stimuliPeople do what they do at the time that they do it for reasons that make sense to them at the timeHuman Performance is NOT Common SenseCopyright, Fisher IT, Inc.
6 Copyright, Fisher IT, Inc. DefinitionsWe MUST learnto separate theERRORS from theEVENTError: An action or inaction that unintentionally:Results in an undesirable or unwanted condition ORLeads a task or system outside of limits ORDeviates from a set of rulesEvent (or incident): The undesirable result of an error, a set of errors or a set of conditionsDeviation: Not strictly complying with a rule, standard or expectationViolation: Intentionally not complying with a rule, standard or expectationActive Error: An action or inaction that results in immediate consequenceLatent Error: An action or inaction that results in consequences that are delayed or create latent conditionsErrors and violationsare different thingsWe MUST pay attentionto all types of errorsCopyright, Fisher IT, Inc.
7 For Every Deviation From A Definition…Your Program Weakens!Copyright, Fisher IT, Inc.
8 You cannot ‘correct’ your way to excellence The Three Legged StoolPrevention – 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?You cannot ‘correct’ your way to excellenceCopyright, 2013, Fisher IT, Inc.
9 Copyright, Fisher IT, Inc. Three Key Indicators…PreventionThe number and quality of Pre-Task briefs should increaseDetectionThe number and quality of MANAGEMENT observations should increaseCorrectionThe number and quality of non-injury (near miss, close call, etc.) should increaseCopyright, Fisher IT, Inc.
10 Human Performance Improvement is about improving our abilities We are hired to do an OCCUPATION (operator, mechanic, mobile equipment operator, janitor)These Occupations require us to do JOBSThese jobs contain TASKS(sections in a procedure or checklist)These tasks contain ACTIONS or Steps (lock-out-tag-out THIS pumpHang tags on each electrical supplyHang locks on each electrical supplyHang locks on each water supplyDrive Mobile Equipment,Perform Lock-out-tag-outOperate equipment,WeldDrive fork lift into THIS tight place to handle THIS load THIS wayLift load up to see tight spaceLoad goes into area in truckHuman Performance Improvementis about improving our abilitiesat the TASK and STEP levelCopyright 2013, Fisher IT, Inc.
11 Pre-Task Brief Measures NumberCount them allSegregate those with high risk and / or fatality-serious injury potentialQualityCapability of supervisors to perform PTBsEffectiveness of PTB in the fieldCopyright, Fisher IT, Inc.
12 Organizational values influence individual behaviors… True or False?Organizational values influence individual behaviors…Copyright, Fisher IT, Inc.
13 Management Observation Measures NumberAgain – count them allPercentage of HRT / FSIP that get observedQualityPercent that are value basedLessons learnedCopyright, Fisher IT, Inc.
14 Copyright, Fisher IT, Inc. TRUE BUT….The values of the small organization always trump the values of the big orgainzation related to individual behaviors…Copyright, Fisher IT, Inc.
15 Near Miss Measures (and root cause measures) NumberDo I need to say it again?Ratio of near miss report to eventsQualityEvent investigation tool checklist (or equivalent)Do cause analyses follow the process?Root Cause Corrective Action ReviewsCopyright, Fisher IT, Inc.
16 “We have good processes… If we could just get people to follow them we wouldbe fine!”Copyright, Fisher IT, Inc.
21 Use this path to determine system failures Deviation AnalysisIndividual DrivenViolationsWas 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?YESNOUse this path to determine system failuresAre there deficiencies in:Knowledge/skillTrainingExperienceSelection ?Does the individual have a history of unsafe acts?YesUse Deviation Potential ModelTo determine whether “knowingly violated”Violation – An action or inaction that intentionally deviates from a ruleor standardError – An action or inaction that unintentionally creates a problem or deviates from a rule or standardANDUsePerformance Mode Modelto assistUse Performance Mode Model to assistIndividual & System Driven Violations & ErrorsSystem Driven ErrorsCopyright, Fisher IT, Inc.
22 Copyright, Fisher IT, Inc. Root Cause AnalysisShould NOT be based on failed barriersShould always analyze the WITH modelShould look for the REASON for a deviation using the modelsShould 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 rightCopyright, Fisher IT, Inc.
23 Copyright, 2012, Fisher IT, Inc. Closing SummaryOrganizations that integrate human performance concepts into their day-to-day work improve:Performance in safety, quality, effectiveness & efficiency andCommunication which significantly improves overall engagementUse the new language to describe errors, events, deviations and violationsUse the new knowledge to analyze problemsRecognize the performance mode you are in to minimize the error potentialRecognize the triggers that tell you a trap exists that increases the probability and potential for errorsUse the tools to avoid or minimize the impact of the trapsCopyright, 2012, Fisher IT, Inc.