0. Human Performance Improvement
Principles for Managers
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1. Course Objective
Management will be able to create an environment where workers can make good decisions by:
Recognizing the role of the individual and human fallibility in human performance
Identifying how organizational systems influence human behavior
Embracing the role of the leader to manage organizational systems and positively influence human behavior
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2. When Good Pets Go Bad
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3. Human Performance
“People do not operate in a vacuum, where they can decide and act all-powerfully. To err or not to err is not a choice. Instead, people’s work is subject to and constrained by multiple factors”.
— Sidney Dekker
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4. What is Human Performance?
An individual…
working within
organizational systems…
to meet expectations
set by leaders.
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5. How to Improve Human Performance
Reinforce desired behaviors
Remove error traps
Create error-tolerant systems
Address limitations of human nature
Individual
Incentives to meet leader’s expectations
Organization
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6. Definitions
Operational Upset: A condition that adversely affects, or may adversely affect, DOE or contractor personnel, the public, property, environment or the DOE mission.
Error: An unintentional deviation from an expected behavior.
Violation: Deliberate, intentional acts to evade a known policy or procedure requirement for personal advantage usually adopted for fun, comfort, expedience, or convenience
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7. HPI Principles People are fallible
Error-likely situations are predictable
Individual behaviors are influenced
Operational upsets can be avoided
People achieve high levels of performance based encouragement and reinforcement.
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8. People are fallible, and even
The Individual
HPI Principle #1:
People are fallible, and even
the best make mistakes.
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9. Origins of Human Error Human Errors Operational Upsets
System Induced Error
Operational Upsets
Slip, trip or lapse
Human Error
Equipment Failures
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10. Basketball Count the number of passes between white-shirted players
You MUST be accurate
PAY ATTENTION!
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11. Limitations of Human Nature
Mistakes arise directly from the way the mind handles information, not through stupidity or carelessness.
— Dr. Edward de Bono
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12. Limitations of Human Nature
See page 4 in your Concepts Guide
Stress
Avoidance of mental strain
Inaccurate mental models
Limited working memory
Limited attention resources
Mind set
Difficulty seeing own errors
Limited perspective
Susceptible to emotion
Focus on the goal
Fatigue
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13. Hazardous Attitudes Pride: “Don’t insult my intelligence.”
See page 6 in your Concepts Guide
Pride: “Don’t insult my intelligence.”
Heroic: “I’ll get it done, by hook or by crook.”
Invulnerable: “That can’t happen to me.”
Fatalistic: “What’s the use?”
Bald Tire: “Gone 60K miles without a flat yet.”
Summit Fever: “We’re almost done.”
Pollyanna: “Nothing bad will happen.”
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14. Risk
“Risks that you can control are much less a source of outrage than risks you can NOT control.”
— Peter Sandman
… in other words, the risks that scare people and the risks that actually kill people are very different
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15. Performance Modes
See page 7 in your Concepts Guide
When switching from one performance mode to another a worker is presented with a new situation but has only old information on which to base decisions.
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16. Error-likely situations are predictable, manageable, and preventable.
Error Traps
HPI Principle #2:
Error-likely situations are predictable, manageable, and preventable.
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17. Saw StopTM
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18. Error Precursors See page 18 in your Concepts Guide Task Demands
Limited short-term memory
Personality conflicts
Mental shortcuts (biases)
Lack of alternative indication
Inaccurate risk perception (Pollyanna)
Unexpected equipment conditions
Mindset (“tuned” to see)
Hidden system response
Complacency / Overconfidence
Workarounds / OOS instruments
Assumptions (inaccurate mental picture)
Confusing displays or controls
Habit patterns
Changes / Departures from routine
Stress (limits attention)
Distractions / Interruptions
Illness / Fatigue
Lack of or unclear standards
“Hazardous” attitude for critical task
Unclear goals, roles, & responsibilities
Indistinct problem-solving skills
Interpretation requirements
Lack of proficiency / Inexperience
Irrecoverable acts
Imprecise communication habits
Repetitive actions, monotonous
New technique not used before
Simultaneous, multiple tasks
Lack of knowledge (mental model)
High Workload (memory requirements)
Unfamiliarity w/ task / First time
Time pressure (in a hurry)
Task Demands
Individual Capabilities
Work Environment
Human Nature
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19. Error Prevention Tools
Self-checking
Peer-checking
Concurrent verification
Independent verification
Three-way communication
STAR
Pre-job briefing
Post-job briefing
Procedure use & adherence
Problem-solving
Questioning attitude
Conservative decision making
Stop & collaborate
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20. The Organization
HPI Principle #3:
Individual behavior is influenced by organizational processes and values.
