Presentation on theme: "This is what we DON’T want. Doubtful there was a plan."— Presentation transcript:
1 Human Performance Improvement Work Group WECC Strawman Class Based on INPO and DOE manuals This is what we DON’T want.Doubtful there was a plan.How much forethought do you think there was?PPE?…. With that let’s “dive into the lesson.” (Not like this guy.)
2 Objectives Objectives: Explain why human performance improvement is important to you and your Company.Describe what can influence human performance.Identify and apply Eight fundamental Human Performance Error Prevention Tools to improve safety and reduce errors.Reinforce the knowledge and usage of the HP tools so that they become commonplace in the daily work environmentAsk questions:Why is HP improvement important to YOU?Personal SafetyFamilyEquipment DamageSystem OperationProductivityWhat can influence =At Risk BehaviorsError PrecursorsPerformance ModesSafety BarriersThere are actually 16 tools. More will follow as our culture matures.
3 This is what we DON’T want. Doubtful there was a plan.How much forethought do you think there was?PPE?…. With that let’s “dive into the lesson.” (Not like this guy.)
4 Lessons Lessons: Performance Improvement Overview Human Performance Error Prevention ToolsStart at a “HIGH” level with Company VISION and VALUESWork down to an overview of HP Improvement fundamentals and what some of the drivers are – both Organizationally and Individually.Then get into the details of 8 fundamental HP EPTs.Ask what they are:Tailboards (Job Brief)STAR3-Way Communication2-Minute RuleStop When UnsureQuestioning AttitudePhonetic AlphabetProcedure Use and Adherence
5 What causes humans to fail At Risk BehaviorsNormally, humans make about ???? errors per hour.5 errors per hourXXX COMPANY 20,000 employeesx 5/hr100,000 errors per hour5 errors from Shane bush classIf we have 20,000 employees in XYZ COMPANY, that is 100,000 errors per hour COMPANY WIDE.
6 What causes humans to fail At Risk BehaviorsThis is made worse when the person:Is in a hurryUnder a high workloadDoing more than one thing at a timeDoing the same thing over & over
7 Traps in the Work Environment DistractionsInterruptionsUnplanned changesError PrecursorsThose things that “set-up” a mistake to happenTask demands are greater than the worker’s abilitiesConfusing conditions make the job harderNew techniques not used beforeMental shortcutsLack-of or unclear standardsIllness / FatigueLatent Conditions:Conditions of either task or work environment requires the worker to stop and restart a task (breaks their pattern) (e.g., operating a SCADA device or climbing a rock)Departure from a well-established routine. Unfamiliar task or jobsite conditions that potentially disturbs an individual’s understanding of the task or equipment status (e.g., while switching on bus disconnects, the switchman answers his personal cell phone)Characteristics of displays and controls that can confuse:missing or vague contentNo indication of a specific process parameterillogical organization and/or layoutPoor identification of displayed informationcontrols placed too close together
8 Performance Improvement Overview: Common Error Precursors Task DemandsIndividual Capabilitieso High workload (memory requirements)o Unfamiliarity with task / First timeo Time pressure (in a hurry)o Lack of knowledge (faulty mental model)o Simultaneous, multiple taskso New technique not used beforeo Repetitive actions / Monotonyo Imprecise communication habitso Irrecoverable actionso Lack of proficiency; Inexperienceo Interpretation requirementso Unsystematic problem-solving skillso Unclear goals, roles, or responsibilitieso “Can do” attitude for safety-critical tasko Lack of or unclear standardso Illness or fatigue; general healthWork EnvironmentHuman Natureo Distractions / Interruptionso Stresso Changes / Departure from routineo Habit patternso Confusing procedure / Vague guidanceo Assumptionso Confusing displays / controlso Complacency / Overconfidenceo Work-arounds / OOS instrumentationo Mind set (intentions)o Hidden system responseso Inaccurate risk perceptiono Unexpected equipment conditionso Mental shortcuts or biaseso Lack of alternative indicationo Limited short-term memoryIn Summary:By themselves, error precursors do not define an error-likely situation. A human act or task must be either planned or occurring concurrent with error precursors to be considered error-likely. Error precursors increase the probability for error at the moment of a specific action, that is, error-likely. An error-likely situation—an error about to happen—typically exists when the demands of the task and its environment exceed the capabilities of the individual(s) or the limitations of human nature. Error precursors interfere with successful performance and increase the probability for error for the worker.
