Human Performance Improvement A Case Study

Objectives Given a case study involving an emergency scenario, determine the Human Performance Improvement tools and techniques that should have been used to avoid errors. Mastery will be indicated during successful participation in instructor-led discussions of the emergency.

Learning Objectives LO01 Describe how Self-Checking can help workers avoid errors. LO02 Describe how Three-Way Communication can help workers avoid errors. LO03 Describe how a Questioning Attitude can help workers avoid errors. LO04 Describe how a Two-Minute Drill can help workers avoid errors. LO05 Describe how Place-Keeping can help workers avoid errors.

Learning Objectives LO06 Describe how use of the Phonetic Alphabet can help workers avoid errors. LO07 Describe how use of Stop When Unsure can help workers avoid errors. LO08 Describe how use of Procedure Use and Adherence can help workers avoid errors. LO09 Describe how use of Conservative Decision Making can help workers avoid errors.

Introduction The basic purpose of Human Performance Improvement (HPI) tools and techniques is to help the individual performer maintain positive control of a work situation. Positive control means that what is intended to happen is what happens, and that is all that happens. Before taking an action, a conscientious individual understands the significance of the action and its intended result.

Introduction Human performance tools deliberately slow things down to ultimately speed things up by avoiding delays that accompany events triggered by errors. The performer’s primary goal is to retain positive control at critical steps when error-free performance is essential for safety. Using these human performance tools does not guarantee perfect performance, but individuals can greatly reduce their chances of erring by using the tools thoughtfully and rigorously.

A Sample Set of Tools Self-Checking - Self-checking helps a performing individual to focus attention on the appropriate component or activity, think about the intended action, understand the expected outcome before acting, and verify the results after the action. Three-Part Communication - First, the sender gets the attention of the receiver and clearly states the message. Second, the receiver repeats back the message. Third, the sender informs the receiver whether the message is properly understood, or corrects the receiver.

A Sample Set of Tools Questioning Attitude - A questioning attitude fosters thought before action is taken and helps individuals maintain an accurate understanding of work conditions. Two-Minute Drill - Take time before starting a job to become aware of the immediate work environment, to detect conditions unanticipated by work planning and the pre- job briefing, and to confirm those that were.

A Sample Set of Tools Place-Keeping - Involves physically marking steps in a procedural document to control their orderly completion. Phonetic Alphabet - Using a word for each letter to reduce the chance that the person listening will confuse the letters. The effects of noise, weak signals, and accent are reduced. Stop When Unsure - Whenever a question arises and what to do remain uncertain – stop and ask.

A Sample Set of Tools Procedure Use and Adherence - Means understanding the procedure's intent and purpose, and following its direction and sequence. If the procedure cannot be used as written, then the activity is stopped, and the procedure is revised before continuing. Conservative Decision-Making - Personnel attempt to understand all possible effects of various alternatives and choose the one that best meets the needs within known constraints.

The Training Activities A series of preventable human errors led to devastating results is the runaway train event portrayed in the movie, “Unstoppable”. Actual events which served as the inspiration for the movie took place in May 2001 in mid- state Ohio (the film version uses Pennsylvania as the scene of the events).

The Training Activities Engine 8888 (“Crazy Eights”) was an engine operated by the CSX Railroad. It traveled on its own, with a chemically hazardous load, up to 47 mph for almost 2 hours from Toledo to 55 miles NW of Columbus. Only through the actions of three train personnel was the train eventually stopped.

The Training Activities The movie supplies several events of that day that are surprisingly similar to the events System Operators encounter in emergency situations. This training will explore how the application of human performance improvement tools and techniques would have prevented this tragic railroad event and also present opportunities for improving performance in our own departments.

The Training Activities This training will include watching a segment of the movie “Unstoppable” and then participating in a facilitated discussion of the human performance improvement opportunities during that segment. Your grade will be determined based on your participation in the discussions.

Enjoy the Show!