1. Human Performance Improvement
Human Performance Improvement (HPI)
Orientation Briefing (1 hour)
This is a presentation on Human Performance Improvement.
Fluor has undertaken this HPI initiative at its large complex nuclear projects in order to improve communications, worker safety and operational reliability. The goal is to foster develop a highly reliable organization that focused on preventing and mitigating events.
HPI was developed in the US Nuclear Power Industry by the Institute of Nuclear Power Operators to address plant and system safety.
Fluor has adapted HPI to Health, Safety & Environmental programs as a safety culture improvement tool that engages the workforce in the planning stages of work to identify errors precursors and error likely situations, that if left unmitigated, could result in adverse events.
This presentations is a high level overview of the concepts of HPI used to introduce HPI concepts to the audience.

2. HPI Orientation Briefing– What you should hear in this briefing :
Basic HPI Concepts and Principles
Active Errors/Latent Errors
The “Anatomy of an Event” Model
Human Performance Principles
Common Error Precursors
Common Error- Prevention Tools
Defenses – The Swiss Cheese Model
Examples of Defenses
An analysis of events in the nuclear industry by INPO classified as significant 1995 through 1999 revealed that 3 of every 4 events were caused by human error.
The INPO study disclosed that “the risk is in the people- the way they are trained, their level of professionalism and performance, and the way they are managed.”
Human Performance is behavior plus results. Good results can be achieved with questionable behavior, however, for long-term sustained value-added results, one must look closely at behavior, what influences it, motivates it and shapes it.
HPI is designed to evaluate those organizational and administrative systems, values, job-site conditions that influence behaviors and affect the level of performance achieved by the organization.

3. Most accidents or injuries due to human error (not hardware failure)
HPI – Why?
Industry data shows -
Most accidents or injuries due to human error (not hardware failure)
Three out of four significant events due to human error
70 percent of those human errors are due to organization process weaknesses

4. HPI – Why?
Events
Minimize the frequency and severity of events, incidents, injuries
Evaluate Consequences, Manage Risks!

5. What we know about human error:
HPI – What we know…
What we know about human error:
It abounds in every industry
It is a major contributor to events, incidents and occurrences
It is costly, adverse to quality and safety
It impacts productivity
It is often due to process weaknesses , not from lack of skill or knowledge

6. HPI – Five Principles
People are fallible, and even the best make mistakes (~ 5/hr.)
Error-likely situations are predictable, manageable, and preventable
Individual behavior is influenced by organizational processes and values
People achieve high levels of performance through the encouragement and reinforcement received from leaders, peers, and subordinates
Events can be avoided by understanding the reasons mistakes occur
The Five Key Principles of HPI
Humans are fallible. We all make mistakes. Most go unnoticed because there are no negative consequences to them.
Errors are predictable. It is predictable that error rates will increase given certain stresses and situations.
Pilots flying in adverse weather conditions double their error rate. Consider fighter pilot’s error rates…even higher error rates. Yet airplanes are not falling from the skies each time the thunderstorms arise. Because errors and error-likely situations have been considered and Defenses, both physical engineered systems and administrative have been put in place to prevent or minimize the effects of human error.
Behavior is driven by the organization, the management, the paper, the job conditions. Everyone is part of the organization- worker, supervisor, manager, procurement, engineer, client.
Encouragement and reinforcement drive behaviors to achieve good or poor results.
Training and new operator to a procedure and testing him in a classroom he demonstrates knowledge. Paring the same new operator up with an experienced one, he learns “how work really gets done…” Which way do you think the new operator will perform the job over time?
Events can be avoided if we know where to look based on past performance.

