1. Human Performance Fundamentals
Turning Defense into Offense
Human Performance Fundamentals

2. Introductions
Name
Position
Location
Time on job
Expectations

3. Housekeeping Restrooms Exits (fire assembly area) Breaks Cell Phones
Parking Lot
Safety Note

4. Purpose of this Training
To reduce the frequency and severity of events and improve operational performance.
Senior Management Quote Here

5. At (your company name here), we value safety
HP Tools and Concepts
Error free = event free
Event-Free Clocks
Goal is ZERO accidents

6. Why Learn this at (your company name here)?
Values: what we care about most; our beliefs.
Culture: all the common values of the company. These influence everyone’s attitudes, choices, and behavior.
Performance Improvement: we can anticipate an error-free workplace

7. Training Objectives Describe the types and causes of human error
Describe human performance concepts and principles
Apply the principles of human performance in a case study
Identify the human performance tools
Apply the appropriate tools in work situations

8. Types and Causes of Human Error
Module 1
Types and Causes of Human Error

9. Defining Human Performance
Department of Energy (DOE)
Concepts
Principles
System
Not step-by step process
Behaviors

10. Little Things Lead to Big Things!1 10 30
600

11. Layers of Responsibility Contributing to Human Performance
Individuals
Leaders
Organization

12. The Elements that Impact Human Performance
It is a system of interdependencies

13. Counting Exercise
Read the following sentence and count the number of F’s you find.

14. Counting Exercise
FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF YEARS.

15. Counting Exercise
FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF YEARS.
Did you find six?

16. Reading Exercise
Clearly read the following paragraphs.

17. Reading Exercise
Aoccdrnig to rscheearch at Cmabrigde Uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are wirttn, the olny iprmoetnt tihng is that the frist and lsat ltteer be at the rghit pclae.
The rset can be a total mses and you can sitll raed it wouthit porbelms. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. Amzanig huh?

18. Types of Errors:
Active Error – An obvious mistake that has immediate, visible consequences.
Latent Error –
A hidden mistake that has consequences that are not immediate. *
(Seat belts are a good idea)

19. How we commit errors Human Error Unintended Action Intended Slip Lapse
Mistake
Attention Failure
Intrusion, Omission,
Misorder, Mistiming
Planning Failure
Misapplication of good rule
Application of bad rule
Violation
Memory Failure
Forgetting intention
Lost place
Omitting planned item
Mis-order, Mistiming
Shortcuts

20. Human Information Processing
Shared Attention Resources
Sensing
Thinking
Acting
Information Flow Path
Source: Wickens, 1992

21. Performance Modes Error Rate Reduction Attention (to task)
High
Low
Attention (to task)
1 in 10
Knowledge Based
Patterns
Error Rate Reduction
Inaccurate Mental Picture
1 in 100
Rules Based
If - Then
1 in 1,000
Misinterpretation
Source: James Reason. Managing the Risks of Organizational Accidents, 1998.
Skills Based
Auto
Inattention
Familiarity (w/ task)
Low
High

22. Error Traps produce an error-likely situation
Human Nature
Error Traps
Task Demands
Error Traps
Error Traps produce an error-likely situation
Work Environment
Error Traps
Individual Capabilities
Error Traps

23. Recognize and work with it.
Sometimes we’re up and
sometimes we’re down!
Recognize and work with it.

24. Event Causation

25. Human Performance Concepts and Principles
Module 2
Human Performance Concepts and Principles

26. Five Principles of Human Performance
People are fallible.
Error situations are predictable.
Organization influences behavior.
Reinforcement effects performance.
Understanding the past helps avoid events.

27. Layers of Responsibility Contributing to Human Performance
Individuals
Leaders
Organization

28. Behavior vs. Result Which shooter had better “results”? 5 4 3 2 1 5 4

29. Performance Formula Behavior: the way you do your job
Results: getting your job done
Performance: everyone succeeding together

30. Functions of Defenses Create Awareness Detect and Warn Protect Recover
Contain
Enable Escape

31. Defense in Depth

32. Sources of Latent Organizational Weakness
Processes
Control of work
Training
Accountability policy
Equipment design
Process development
Use of work force
Values
Priorities
Measures & controls
Coaching & teamwork
Rewards & sanctions
Reinforcement

33. Applying the Principles
Module 3
Applying the Principles

34. Develop Case Study/Video for your Organization

35. Questions on the Case Study
What were the consequences of this event, short and long range, and what was their significance?
What were some of the latent organizational weaknesses?
What defenses were removed or flawed?
What values or organizational beliefs may have contributed to the event?
What were some of the error traps?
What can we learn from this case study?

