This is what we DON’T want. Doubtful there was a plan.

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.)

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 environment Ask questions: Why is HP improvement important to YOU? Personal Safety Family Equipment Damage System Operation Productivity What can influence = At Risk Behaviors Error Precursors Performance Modes Safety Barriers There are actually 16 tools. More will follow as our culture matures.

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.)

Lessons Lessons: Performance Improvement Overview
Human Performance Error Prevention Tools Start at a “HIGH” level with Company VISION and VALUES Work 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) STAR 3-Way Communication 2-Minute Rule Stop When Unsure Questioning Attitude Phonetic Alphabet Procedure Use and Adherence

What causes humans to fail
At Risk Behaviors Normally, humans make about ???? errors per hour. 5 errors per hour XXX COMPANY 20,000 employees x 5/hr 100,000 errors per hour 5 errors from Shane bush class If we have 20,000 employees in XYZ COMPANY, that is 100,000 errors per hour COMPANY WIDE.

What causes humans to fail
At Risk Behaviors This is made worse when the person: Is in a hurry Under a high workload Doing more than one thing at a time Doing the same thing over & over

Traps in the Work Environment
Distractions Interruptions Unplanned changes Error Precursors Those things that “set-up” a mistake to happen Task demands are greater than the worker’s abilities Confusing conditions make the job harder New techniques not used before Mental shortcuts Lack-of or unclear standards Illness / Fatigue Latent 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 content No indication of a specific process parameter illogical organization and/or layout Poor identification of displayed information controls placed too close together

Performance Improvement Overview: Common Error Precursors
Task Demands Individual Capabilities o High workload (memory requirements) o Unfamiliarity with task / First time o Time pressure (in a hurry) o Lack of knowledge (faulty mental model) o Simultaneous, multiple tasks o New technique not used before o Repetitive actions / Monotony o Imprecise communication habits o Irrecoverable actions o Lack of proficiency; Inexperience o Interpretation requirements o Unsystematic problem-solving skills o Unclear goals, roles, or responsibilities o “Can do” attitude for safety-critical task o Lack of or unclear standards o Illness or fatigue; general health Work Environment Human Nature o Distractions / Interruptions o Stress o Changes / Departure from routine o Habit patterns o Confusing procedure / Vague guidance o Assumptions o Confusing displays / controls o Complacency / Overconfidence o Work-arounds / OOS instrumentation o Mind set (intentions) o Hidden system responses o Inaccurate risk perception o Unexpected equipment conditions o Mental shortcuts or biases o Lack of alternative indication o Limited short-term memory In 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.

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 worker What: Changes in equipment or system When: Immediate Visible: 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 staff What: Changes to documents, processes, procedures When: Lies in wait Visible: No Can you give me some examples of an Active Error? Can you give me some examples of a Latent Error?

Performance Improvement Overview: When Safety Barriers Fail
Events occur if all barriers and the frontline fail... Employees Training Process Oversight Engineered Barriers Engineered Barriers When all barriers* fail = Defense in Depth fails = Errors (We Fail) *Organizational + Individual Field Employees are the last line of defense for supervision in the process. Your contribution to effective Human Performance is Critical The 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.

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.

Human Performance Error Prevention Tools

Human Performance Error Prevention Tools: Event Prevention
How do We Prevent Events? Anticipate, prevent, and catch errors at the job site: Work Preparation Work Performance Work Feedback Error Prevention Tools Develop and Implement Defense in Depth: Process Improvement Adequate Training Oversight Teamwork Remember the issues that cause events: (Refer to previous lesson – Performance Improvement Overview) At-Risk Behavior Error Precursors Performance Modes Failure of Defense in Depth Organizational Individual So then, how do we mitigate these error causing mechanisms? Tailboards JHA HP EPT Organizational Improvements Work Practices Process Procedures Training Observations Brother’s Keeper

The Eight Human Performance Tools: Tailboards (Job Briefs)
S.T.A.R. – Stop, Think, Act, Review Also known as “Self-Verification” Three-way communication Two-Minute Rule Stop When Unsure Questioning Attitude Phonetic Alphabet Procedure Use and Adherence Show slide and review.

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 supervisor Behavior 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.

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 role Designated Challenger The pre-job brief helps individuals to better understand what to accomplish and what to avoid. Pre-job briefings help participants avoid surprises in the field and reinforce the idea that there are no “routine” activities.

WHAT should be covered:
TAILBOARDS WHAT should be covered: Task Purpose Documentation Review Task Assignments Safety Hazards and Mitigation Human Performance Special Requirements or Unusual Conditions Operating Experience Stop-Work Criteria Oversight Questions 1. Task purpose, scope, and nature of work 2. Review of procedures, work package documents, drawings, turnover information, prerequisites, permits, etc. that will be used to complete the task 3. Task assignments, identifying and understanding roles and responsibilities, qualifications, personal limitations, handoffs, and the controlling authority 4. 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 material Environmental 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 effectiveness 7. 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 involvement 10. Questions and concerns workers may have with the job

Human Performance Error Prevention Tools: TAILBOARDS
S.A.F.E.R Self Explanatory Helpful acronym to ensure the important components of a proper tailboard are covered. Tailboarding is a skill that is learned and developed over time.