9 Two Kinds of Errors.Two kinds of error (based upon the kinds of results they obtain).Active errors - errors that change equipment or system state triggering immediate undesired consequences.Who: Hands on workerWhat: Changes in equipment or systemWhen: ImmediateVisible: Yes.Latent Conditions (typically by management and staff) - errors resulting in undetected organization-related weaknesses or equipment flaws that lie dormant.Who: Management or Administrative staffWhat: Changes to documents, processes, proceduresWhen: Lies in waitVisible: NoCan you give me some examples of an Active Error?Can you give me some examples of a Latent Error?
10 Performance Improvement Overview: When Safety Barriers Fail Events occur if all barriers and the frontline fail...EmployeesTrainingProcessOversightEngineered BarriersEngineered BarriersWhen all barriers* fail = Defense in Depth fails = Errors (We Fail)*Organizational + IndividualField Employees are the last line of defense for supervision in the process. Your contribution to effective Human Performance is CriticalThe guiding principles of Human Performance tell us that no matter how proficient we are, we can all make mistakes; that situations in which errors occur are often predictable and therefore preventable; that we are impacted by the culture of the organization in which we perform activities; that we respond to positive reinforcement from our coworkers; and that if we tie all of this together and learn from past mistakes, we can avoid errors.Having knowledge of the performance modes and the associated error modes, we can recognize the pitfalls we face in a task and take appropriate measures to minimize the chance for error.
11 Performance Improvement Overview: Common Error Precursors An event is an unwanted, undesirable change in the state of facility structures, systems, or components or human/organizational conditions (health, behavior, administrative controls, environment, and so on) that exceeds established significance criteria.
13 Human Performance Error Prevention Tools: Event Prevention How do We Prevent Events?Anticipate, prevent, and catch errors at the job site:Work PreparationWork PerformanceWork FeedbackError Prevention ToolsDevelop and Implement Defense in Depth:Process ImprovementAdequate TrainingOversightTeamworkRemember the issues that cause events: (Refer to previous lesson – Performance Improvement Overview)At-Risk BehaviorError PrecursorsPerformance ModesFailure of Defense in DepthOrganizationalIndividualSo then, how do we mitigate these error causing mechanisms?TailboardsJHAHP EPTOrganizational ImprovementsWork PracticesProcessProceduresTrainingObservationsBrother’s Keeper
14 The Eight Human Performance Tools: Tailboards (Job Briefs) S.T.A.R. – Stop, Think, Act, ReviewAlso known as “Self-Verification”Three-way communicationTwo-Minute RuleStop When UnsureQuestioning AttitudePhonetic AlphabetProcedure Use and AdherenceShow slide and review.
15 Tool #1 – Tailboards:A pre-job meeting of workers and/or supervision conducted before the performance of a job to discuss the tasks involved, hazards and related safety precautions.Tailboards process – how very critical that is completed seriously. Crew foremen are the last line of defense don’t just check the boxes, do a thorough job. Need feedback from Crew foremen to first line supervisorBehavior Cognitive and Perceptual are over 70 &Tailboards process – how very critical that is completed seriously. Crew foremen are the last line of defense don’t just check the boxes, do a thorough job. Need feedback from Crew foremen to first line supervisor.Also of Critical importance is the OJT training that is done and a tailboard is a very good place to make sure that even your greenest people know their role in the task at hand.
16 Human Performance Error Prevention Tools: TAILBOARDS WHY:Helps personnel to better understand what is to be accomplished and what should be avoided. They help personnel avoid surprises in the field and reinforce the idea that there are no routine tasks.Allows an interaction between members of the crew so that there is an understanding of each members roleDesignated ChallengerThe pre-job brief helps individuals to better understand what to accomplishand what to avoid. Pre-job briefings help participants avoid surprises in thefield and reinforce the idea that there are no “routine” activities.
