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Human Performance Improvement Principles

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Presentation on theme: "Human Performance Improvement Principles"— Presentation transcript:

1 Human Performance Improvement Principles
Facilities Division Lawrence Berkeley National Laboratory Janice Sexson

2 “Humans rather than technical failures now represent the greatest threat to complex and potentially hazardous systems” James Reason, 1995


4 Why A Human Performance Improvement Approach?
To proactively prevent “occurrences” triggered by human error

5 Occurrence A condition that adversely affects, or may adversely affect, DOE or contractor personnel, the public, property, environment or the DOE mission


7 Facts About Human Error
It thrives in every industry It is a major contributor to events and occurrences It is costly, adverse to safety and hinders productivity The greatest cause of human error is weakness in the organization not the lack of skill or knowledge

8 Hazardous Attitudes Pride-Don’t insult my intelligence
Heroic-I’ll get it done, hook or by crook Invulnerable-That can’t happen to me Fatalistic-what's the use Bald Tire-Got 60 K miles and haven’t had a flat tire yet Summit Fever-We’re almost done Pollyanna-Nothing bad will happen

9 Individual Error-reduction tools
Human Error Individual Error-reduction tools Discussing Lessons Learned Behavior based safety Error-Precursor Peer-Check Enhanced Pre-Job Briefing 3 way communication

10 Latent Organizational Weaknesses
How to address latent organizational weakness Understand Safety Principles Align the organization’s values, attitudes, and “norms” to focus on continuously improving systems and processes Encourage reporting of error-prone conditions and error-likely situations Eliminate and mitigate Communicate progress


12 Principles People are fallible, and even the best make mistakes
Error-likely situations are predictable, manageable, and preventable Individual behavior is influenced by organization processes and values

13 Principles People achieve high levels of performance based largely on the encouragement and reinforcement received from leaders, peers, and subordinates An understanding of the reasons mistakes occur, and application of the lessons learned from past events can avoid future events


15 Blame Cycle A Human Error Happens
Worker is counseled and/or disciplined Trust levels reduced because of managements actions Worker no longer feels safe to communicate Management is less aware of working conditions Latent organization weakness persist Error likely workplace exists

16 Human Performance “Event are not so much the result of error-prone workers as they are the outcome of error-prone tasks and error-prone work environments, which are controlled by the organization.”

17 Human Beings

18 Notable Organizational Behaviors
Managers foster a culture that values prevention of events Managers strengthen the integrity of defenses to prevent or mitigate the consequences Managers preclude the development of error-likely situations Managers create a learning environment that promotes continuous improvement

19 Leadership Behavior Facilitate open communication
Promote teamwork to eliminate error-likely situations and strengthen defenses Search for and eliminate organizational weaknesses that create error-likely situations Reinforce jobsite behaviors Value the prevention of errors

20 Individual Tools Questioning attitude Clear communication techniques
Stop when unsure

21 Management Tools Solicit and act on feedback from worker
Determine fundamental causes Monitor trends Self-Assessment Process mapping Task Analysis Benchmarking

22 Summary Question Communicate Stop

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