7. HPI - Two Kinds of Errors
Active Error
Typical: Plant-touchers
Latent Error
Typical: Paper-touchers
(leading to latent conditions)

8. HPI - Anatomy of An Event
Error Precursors
Vision, Beliefs, &
Values
Latent Organizational Weaknesses
Mission
Goals
Policies
Processes
Programs
Flawed Defenses
Initiating Action

9. Individual Capabilities Work Environment Human Nature
HPI - Error Precursors
Task Demands
Individual Capabilities
Work Environment
Human Nature 2

10. HPI - Error Precursors – Short List
TASK DEMANDS
INDIVIDUAL CAPABILITIES
Time pressure (in a hurry)
Unfamiliarity with task / First time
High workload (memory requirements)
Lack of knowledge (mental model)
Simultaneous, multiple tasks
New technique not used before
Repetitive actions, monotonous
Imprecise communication habits
Irrecoverable acts
Lack of proficiency / Inexperience
Interpretation requirements
Indistinct problem-solving skills
Unclear goals, roles, and responsibilities
“Hazardous” attitude for critical task
Lack of or unclear standards
Illness / Fatigue
WORK ENVIRONMENT
HUMAN NATURE
Distractions / Interruptions
Stress (limits attention)
Changes / Departures from routine
Habit patterns
Confusing displays or controls
Assumptions (inaccurate mental picture)
Workarounds / OOS instruments
Complacency / Overconfidence
Hidden system response
Mindset (“tuned” to see)
Unexpected equipment conditions
Inaccurate risk perception (Pollyanna)
Lack of alternative indication
Mental shortcuts (biases)
Personality conflicts
Limited short-term memory

11. HPI – Most Common Error Precursors
Time Pressure
Interpretation of Requirements
Unclear Roles and Responsibilities
Distractions, Interruptions
Work-arounds
Inaccurate risk perception
First time with task
Lack of knowledge
Technique not used before
Imprecise communication
Assumptions
Complacency, overconfidence

12. HPI – Common Error-prevention Tools
Pre-job Briefing
Self-checking
S.T.A.R.
Peer-checking
Three-way communication
Phonetic Alphabet
Post-job Briefing
Mental Models
Questioning Attitude
Situational Awareness
Procedure use & adherence
Stop when unsure

13. HPI - Error-prevention Tools - Pre-job Briefing
A pre-job briefing is a meeting of individual performers and their supervisor (or lead) conducted before performing a job to discuss the tasks, critical steps, hazards, and related safety precautions.
[Participants clarify the task's objectives, roles and responsibilities, and resources. Interaction among participants is mandatory]

14. HPI - Error-prevention Tools - Pre-job Briefing
A Dialog (SPEAK):
Safety Critical Steps?
Prior Performance?
Error-likely Situations?
Anticipate Worst-case Consequences (What can go wrong?)
Key Defenses?

15. HPI - Error-prevention Tools - Pre-job Briefing (your role)
Your Role in a PJB:
Be Prompt (on time)
Participate (add to the conversation)
Listen (pay attention to discussion)
Ask Questions
Prepare to Conduct Work Using Appropriate Controls

16. HPI - Error-prevention Tools – Post-job Briefing
A Post-job Briefing is a meeting conducted after a task is completed. In the post-job briefing, questions are asked to identify flawed defenses, error precursors, and weak organizational processes for future resolution.

17. HPI - Error-prevention Tools – Post-job Briefing
A Dialog (CLEAR):
Changes needed?
Lessons learned?
Errors left uncorrected?
Adequate resources?
Results not expected?

18. HPI - Error-prevention Tools – Self-Checking
Use of S-T-A-R:
Stop: focus on the correct component
Think: consider the intended action
Act: take appropriate action
Review: review results (as expected?)
Use as you prepare to work on components, systems or structures

19. HPI - Error-prevention Tools – 3-way Communication
Sender: state message to receiver
Receiver: reply with paraphrased message received
Sender: confirm or correct message as received (affirmative/negative)

20. HPI - Error-prevention Tools – Phonetic Alphabet

21. HPI - Error-prevention Tools – Mental Models
Situational Awareness:
Be aware of your surroundings, the jobsite conditions, and the existence of error-likely situations…..
Questioning Attitude:
Do not proceed in the face of uncertainty; base your actions on facts….

22. HPI - Defenses, Controls and Barriers- The ‘Swiss cheese’ model
The Reason model…“defense in depth”
Some holes due
to active errors
Other holes due to
latent (hidden)
conditions
Hazards
Incident or Event

23. HPI - Examples of Defenses
Training, qualification
Self-assessment
Procedures
Planning and scheduling
Fieldwork supervision
Problem reporting
Engineered safety features
Hazardous energy control (LO/TO)
Personnel protective equipment (PPE)
Reviews/approvals
Safety briefings