17 WHAT should be covered: TAILBOARDSWHAT should be covered:Task PurposeDocumentation ReviewTask AssignmentsSafety Hazards and MitigationHuman PerformanceSpecial Requirements or Unusual ConditionsOperating ExperienceStop-Work CriteriaOversightQuestions1. Task purpose, scope, and nature of work2. Review of procedures, work package documents, drawings, turnover information, prerequisites, permits, etc. that will be used to complete the task3. Task assignments, identifying and understanding roles and responsibilities, qualifications, personal limitations, handoffs, and thecontrolling authority4. Safety hazards and mitigating methods:• identification of safety hazards• work procedures involved• special precautions• control of energy sources, including permits and clearances• personal protective equipment (PPE)5. Human performance, addressing HU Error Prevention tools for each critical step relevant to risks with industrial and environmental safety as well as risks to operations/production.6. Special requirements or unusual conditions (as applicable):• Resources, tools, and materialEnvironmental conditions (Hot, Cold, etc.)Environmental Hazards• Foreign material exclusion (FME) and housekeeping• Interfaces with other organizations• Interaction with other activities planned or in progress• Communication methods and potential obstacles to their effectiveness7. Operating experience, specifying how similar errors, events, or the causes of similar events will be avoided.8. Stop-work criteria, reviewing contingencies, changes in task conditions or its scope, and person(s) responsible for making critical decisions.9. Oversight, defining the degree of management and supervisory involvement10. Questions and concerns workers may have with the job
18 Human Performance Error Prevention Tools: TAILBOARDS S.A.F.E.RSelf ExplanatoryHelpful acronym to ensure the important components of a proper tailboard are covered.Tailboarding is a skill that is learned and developed over time.
19 Contractor in work area – situational awareness
23 WHAT: Tool #2 - STAR: (Self Checking) A “Self-Checking” tool where the performer pauses to focus his/her attention, reflects on the intended action and the associated outcome.Performer must have a sound knowledge of the task to know what to expect.The performer pauses to focus his or her attention, taking a moment to reflecton the intended action, the component, and its expected outcome. Theperformer thinks about whether the proposed action is the right action for thesituation. Again, it must be emphasized that the performer needs a soundtechnical knowledge to know what the right thing to do is. If uncertain, theperformer resolves any questions or concerns before proceeding. Whenprepared, the performer takes the action, followed by a review of the resultsof the action to decide if the right result was obtained.Attention varies. Human error is a specific action, and specific actions arerequired to avoid it. It is particularly effective for skill-based, repetitive tasks, which people can usually perform without a lot of conscious thought. But, attention must peak when the risk is greatest—when altering a component’s status. Consequently, rigor and care when using self-checking are essential. However, this technique also helps prevent errors when noting, recording, or entering data and performing calculations.
24 Human Performance Error Prevention Tools: STAR WHY:Helps the performer focus attention on the appropriate component, think about the intended action, understand the expected outcome before acting, and verifying the results.Boosts attention and thinking just before an action is performed.Self-checking helps the performer focus attention on the appropriatecomponent, think about the intended action, understand the expected outcomebefore acting, and verify the results after the action. When used rigorously,self-checking boosts attention and thinking just before a physical action isperformed.
25 Human Performance Error Prevention Tools: STAR WHEN should it be performed:When operating equipment.When performing test programs.When manipulating any controls.When entering data into a computer.When revising drawings.• When manipulating or altering plant equipment or controls• When entering plant data into a computer or recording it on a form• When performing a calculation• When revising drawings or procedures using cut-and-paste on a computer orby making handwritten annotations• Prior to and during an impending change in equipment status• When assembling components that contain similar parts that potentiallycould be interchangedADD LOB Specific Tasks where STAR would apply – Error likely tasks etc.
26 Human Performance Error Prevention Tools: STAR HOW should it be performed:Caution: If visual or physical contact with the object is lost, then self-checkagain the proper component to be manipulated.1. Stop – Pause.• Focus attention on the task’s immediate objective.• Eliminate distractions.2. Think – Understand what will happen when correct action is taken on thecorrect component.• Verify the action is appropriate, given the equipment status.• Understand the expected result(s) of the action.• Consider a contingency if an unexpected result occurs.• If uncertain, use the questioning-attitude tool.3. Act – Perform the correct action on the correct component.• Without losing eye contact, read and touch the component label.• Compare the component label with the guiding document.• Without losing physical contact, perform the action.4. Review – Verify anticipated result obtained.• Perform the contingency, if the expected result does not occur.• Notify supervisor, as needed.