36. Human Performance Tools
Module 4
Human Performance Tools

37. Error-Prevention Tools
1. Self-checking - S.T.A.R.
2. Peer-checking - Team S.T.A.R.
3. Three-Way Communication
4. Pre-Job Briefing (FKA Tailboard)
5. STOP if Unsure
6. 2-Minute Drill

38. Error-Prevention Tools (continued)
7. Questioning Attitude
8. Turnover
9. Place Keeping
10. Flagging
11. Phonetic Alphabet
12. Conservative Decision Making

39. Error-Prevention Tools (continued)
Procedure Use and Adherence
Concurrent Verification
Post-job Review
Management Tools include:
1. Observations
2. Self-Assessments
3. Operating Experience

40. Self-Checking - S.T.A.R STOP – Is my attention focused on the task?
THINK – What action am I about to perform?
ACT – Am I performing correctly?
REVIEW – Did I get the expected results? *

41. Peer-Checking Team S.T.A.R
Use a second set of eyes to detect and correct.
Both individuals actively participate in task performance.
Use this tool prior to the performance of critical tasks.

42. Sometimes we just blow it!

43. 3-Way Communication
Helps you verify that the correct information is transferred.
Used during the execution of critical steps to formalize the communication.
Repeat-back is required when obtaining a clearance or a switching order.
Regulatory requirement in certain situations
Critical transactions (i.e. communicating to control personnel)

44. 3- Way Communication
What Dennis said (as he was leaving the room):
“Don, turn off the foam machine”
What Don heard:
“Don’t turn off the foam machine.”

45. The Result

46. Pre-Job Briefing What is the task to be accomplished?
Who’s doing what?
How will we communicate?
What safety equipment do I need?
What is the worst thing that could happen and how am I going to prevent it?
Will add link to APS P-JB video when it is published.

47. STOP if Unsure If you have a feeling something is not right – Stop!
If you are not positive of the course of action or the outcome of your actions – Stop!

48. Two-Minute Drill Initial worksite assessment.
Use after a break or distraction.
Helps to reset and verify work conditions.
Provides a chance to assess changing workplace hazards at the workplace.
Will add link to APS 2-Minute Drill video when it is published.

49. Questioning Attitude Challenges assumptions
Stimulates a healthy skepticism
Vigilance when things don’t seem right
Being open to challenges by others
Use when uncertain, confused, doubtful

50. Turnover Information/awareness continuity Accurate transfers
Transferring responsibilities
Over communicate – Don’t assume
Record information – Ensure accuracy
Ask clarifying questions

51. Place Keeping Prevents step duplication or omission
Records step completed and yet to be performed
Use during Switching and Clearance procedures
Circle & Slash the step number, sign or initial a blank or, check a box

52. Flagging Correct equipment identification
Alerts others that equipment is unavailable
Shields components from inadvertent use
Used on similar–looking equipment
Mandates use of peer and self-checking
Remains in place until work is complete

53. Phonetic Alphabet Provides understandable difference between letters
Use when letters might sound alike
Use in high noise areas
Use at times of poor radio/telephone reception

54. Standard Phonetic Alphabet

55. Conservative Decision Making
Deliberate and methodical
Clarifies goals and options
Planning
Resources and expertise
Minimize uncertainty
Facts only – challenge assumptions

56. Procedure Use & Adherence
Understand a procedure’s intent and purpose and follow its direction.
Perform all actions as written.
Stop if procedure cannot be used as written.
Procedure may be corrected before continuing.
Expectation: Frequent document use instead of memory and recall.

57. Concurrent Verification
Separate confirmation by two individuals
Error prevention on equipment status/condition changes
Independent conclusions by all parties
Verifier takes no cues from performer
Not Peer Checking

58. Post-job Review Identifies what went well
Identifies potential improvements
Allows feedback from active participants
Identifies actual versus planned outcome
Determines future changes in similar tasks
Reviews lessons learned

59. Module 5
Apply the Tools

60. How valuable is good communication?
German Coast Guard Film

61. Kids football team film

62. Objective Review Describe the types and causes of human error
Describe human performance concepts and principles
Apply the principles of human performance in a case study
Identify the human performance tools
Apply the appropriate tools in work situations

63. “What’s the worst that could happen and how am I going to prevent it?”
The Big Question
Questioning Attitude
“What’s the worst that could happen
and how am I going to prevent it?”

64. Your turn
Questions?

65. Thank You

66. Knowledge Check Complete the knowledge check on your own.
Knowledge Check
Complete the knowledge check on your own.
XX% minimum is required.
You may use your notes.
Time limit: XX minutes.