Contractor in work area – situational awareness

Contractor – Situational Awareness

A tailboard in action C

How would you tailboard this situation?

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 reflect on the intended action, the component, and its expected outcome. The performer thinks about whether the proposed action is the right action for the situation. Again, it must be emphasized that the performer needs a sound technical knowledge to know what the right thing to do is. If uncertain, the performer resolves any questions or concerns before proceeding. When prepared, the performer takes the action, followed by a review of the results of the action to decide if the right result was obtained. Attention varies. Human error is a specific action, and specific actions are required 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.

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 appropriate component, think about the intended action, understand the expected outcome before acting, and verify the results after the action. When used rigorously, self-checking boosts attention and thinking just before a physical action is performed.

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 or by making handwritten annotations • Prior to and during an impending change in equipment status • When assembling components that contain similar parts that potentially could be interchanged ADD LOB Specific Tasks where STAR would apply – Error likely tasks etc.

HOW should it be performed: Caution: If visual or physical contact with the object is lost, then self-check again 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 the correct 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.

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 several manual actions in succession • Workers perform one action at a time • Workers recognize when uncertainties or discrepancies exist, and do not perform 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

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.

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

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.

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 Message Communication 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.

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 carefully performed Two-Minute Rule review will take as much time as needed to help the worker develop an accurate understanding of critical indicators, system/equipment condition, the work environment, hazards, and even team members. Taking the time necessary to get acquainted with the immediate work area helps people establish a healthy sense of uneasiness, boosting their questioning attitude and enhancing the accuracy of their situation awareness. In addition to the Two-Minute Rule, the Job Hazard Analysis (JHA) form is the 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 potential hazards as well as potential controls for personnel to implement.

WHEN should it be performed? All work activities Upon 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.

HOW: Explore the job site and adjacent areas. Talk with co-workers Mitigate hazards 1. Explore the job site for a few minutes by walking and looking around the work area (near the hands-on touch points) and adjacent surroundings to identify 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 briefing 2. Talk with coworkers or the supervisor about unexpected hazards or conditions and the precautions to take. 3. Eliminate hazards, install appropriate defenses, or develop contingencies before proceeding with the task.

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. 35 35

Photo by isafmedia. Used with permission.
36 36

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. Primarily Scanning Primarily Focusing Communicating 37 Photo by isafmedia. Used with permission. 37

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.

Primarily Focusing Communicating Scanning

Neither Scanning nor Focusing
40

Human Performance Error Prevention Tools: Stop When Unsure
Tool #5 – Stop When Unsure WHAT: 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 in unfamiliar territory. Given that the chances for error are particularly high 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 prompts performers to gain more accurate information about the work situation from other knowledgeable persons before proceeding with the activity. It involves a brief stoppage of work to allow workers, their supervisor, or other knowledgeable persons to discuss and resolve the issue before resuming the task. Help should come from those who possess the expertise, not necessarily from those of higher rank or seniority. Contacting the immediate supervisor is appropriate and necessary, but contacting individuals with the experience or expertise with the situation would also be beneficial. Only in the event that urgent action is needed to avoid 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, stop and ask! Every person has the responsibility and authority to STOP work when uncertainty persists, even if it seems simple and straight forward. Things are not always as they seem. One station instituted a policy that “You cannot answer your own question,” to promote collaboration and group problem-solving.

WHEN should it be performed? When uncertainty, doubt, confusion, or questions persist When encountering conditions inconsistent with the procedure 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 or procedures When unfamiliar with an important work situation When inexperienced or lacking knowledge with a task When 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 or procedures • When unfamiliar with an important work situation • When inexperienced or lacking knowledge with a task • When someone else expresses doubt or concern LOB Specific Examples. Ask participants for examples.