27 Human Performance Error Prevention Tools: STAR How:Halt conversation prior to performing action.Perform one action at a time.Pause and self check between actions when performing multiple actions.Recognize when uncertainties or discrepancies exist and STOP.Personnel are alert and un-fatigued.Re-perform self check after loosing visual of physical contact.Ensure:• Workers understand the intent of a procedure step before performing it;workers understand a procedure before performing it• Workers reference the guiding document when self-checking• Workers pause and self-check between actions when performing severalmanual actions in succession• Workers perform one action at a time• Workers recognize when uncertainties or discrepancies exist, and do notperform the action• Workers halt conversations prior to performing the action• Workers limit themselves to looking at the component being manipulated• Workers re-perform self-checking after losing visual or physical contact• Workers are aware when the action to be performed is a critical step• Workers are alert and un-fatigued while performing a critical step• Workers take the time to verify that results are correct• Workers self-check when flagging is used
28 Human Performance Error Prevention Tools: Tool #3 Tool #3 – Three Way Communication:Fundamental Human Performance Error Prevention Tool where the communication originator (SENDER) verifies that the RECEIVER understands the message as intended. The RECEIVER ensures he/she understands what the sender is saying.Introduce WHAT – WHY – WHEN – HOW philosophy.
29 Human Performance Error Prevention Tools: 3-Way Communication WHAT:Fundamental Human Performance Error Prevention Tool where the communication originator (SENDER) verifies that the RECEIVER understands the message as intended. The RECEIVER ensures he/she understands what the sender is saying.Review Slide
30 Human Performance Error Prevention Tools: 3-Way Communication WHY:Promotes reliable transfer of information and understanding, which ensures correct subsequent action.WHEN should it be applied:When providing critical information.When providing equipment status.When directing operation of equipment.When directing others to perform a task.Ensures complete communication. Both sender and receiver are assured the message was communicated and understood.
31 3 Way Communication The initiator makes a statement. The participator repeats the statement in confirmation.The initiator confirms back that the statement is correct.The MessageCommunication involves a sender, the receiver, and a message. The person originating the communication is the sender and is responsible for verifying that the receiver understands the message as intended. Use 3-Way Communication in your radio conversations whenever important information needs to be conveyed such as,- Describing the operation or condition of equipment.- Carrying out steps of an approved procedure.- Task assignments.- Safety of personnel or the environment.3-Way Communication works like this:The sender states the message.The receiver repeats the message back. A message can be paraphrased in the receiver’s own words, but specific terminology and proper names are repeated word for word.The sender acknowledges the receiver’s reply by responding in one of two ways. If the receiver recited the message back correctly, the sender responds with an affirmation statement (“that is correct”). If the receiver did not recite the message back correctly, the senders says “that is not correct” (or words to that affect), then re-states the original message.This sequence is repeated as many times as necessary until the sender confirms the message was understood.
32 Human Performance Error Prevention Tools: 2-Minute Rule Tool #4 – Two Minute Rule:WHAT:A fundamental HP EPT that helps the worker develop an accurate understanding of the work environment, associated hazards, equipment condition/status, and other critical work site attributes.WHY is it important?:Improves situational awareness of the job site.Sometimes referred to as the “Job-Site Review” and “Take Two,” a carefullyperformed Two-Minute Rule review will take as much time as needed to helpthe worker develop an accurate understanding of critical indicators,system/equipment condition, the work environment, hazards, and even teammembers. Taking the time necessary to get acquainted with the immediatework area helps people establish a healthy sense of uneasiness, boosting theirquestioning attitude and enhancing the accuracy of their situation awareness.In addition to the Two-Minute Rule, the Job Hazard Analysis (JHA) form isthe tool used by all personnel to identify and control workplace hazards. The JHA form is to be completed at the worksite and reviewed by all personnel involved in the job prior to performing work. The JHA lists potentialhazards as well as potential controls for personnel to implement.