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21. New vs. Old View of Human Error
Human error is a cause of accidents
To explain failure, investigations must seek failure
They must find people’s inaccurate assessments, wrong decisions and bad judgments
Human error is a symptom of trouble deeper inside a system…
To explain failure, do not try to find where people went wrong.
Instead, find how people’s assessments and actions made sense at the time, given the circumstances that surrounded them.
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22. The Dryden Event
Air Ontario Flight 363 Fokker F28 Dryden, Canada March 10, 1989
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23. Types of Error
See page 12 in your Concepts Guide
Active Errors change equipment, system or processes that trigger immediate undesired consequences.
Latent Errors result in undetected organization-related weaknesses or equipment flaws that lie dormant.
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24. Understanding Events Incentives are the cornerstone of human behavior
Dramatic events often have distant even subtle causes
Conventional wisdom is often wrong
Knowing what to measure and how to measure it makes a complex world much less complicated
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25. Organizational Processes
Workplaces and organizations are easier to manage than the minds of individual workers. You cannot change the human condition, but you can change the conditions under which people work.
— Dr. James Reason
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26. The Value of Error Tolerance
Error without consequence is a good thing — it shows that our systems are error-tolerant and that they are working.
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27. Defenses in Depth Redundancy: many layers of protection.
See page 14 in your Concepts Guide
Redundancy: many layers of protection.
Diversity: many different varieties of protection.
Independence: separate/autonomous layers of protection.
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28. Traditional Heisenberg Model
See page 16 in your Concepts Guide
Number of errors is relative to the severity of consequences
For every major accident there are many errors
Leads us to assume that driving down errors will eliminate major accidents
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29. New View of Heisenberg Model
The consequence of error has no relationship to the number of errors
It is related to the number and integrity of defenses
Any error can lead to a major accident if defenses fail
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30. Zero Operational Upsets
See page 20 in your Concepts Guide
Re + Md → OU
Reducing Error AND Managing Defenses leads to Zero Operational Upsets
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31. Medical Mistakes
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32. Organizational Values
HPI Principle #4:
Operational upsets can be avoided by understanding the reasons mistakes occur and applying the lessons learned from past events.
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33. Blame Cycle
See page 23 in your Concepts Guide
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34. Culpability Decision Tree
See page 26 in your Concepts Guide
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35. Accountability vs. Culpability
See page 40 in your Concepts Guide
Accountability
Culpability
The power to accomplish performance objectives
The blame for failure
vs.
A starting point for improvements
A dead end that discourages reporting
vs.
Arises from empowerment and partnership
Is disempowering and divisive
vs.
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36. Performance Culture
See page 28 in your Concepts Guide
Encourage Reporting: Value errors as leading safety data
Create a Just Work Environment: Don’t try and punish errors out of the system
Flexibility: Prepare workers to adapt effectively to changing demands
Learning: Create opportunities for observation, reflection and feedback
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37. Barriers to a Learning Organization
20 years of experience = 1 year of learning repeated 20 times
Experts use their informational advantage to reinforce their biases
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38. Human to Systems Interface
People will never perform better than what the organization will allow
If a system relies on people doing the right thing every time, it will fail
No working system remains in stasis
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39. The Leader
HPI Principle #5:
People achieve high levels of performance based largely on the encouragement and reinforcement received from peers, leaders, and subordinates.
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40. Fallacy of Competing Resources
See page 31 in your Concepts Guide
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41. How Leaders Influence Protection vs. Production
See page 33 in your Concepts Guide
What they pay attention to, measure, and control
Their reactions to critical incidents or crises
The allocation of resources
Their criteria for allocation of rewards and punishment
Their criteria for selection, advancement, and termination
Their deliberate attempts to coach or model behaviors.
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42. Reality Check
Safety values express how you desire safety to be in your organization.
Safety systems are real defenses and actionable programs that provide measurable safety data sets.
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43. Implementing HPI HPI is not just training
It is a way of doing business that includes:
Behavioral observation and walk-arounds
Conduct of operations and work management
Systems development and re-engineering
Issues reporting, management and corrective actions
Event investigation and lessons learned
Performance management and assurance
Simulations and training
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