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

Human Performance Error Prevention Tools: Questioning Attitude
Tool #6 – Questioning Attitude WHAT: 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 of interest. A questioning attitude fosters situation awareness, encouraging thought about safety before action is taken. Being mindful of the work situation helps a person maintain an accurate understanding of work conditions at any given time, avoiding blind spots. This tool alerts people to imminent hazards, warning signs, and uncertainties in the work environment or with the work plan and encourages the user to stop and resolve those hazards, warnings, or uncertainties before proceeding with the job. Doubt must be followed up with the discovery of facts, not assumptions, to reveal more knowledge about the situation, which eliminates the doubt. Complacency and lack of knowledge undermine awareness. Most people tend to assume everything is alright and that activities always go as planned. Also, a weak knowledge of fundamental sciences, theory, and equipment design has contributed to unawareness of what is happening—“You don’t know what you don’t know.” People, in general, are reluctant to fear the worst, and a healthy questioning attitude will overcome the temptation to rationalize away “gut feelings” that something is not right. A questioning attitude promotes a preference for facts over assumptions and opinion. Questions such as “What if…,” or “Why is this acceptable?” help improve recognition of improper assumptions and possible mistakes. The structured approach described below promotes the discovery of facts. Facts depend on the reliability of the information source and the accuracy of that information. Facts are verifiable and visible expressions of behaviors and information. Without sufficient facts, the performer stops the activity to address an unpredictable work situation that could lead to either a serious mistake or a significant event. A good prejob briefing enhances a person’s questioning attitude. The prejob briefing sensitizes a worker to what should be and what should not be. A well-prepared worker knows the potential hazards, critical steps, important parameters, and error-likely situations and their potential consequences before starting the work activity. This knowledge helps a worker more readily detect off normal situations.

Tool #6 – Questioning Attitude WHY 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.

WHEN should it be performed? During self-checking (Think step of STAR) Before performing an important step or phase of an activity When making a decision about an important activity When experiencing uncertainty, confusion, or doubt When experiencing a “gut feeling” that “something is not right” When encountering unanticipated changes in conditions When conflicts or inconsistencies exist between plans, procedures and actual conditions After encountering unexpected results After discovering missing information or resources Upon 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.

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 situations that 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 independent sources 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 been resolved with facts. Otherwise, do not proceed in the face of uncertainty!

Perception, Comprehension, and Projection. SCAN FOCUS ACT. A shorter way of saying it

Situational awareness
Example of good sit awareness – Stinger would have hit pole

Moved truck to not hit pole

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.

Human Performance Error Prevention Tools: Phonetic Alphabet
Tool #7 – Phonetic Alphabet WHAT: 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 confused in stressful or noisy situations. The phonetic alphabet specifies a word for each letter of the English alphabet. By using a word for each letter there is less chance that the person listening will confuse the letters. For example, some letters sound alike when spoken and can easily be confused such as "D" and "B". Using the phonetic alphabet, "Delta" and "Bravo" are more easily differentiated. The effects of noise, weak telephone or radio signals, and an individual’s accent are reduced through the use of the phonetic alphabet.

Review the letters

WHY is it important?: The phonetic alphabet can reduce the effects of noise, weak telephone or radio signals, or even a person’s accent WHEN should it be performed? When communicating alpha numeric information When specifying phase or channel designations When a sender or receiver may misunderstand the designations of an order

HOW to use the Phonetic Alphabet?: Speak distinctly and slowly Use terms like “Stop” , “Correct”, “Wrong” Do Not use Slang Terms When 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 or activity to avoid harm. “CORRECT” confirms understanding. “WRONG” conveys an incorrect understanding of the meaning of the intended message. Similarly, other words can be reserved for special meanings related to the organization’s operational activities.

Tool #8 – Procedure Use and Adherence WHAT: 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 duties Procedure adherence means understanding the procedure’s intent and purpose and following its direction. The user performs all actions as written in the sequence specified by the document. However, if it cannot be used as written, then the activity is stopped, and the procedure is corrected before continuing. Following the procedure without question does not guarantee safety because procedures sometimes contain hidden flaws. But, understanding the overall purpose and strategy of the procedure promotes safer outcomes. Ideally, adhering to procedures keeps the plant’s configuration within its safety analyses and licensing requirements.

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 error Continuous Use – for complex or infrequent work activities for which 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.

WHEN should it be performed? When manipulating, altering, monitoring, or analyzing equipment When a procedure exists for a work activity When required When manipulating, altering, monitoring, or analyzing equipment • When a procedure exists for a work activity • When required

HOW: Make sure you have the correct procedure or SW log and it has been checked Review 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 the work area (near the hands-on touch points) and adjacent surroundings to identify 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 briefing 2. Talk with coworkers or the supervisor about unexpected hazards or conditions and the precautions to take. 3. Eliminate hazards, install appropriate defenses, or develop contingencies before proceeding with the task.

Human Performance Error Prevention Tools: The Four Tools
The Eight Human Performance Tools: Tailboards (Job Briefs) S.T.A.R. – Stop, Think, Act, Review Also known as “Self-Verification” Three-way communication Two-Minute Rule Stop When Unsure Questioning Attitude Phonetic Alphabet Procedure Use and Adherence Show slide and review.

Individuals Leaders Organization
Human Performance Error Prevention Tools: The Working Connection Each employee has a role and a responsibility in error prevention, at all levels in an organization. Individuals Show slide Leaders Organization

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

Human Performance Error Prevention Tools: Visibility
Role of Visibility between Peers and Leaders: Observations Role modeling Reinforcing expectations Coaching Recognition Brother’s Keeper Show slide and review bullets

This is what we want to strive for.
Success and a happy crew.

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.”

This is what we DON’T want. Doubtful there was a plan.

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