33 Human Performance Error Prevention Tools: 2-Minute Rule WHEN should it be performed?All work activitiesUpon arriving at the work location.During job walk down.After breaks, lunch, or other interruptions.Anytime conditions change.• Upon arriving at the physical work location.• Prior to interaction with risk-important equipment.• During a walk down.• When a potential safety hazard is present.• After extended breaks or interruptions, such as lunch.LOB Specific Examples.Ask participants for examples.
34 Human Performance Error Prevention Tools: 2-Minute Rule HOW:Explore the job site and adjacent areas.Talk with co-workersMitigate hazards1. Explore the job site for a few minutes by walking and looking around thework area (near the hands-on touch points) and adjacent surroundings toidentify conditions such as the following:• industrial safety and environmental hazards• trip-sensitive equipment to avoid jarring or disturbing• correct component• critical parameters or indicators important for task success• error precursors (at critical steps)• conditions consistent with the procedure and prejob briefing2. Talk with coworkers or the supervisor about unexpected hazards orconditions and the precautions to take.3. Eliminate hazards, install appropriate defenses, or develop contingenciesbefore proceeding with the task.
35 Four Mental States of Situational Awareness Tuned out - Unaware of surroundings. Mental Radar is off. OK at home, or on brief breaks at work when resting safely outside workzone away from all hazards.Scanning – Mental Radar is actively scanning 360° for hazards and anomalies and visualizing likely outcomes. Aim to spend most of your time in this state.Focused – You notice something, but may not know if it’s a hazard or not. You assess it, then either avoid it, or control it safely. Beware tunnel vision here.Red Alert – You’re aware of an imminent hazard. You’ve already prepped safe, decisive actions and back up plans. You control the hazard safely. No surprises.3535
37 The sniper’s mental state is Focused The sniper’s mental state is Focused. The spotter’s mental state is Scanning. Both communicate effectively with each other. The result? Situational Awareness that you can bet your life on.PrimarilyScanningPrimarilyFocusingCommunicating37Photo by isafmedia. Used with permission.37
38 We spend perhaps 95%+ of each typical day in only two of these mental states – Scanning and Focusing. One “secret” to Situational Awareness is to alternate between these two mental states when you work alone, and to ensure that team members coordinate the two states effectively when working on a team.Scanning – Mental Radar is actively scanning 360° for hazards and anomalies and visualizing likely outcomes. Aim to spend most of your time in this state.Focused – You notice something, but may not know if it’s a hazard or not. You assess it, then either avoid it, or control it safely. Beware tunnel vision here.
41 Human Performance Error Prevention Tools: Stop When Unsure Tool #5 – Stop When UnsureWHAT:When confronted with confusion or uncertainty, a person is in unfamiliar territory. Given that the chance for error is particularly high in such situations, the best course of action, when unsure, is to stop and get help from other people.WHY is it important?When confronted with confusion or uncertainty, a person is inunfamiliar territory. Given that the chances for error are particularlyhigh in such situations (1 in 2 to 1 in 10), the best course of action,when unsure, is to stop and get help from other people. Essentially,“Stop When Unsure” is a communication technique. It promptsperformers to gain more accurate information about the work situationfrom other knowledgeable persons before proceeding with theactivity. It involves a brief stoppage of work to allow workers, theirsupervisor, or other knowledgeable persons to discuss and resolve theissue before resuming the task.Help should come from those who possess the expertise, notnecessarily from those of higher rank or seniority. Contacting theimmediate supervisor is appropriate and necessary, but contactingindividuals with the experience or expertise with the situation wouldalso be beneficial. Only in the event that urgent action is needed toavoid imminent and serious consequences should action be taken(action that you are qualified to take) before supervision is contacted.Whenever a question arises and what to do remains uncertain, stopand ask! Every person has the responsibility and authority to STOPwork when uncertainty persists, even if it seems simple and straightforward. Things are not always as they seem. One station instituted apolicy that “You cannot answer your own question,” to promotecollaboration and group problem-solving.
42 Human Performance Error Prevention Tools: Stop When Unsure WHEN should it be performed?When uncertainty, doubt, confusion, or questions persistWhen encountering conditions inconsistent with the procedureIf beyond the scope of the plan or processWhen feeling distrustful of another individualWhen unexpected results or unfamiliar situations are encounteredWhen something expected does not happenWhen uncertain regarding compliance with expectations or proceduresWhen unfamiliar with an important work situationWhen inexperienced or lacking knowledge with a taskWhen someone else expresses doubt or concern• When uncertainty, doubt, confusion, or questions persist• If outside of conditions assumed by a technical procedure• When encountering conditions inconsistent with the procedure• When outside the bounds of key parameters• If beyond the scope of the plan or process• When feeling distrustful of another individual• When unexpected results or unfamiliar situations are encountered• When something expected does not happen• When uncertain regarding compliance with expectations orprocedures• When unfamiliar with an important work situation• When inexperienced or lacking knowledge with a task• When someone else expresses doubt or concernLOB Specific Examples.Ask participants for examples.
43 Human Performance Error Prevention Tools: Stop When Unsure HOW:Stop the activity.Place the equipment and the job site in a safe condition.Notify your immediate supervisor.Dismissing contrary evidence or points of view• Discounting the concerns of less experienced individuals• Not asking for help from more knowledgeable persons• Not asking for help for fear of embarrassment• Feeling inadequate if you have to ask for help• Emphasizing “who’s” right instead of “what’s” right• Thinking the task is “routine” or “simple”• Believing nothing bad can happen• Assuming “skill of the craft” is sufficient to address a situation• Not having clear abort criteria• Being unaware of critical attributes or critical parameters• Answering one’s own questions regarding a critical step
45 Human Performance Error Prevention Tools: Questioning Attitude Tool #6 – Questioning AttitudeWHAT:Attitude is a state of mind or a feeling toward a subject or object of interest.A questioning attitude promotes a preference for facts over assumptions and opinion. Questions such as “What if…,” or “Why is this acceptable?”Attitude is a state of mind or a feeling toward a subject or object ofinterest. A questioning attitude fosters situation awareness,encouraging thought about safety before action is taken. Beingmindful of the work situation helps a person maintain an accurateunderstanding of work conditions at any given time, avoiding blindspots. This tool alerts people to imminent hazards, warning signs, anduncertainties in the work environment or with the work plan andencourages the user to stop and resolve those hazards, warnings, oruncertainties before proceeding with the job. Doubt must be followedup with the discovery of facts, not assumptions, to reveal moreknowledge about the situation, which eliminates the doubt.Complacency and lack of knowledge undermine awareness. Mostpeople tend to assume everything is alright and that activities alwaysgo as planned. Also, a weak knowledge of fundamental sciences,theory, and equipment design has contributed to unawareness of whatis happening—“You don’t know what you don’t know.” People, ingeneral, are reluctant to fear the worst, and a healthy questioningattitude will overcome the temptation to rationalize away “gutfeelings” that something is not right.A questioning attitude promotes a preference for facts overassumptions and opinion. Questions such as “What if…,” or “Why isthis acceptable?” help improve recognition of improper assumptionsand possible mistakes. The structured approach described belowpromotes the discovery of facts. Facts depend on the reliability of theinformation source and the accuracy of that information. Facts areverifiable and visible expressions of behaviors and information.Without sufficient facts, the performer stops the activity to address anunpredictable work situation that could lead to either a seriousmistake or a significant event.A good prejob briefing enhances a person’s questioning attitude. Theprejob briefing sensitizes a worker to what should be and what shouldnot be. A well-prepared worker knows the potential hazards, criticalsteps, important parameters, and error-likely situations and theirpotential consequences before starting the work activity. Thisknowledge helps a worker more readily detect off normal situations.
46 Human Performance Error Prevention Tools: Tool #6 Tool #6 – Questioning AttitudeWHY is it important?:A questioning attitude fosters situational awareness, promotes a preference for facts over submission and opinion, and encourages thought about safety BEFORE action is taken. Without sufficient facts or verification, the performer stops the activity to address unexpected work situations that could lead to either a serious mistake or a significant event.Introduce WHAT – WHY – WHEN – HOW philosophy.
47 Human Performance Error Prevention Tools: Questioning Attitude WHEN should it be performed?During self-checking (Think step of STAR)Before performing an important step or phase of an activityWhen making a decision about an important activityWhen experiencing uncertainty, confusion, or doubtWhen experiencing a “gut feeling” that “something is not right”When encountering unanticipated changes in conditionsWhen conflicts or inconsistencies exist between plans, procedures and actual conditionsAfter encountering unexpected resultsAfter discovering missing information or resourcesUpon hearing danger words: “I assume,” “probably,” “I think,” “maybe,” “should be,”• Upon arriving at the physical work location.• Prior to interaction with risk-important equipment.• During a walk down.• When a potential safety hazard is present.• After extended breaks or interruptions, such as lunch.LOB Specific Examples.Ask participants for examples.
48 Human Performance Error Prevention Tools: Questioning Attitude HOW:Stop, Look, and Listen –Ask questions – Gather relevant information.Proceed if sure – Continue the activity if the uncertainty has been resolved with facts. Otherwise, do not proceed in the face of uncertainty!1. Stop, Look, and Listen – Proactively search for work situationsthat flag uncertainty (see When to Use the Tool).• Periodically pause—timeout—to check the work situation.• Pause when a flag is recognized.• Identify inconsistencies, confusion, uncertainties, and doubts.• State or verbalize the uneasiness or question in clear terms.2. Ask questions – Gather relevant information.• What are the “knowns” and “unknowns”?• Use independent, accurate, and reliable information sources,especially other knowledgeable persons.• Compare the current situation (knowns) with independentsources of information.• Consider “what if …?” and/or use a “devil’s advocate”approach in a spirit of helpfulness.• Identify persistent inconsistencies, confusion, uncertainties,and doubts.3. Proceed if sure – Continue the activity if the uncertainty has beenresolved with facts. Otherwise, do not proceed in the face ofuncertainty!
49 Human Performance Error Prevention Tools: Questioning Attitude Perception, Comprehension, and Projection.SCANFOCUSACT.A shorter way of saying it
50 Situational awareness Example of good sit awareness – Stinger would have hit pole
52 What do you see in this picture that you could questioning attitude? How would you proceed?“If the oil level is low, do not attempt to remove Bay-O-Net fuses or operate transformer breakers or switches. Deenergize at another location.
53 Human Performance Error Prevention Tools: Phonetic Alphabet Tool #7 – Phonetic AlphabetWHAT:Several letters in the English language sound alike and can be confused in stressful or noisy situations. The Phonetic alphabet specifies a word for each letter of the alphabet reducing the likelihood that the letters will be confused.Several letters in the English language sound alike and can be confusedin stressful or noisy situations. The phonetic alphabet specifies a wordfor each letter of the English alphabet. By using a word for each letterthere is less chance that the person listening will confuse the letters. Forexample, some letters sound alike when spoken and can easily beconfused such as "D" and "B". Using the phonetic alphabet, "Delta" and"Bravo" are more easily differentiated. The effects of noise, weaktelephone or radio signals, and an individual’s accent are reducedthrough the use of the phonetic alphabet.
54 Human Performance Error Prevention Tools: Phonetic Alphabet Review the letters
55 Human Performance Error Prevention Tools: Phonetic Alphabet WHY is it important?:The phonetic alphabet can reduce the effects of noise, weak telephone or radio signals, or even a person’s accentWHEN should it be performed?When communicating alpha numeric informationWhen specifying phase or channel designationsWhen a sender or receiver may misunderstand the designations of an order
56 Human Performance Error Prevention Tools: Phonetic Alphabet HOW to use the Phonetic Alphabet?:Speak distinctly and slowlyUse terms like “Stop” , “Correct”, “Wrong”Do Not use Slang TermsWhen communicating operational information important to safety,people can use key words to convey specific meanings. For instance,individuals use the term “STOP” to immediately terminate any action oractivity to avoid harm. “CORRECT” confirms understanding.“WRONG” conveys an incorrect understanding of the meaning of theintended message. Similarly, other words can be reserved for specialmeanings related to the organization’s operational activities.
57 Human Performance Error Prevention Tools: Tool #8 Tool #8 – Procedure Use and AdherenceWHAT:Understanding the overall purpose and strategy of approved procedures, promotes a safe reliable outcome. Adhering to approved procedures helps to dispel doubt and provides clarification regarding questions in the execution of various tasks and dutiesProcedure adherence means understanding the procedure’s intent andpurpose and following its direction. The user performs all actions aswritten in the sequence specified by the document. However, if itcannot be used as written, then the activity is stopped, and theprocedure is corrected before continuing. Following the procedurewithout question does not guarantee safety because proceduressometimes contain hidden flaws. But, understanding the overallpurpose and strategy of the procedure promotes safer outcomes.Ideally, adhering to procedures keeps the plant’s configuration withinits safety analyses and licensing requirements.
58 Human Performance Error Prevention Tools: Procedure Use and Adherence WHY is it important?:Procedure quality is paramount to safety and reliability. The completeness, accuracy, and internal consistency of the instructions, and its usability (easy to understand and follow) all impact the user. Procedures have been written over the years based on experience and proven uses of equipment. Procedures MUST be followed. Short cuts are often precursors of errorContinuous Use – for complex or infrequent work activities forwhich consequences of an improper action could have immediate,possibly irreversible impact on safety, production, or reliability:- Read and understand each step before performing the step.- Complete each step before starting the next step.- Complete the steps as written in the sequence specified.- Use a placekeeping method.- Keep the document in the user’s presence continuously.
59 Human Performance Error Prevention Tools: Procedure Use and Adherence WHEN should it be performed?When manipulating, altering, monitoring, or analyzing equipmentWhen a procedure exists for a work activityWhen requiredWhen manipulating, altering, monitoring, or analyzing equipment• When a procedure exists for a work activity• When required
60 Human Performance Error Prevention Tools: Procedure Use and Adherence HOW:Make sure you have the correct procedure or SW log and it has been checkedReview the procedure or SW log before starting work, confirming understanding of the procedure’s overall purpose and expected outcome. Make any changes/revisions before you start switching.Follow the procedure as written without deviation being aware of the potential impact the action can have on equipment.1. Explore the job site for a few minutes by walking and looking around thework area (near the hands-on touch points) and adjacent surroundings toidentify conditions such as the following:• industrial safety and environmental hazards• trip-sensitive equipment to avoid jarring or disturbing• correct component• critical parameters or indicators important for task success• error precursors (at critical steps)• conditions consistent with the procedure and prejob briefing2. Talk with coworkers or the supervisor about unexpected hazards orconditions and the precautions to take.3. Eliminate hazards, install appropriate defenses, or develop contingenciesbefore proceeding with the task.
61 Human Performance Error Prevention Tools: The Four Tools The Eight Human Performance Tools:Tailboards (Job Briefs)S.T.A.R. – Stop, Think, Act, ReviewAlso known as “Self-Verification”Three-way communicationTwo-Minute RuleStop When UnsureQuestioning AttitudePhonetic AlphabetProcedure Use and AdherenceShow slide and review.
62 Individuals Leaders Organization Human Performance Error Prevention Tools: The Working ConnectionEach employee has a role and a responsibility in error prevention, at all levels in an organization.IndividualsShow slideLeadersOrganization
63 Human Performance Error Prevention Tools: Individuals Role of the Individual:Apply and use Error Prevention Tools.Coach and reinforce use of EPTs with others.Show slide and review bullets
64 Human Performance Error Prevention Tools: Visibility Role of Visibility between Peers and Leaders:ObservationsRole modelingReinforcing expectationsCoachingRecognitionBrother’s KeeperShow slide and review bullets
65 This is what we want to strive for. Success and a happy crew.
66 Human Performance Make it a Habit The prevention of errors generally depends more on people, either the performer or other people. Self-checking and adhering to established procedures provide individuals with the means of avoiding mistakes, while peer checking (observations) and three-way communication engage another person. Human performance tools are designed to help people anticipate, prevent and catch error precursors while helping the performer maintain positive control.Event investigation root cause(s) are most always related to lack of use of one or more of the HP EPTs.If you come away with one message let it be this:“ENGAGE YOUR BRAIN”“Have your head in the game.”