2. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 1 BNL Human Performance Improvement for Individual Contributors Presented by: John Benante Kerry Mirabella Facilitated By: Rob Fisher, President Fisher Improvement Technologies

3. Make it F.I.T! www.fisherit.com 2 Objectives This course is designed to increase our understanding of… Human performance fundamentals, Identifying the Traps & Triggers that affect performance and the Tools used to prevent error and how to apply them, This will improve our ability to… Recognize error traps, error-likely situations and error precursors, Reduce the errors that affect facility events, and Communicate human performance issues with other workers and management,

4. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 3 Workshop Details 1 Day Facilitated and interactive NOT a standard training session Be open to new ideas The workbooks are yours – the more you take notes – the better your long term outcome Have some fun!

5. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 4 Understanding Human Performance Systems model –Interconnectivity –Latent conditions –Need for multiple feedback loops Human error is a consequence not a cause –Need a systems approach to Human Performance

6. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 5 Human Performance as a System Guiding Principles Organizational values influence individual behaviors Performance is based on reinforcement and self-motivation Recognition that people are fallible Error-likely situations are predictable and preventable Events can be avoided by understanding causes and applying lessons learned

7. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 6 Alarms and Warnings Rules Protective Equipment and Devices Barriers, Guards and Engineered Safeguards Training DANGER! INCIDENT Gaps The “Swiss Cheese Model” Supervisor Defenses

8. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 7 Definitions Error An action or behavior (active or latent) that unintentionally : –results in an undesirable or unwanted condition, –leads a task or system outside of acceptable limits, or –Deviates from a set of rules or standards An Event is the Result!

9. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 8 When we come back we will discuss more definitions

10. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 9 Types of Errors Active Error - Errors that change equipment, system, or plant state triggering immediate undesired consequences. Latent Error - An error, act, or decision that results in organization related weaknesses or equipment flaws that lie dormant until revealed either by human error, testing, or self-assessment.

11. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 10 Definitions Inappropriate Action Human behavior that is inappropriate for a situation and can transform the situation into an event. An inappropriate action does not imply fault or blame. Note:There are often several inappropriate actions involved in an event. Inappropriate actions can be easily written in the format: WHO did WHAT instead of THE REQUIREMENT as stated WHERE

12. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 11 Definitions Time Pressure Distractive Environment High Workload First Time Evolution First Working Days After Days Off One-Half Hour After Wake-up or Meal Vague or Incorrect Guidance Overconfidence Imprecise Communications Work Stress Fatigue Peer Pressure Multi-tasking Off-normal Conditions Error Traps (Precursors) - An unfavorable condition at the job site or a characteristic of the task or an individual that increases the probability for error during a specific action

13. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 12 Definitions Task Demands precursors Specific mental, physical, or team requirements of a task or evolution. Human Nature precursors Generic characteristics of every human being that make individuals vulnerable to error under certain conditions Work Environment precursors General influences on task performance related to workplace, organizational, and cultural conditions. Individual Capabilities precursors Unique mental, physical, and emotional capabilities of a particular person with respect to a particular task Error-Likely Situation - A work situation in which there is a greater opportunity for error when performing a specific action or task due to error precursors. An error-likely situation typically exists when task-related factors exceed the capability of the individual (mismatch) at the point of “touching” the physical or paper plant.

14. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 13

15. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 14 Definitions Latent Organizational Weakness - Undetected deficiencies in the management control processes (e.g., strategy, policies, work control, training and resource allocation) or values (shared beliefs, attitudes, norms and assumptions) creating workplace conditions that can provoke errors (precursors) and degrade the integrity of defenses (flawed defenses). Defenses – Measures or barriers intended to protect against errors or hazards, mitigate consequences of a hazard, or promote consistent behavior.

16. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 15 Anatomy of an Event Event Latent Organizational Weaknesses Mission Goals Policies Processes Programs Initiating Action Flawed Defenses Error Precursors

17. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 16 Space Shuttle Columbia Before and after

18. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 17 Accident Investigation Report

19. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 18 Safe & Event Free Behaviors Individuals Individuals are responsible for: Communicating to create shared values and understanding Anticipating error-likely situations and actively using appropriate error prevention tools Confirming the integrity of defenses Improving personal capabilities

20. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 19 More About Errors… Active Error Conditions –Consequences often immediate –Focus mainly on the sharp-edge Active Failures - Errors Tend to be Variable Error Slips, Lapses, Mistakes Active Failures – Violations Violations are NOT Errors! They are intentional and conscious. Latent Errors –Tend to be Consistent Error –Consequences lie dormant-act in the future –Focus mainly on the soft-edge of control Latent Conditions Poor Design Unworkable Procedures Gaps in Supervision Clumsy Automation Shortfalls in Training Inadequate Tools or Equipment

21. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 20 A Violation is … An action or inaction that intentionally deviates from a set of rules. Violation

22. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 21 When we come back we will discuss Performance Modes

23. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 22 Errors, precursors, error likely situations

24. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 23 What are Traps, Triggers and Tools? Traps –Conditions or situations that people may fall into without recognizing it and cause and error, event or incident Triggers –observable actions or reactions, –a recognized thought or individual perception –or a “gut-feeling” that something isn’t right. Tools –Methods used to recognize and avoid traps and prevent errors, events and incidents Demands of Task Work Environment Individual Factors

25. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 24 Performance Modes Key Words Error Rate SKILL-BASED -- stored patterns HABIT of pre-programmed actions.Familiar (> 50 times)1 per Acting out of habit without Not Thinking1000 conscious thoughts. RULE-BASED -- rules accumulatedThere is a rule, via experience and training. and I KNOW there1 per Can be WRITTEN or VERBALis a rule100 KNOWLEDGE-BASED -- usingYou don’t Know1 in 2 analytical processes and stored knowledge. what to Has NOTHING to do with how smartYou don’t know!!!!!1 in 10 !!!! you are! You are uncertain how to proceed. This PERSON on this TASK at this TIME

26. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 25 Why is this important for people to understand? Helps them keep from “proceeding in the face of uncertainty” which causes many accidents and injuries Makes them aware of the probable failure rate of a task or action Helps them apply the right TOOL to prevent an error, accident or injury

27. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 26 Which Performance Mode Would You Rather Be in? Skills-based Rule-based Knowledge-based

28. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 27 Stress* High work load* Time pressure* Poor communications Vague or poor work guidance Overconfidence in work and/or abilities Infrequent or first time performing a task (new-to-job) Distractions First working day following time off > 4 days The end of a shift or work cycle (e.g. hours 13-16 in a shift or 60-64 in a week) * These “traps” also become “individual” drivers for end of shift or work cycle errors. Top 10 Error Traps…

29. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 28 Time Pressure, Stress & High Workload All feel the same to us –Feels like frustration –Muscles tighten –Deep breathing –Multiple minor errors –Sweating We cannot distinguish between them

30. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 29 Poor Communications, Vague Guidance, First Time or Infrequent task or Overconfidence All put the person in Knowledge–Based (KB) mode Poor communications (Verbal) – The part of the communication left out is the part the receiver is in KB mode on and the quality of communication is the primary responsibility of the sender Vague Guidance (Written) – The parts that are vague or missing keep the user in KB mode First Time / Infrequent Task – The parts of the task that they have never done or don’t remember are KB mode Overconfidence – Shrouds our ability to see when we enter KB mode

31. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 30 Distractions, >4 Days off, End of or Extended Shift Distractions – Split the shared resources the brain needs – its like working with half a brain! >4 days off – Our brains disengage and we need time to re-engage End of shift or extended shift – Fatigue or distractions become additional problems

32. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 31 Practice Assignment Write down at least two examples of error traps. –One work-related example –One outside of work example. Write down one example of where you shifted from skill-based to rule or knowledge-based performance mode.

33. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 32

34. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 33 What is happening in our bodies just after lunch?

35. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 34 Interim Summary Even though as humans we can make errors, being able to recognize the most frequent error-likely situations can help make them more predictable. Becoming familiar with the common error traps or precursors can help reduce the likelihood of error occurrence. Identifying our individual mode of performance (skills, rules, knowledge,), can help to predict when an error is more likely to occur.

36. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 35 BNL tools 1.Self-Checking (STAR) 2.Step – By – Step 3.STOP When Unsure & Seek Out 4.Verbal Communications Place-Keeping Peer Checking / Co-Worker Coaching Am I Ready Checklist

37. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 36 Use a Self-check… “Self-check” is a method to: –review the step to be performed, –potential and expected consequences –ensure proper identification of equipment to be manipulated –verification of desired results STAR is the tool for self-check at the operational level.

38. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 37 Applying STAR at every step… 1.STOP- PAUSE before performing the task step. FOCUS on attention to detail and eliminate distractions. 2.THINK-PRIOR to taking any action. VERIFY the action to be taken. POINT or TOUCH the correct component, equipment or system. VERBALIZE the intended actions and expected results. 3.ACT-PERFORM the intended action. 4.REVIEW-VERIFY that the actual response was the expected response.

39. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 38 This task step doesn’t make sense-I think I’d better STOP and ask for help. Step-by-Step (Procedure Adherence)… STOP when: –A step doesn’t make sense –A step won’t achieve desired results –Technical inaccuracies exist Work-arounds set the next user up for failure. Put the system in a safe condition, if appropriate, and contact your supervisor IMMEDIATELY to resolve the concern. If following a procedure conflicts with safety or reliability DO NOT “work around” procedures! This tool seeks to move you from knowledge to rule based performance mode

40. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 39 I wonder what this step means? Oh, don’t worry about it. Let me show you how we handle it. Obtain correct procedure-right revision! Ensure understanding prior to taking action. Prior to continuing an interrupted task or when changing locations within the sequence of the task, verify you’re at the right place and the right step. Keep your place in switching orders, clearances, and level one procedures by using initials, check marks or recording data. Use flagging or similar markings to identify the components, equipment or systems. Take ownership for procedure quality- submit needed revisions. Step-by-Step (Procedure Adherence)…

41. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 40 OOPPPS as a trigger... Outside of Procedures, Parameters, Processes, Situation STOP When Unsure and based on performance mode –SEEK OUT Help or –Use STEP by STEP “Knowledge-based” situations characterized by –finding yourself in a situation that you are not familiar with, or –where no procedure or process exists –losing track of where you are in a series or sequence of steps. (e.g. trouble-shooting)

42. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 41 STOP When Unsure and Seek Out … Independent information source. Documents Process controls People –Peer-check –Normally not part of the initial job or task. –Has knowledge or can act in a problem-solving role. –Minimize potential bias.  Performed PRIOR to taking action.  Co-worker verifies actions to be taken are correct.  “Looking out for each other.”  Monitor and challenge other’s actions and decisions.

43. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 42 When we come back we will discuss Communication

44. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 43 A little communication goes a long way

45. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 44 3-Way Communication – Clear, Concise, Complete… Use 3-Way Communication in operational activities. Note: Use verbatim-repeat back for high risk, critical importance, now situations! Create understanding during communication. Verify understanding - ask questions.

46. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 45 Improve Critical Communications… Avoid acronyms Use phonetics when identifying or operating system equipment. –AALPHA –BBRAVO –CCHARLIE –DDELTA Sender: “Yes-you want to operate valve 12(B) Bravo for washer 35(A) Alpha.”

47. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 46 Visual Communications Barricading is a physical obstruction such as tapes, ropes, cones, or A-frame type wood or metal structures intended to warn about and limit access to a hazardous area. Barricades are temporary and not to be used as permanent guarding. Flagging is a distinct form of marking that is used to identify isolation devices, valves, components or equipment to be worked on or manipulated, to ensure that people do not work on or manipulate the wrong isolation devices, electrical components or equipment that are similar in location and appearance. Flagging should be standardized and be a distinctive color Flagging DOES NOT indicate proof of positive isolation nor does it eliminate the need for independent verification of isolation.

48. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 47 Error Prevention Tools Placekeeping Placekeeping is a technique of clearly marking instructional steps in a document being used to control a work activity to indicate the completion status of the particular step. Steps which are not applicable are marked as “NA” (in accordance with the provisions of the specific procedure).

49. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 48 Error Prevention Tools Peer Checking Peer-checking is a technique that involves a second person checking the correctness of another person’s actions prior to that action. The fundamental principle is that human beings make mistakes and the involvement of a second person to check the first person’s actions provides a second barrier to prevent errors. Peer-checking does not relieve the performer of performing good self-checking. Effective application of both tools provides two barriers to human error.

50. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 49 Error Prevention Tools Co-Worker Coaching Co-Worker Coaching is a situation in which co- workers remind, advise, or assist each other to ensure the task is done correctly. Co-Worker Coaching is the process where an individual observes, questions and corrects (if necessary), or compliments the actions of another person.

51. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 50 Error Prevention Tools “Am-I-Ready” Checklist What Is It The “Am I Ready?” Checklist is a tool used as a personal pre- job briefing, immediately preceding the work activity. It consists of several questions to gauge the worker’s preparedness for the job. When To Apply This tool is used prior to performing any task that includes an error-likely situation and may be used during any task performance. This tool is used for self-briefings in which the frequency of the work activity is monthly or more frequent. Any job that appears as routine should incorporate the use of this checklist prior to start of the job to ensure complacency and overconfidence is not present.

52. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 51 Am I Ready? Take two minutes at the jobsite before work begins to answer these questions out loud Do I understand the task? (If we are not sure what we are to do, we should not be starting the task.) Can I do it safely? (Hazards, PPE, etc., can I get hurt or hurt someone?) What error traps or error likely situations do I have? (other side) What error reduction tools will I use and when? (STAR, Step-By-Step, STOP and Seek-out) What can go wrong? (How can I get into a situation that I shouldn’t be in and what am I going to do about it?) What’s the worst that can happen? (Significant consequence to people, equipment, or environment) What conditions stop this task? Am I qualified and ready to start?

53. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 52 Pre-job Briefings…. Conducted before the start of shop or field activities. Focused on the: –work activity of the crew –“upstream” and “downstream” operations –error traps. Be face-to-face, three-way communication. Test for misunderstandings

54. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 53 Pre-job Briefings Using S A F E … Summarize “what” are the critical steps. Anticipate “error likely situations” or traps. Foresee the consequences - “What is the “worst thing” that can happen?” Evaluate and apply error prevention defenses. Demands of Task - Physical & Mental Work Environment - Physical & Social Individual Capabilities - Physical, Knowledge & Experience

55. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 54 Pre-job Briefings always cover…. Expected job steps and outcome Hazards associated with the job Error traps Work procedures involved Special precautions Energy source needing control Personal protective equipment STOP work criteria

56. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 55 When we come back we will put it all together

57. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 56 Amazing accidents

58. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 57 How does it all fit…

59. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 58 Traps, Triggers, and Tools – Time Pressure Triggers –Anxiety –Losing appetite –Fast heart beat –Multiple minor errors –Impatience toward coworkers –Emotional outburst Triggers –Tight time schedule –Preoccupied with the task at hand –Doing more than one task at a time Tool –Self Check using S T A R Stop Think Act Review

60. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 59 Traps, Triggers, and Tools – Distractive Environment Triggers –Feeling pulled in too many directions –Not in control of the situation –Low level of concentration on each task Triggers –Frequent distractions –Leaving original job in the middle –Forgetting the condition when returning to a job –Making minor errors Tools –S T A R –Record the As-left Condition Recording the condition before you leave a task in the middle reduces the number of errors by 50% !

61. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 60 Traps, Triggers, and Tools – Vague or Incorrect Guidance Triggers –Guidance is inconsistent with past experience –Guidance is inconsistent with the established work practices and standards –Guidance is inconsistent with other documents Triggers (cont.) –Documents contain obvious, but minor, errors –Not using procedures in the field as required –Laughing at the errors in the procedures Tools –Step-By-Step –STOP when unsure Seek-Out Triggers – Documents are out-dated –Guidance is too vague to do the job –Guidance doesn’t match previous experience

62. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 61 Traps, Triggers, and Tools – Vague or Incorrect Guidance Mental Burden Trap Description –Mental burden causes us to forget things that are important –Mental burden is increased by age and experience Triggers –You were told something once (in training, by a foreman, etc.) and now you have to figure out when and how to apply it. Triggers (cont.) –You were told something earlier (in the procedure or the tailboard) and now you have to figure out when it applies. –You seem to be “forgetting” something Tools –Step-By-Step –STOP when unsure Seek-Out

63. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 62 Traps, Triggers, and Tools – Overconfidence Triggers –Tunnel vision (not assessing all options) –Bias (personal preference) –Mindset (no need for improvement, no need to follow procedures, etc.) –“I've been doing this 20 years” –I know what I am doing –Don’t worry about it –I’ve forgotten more about this than you will ever know –First-time evolution –Implied experience –Short time duration task –Time pressure Overconfidence Is a KILLER ! Tools –Step-By-Step and Seek-Out

64. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 63 Traps, Triggers, and Tools – First Time (or Infrequent) Task Triggers –Unfamiliar with the details –Not knowing the rules –Not knowing where to find information –A new task that has not been done before –You have little related experience –You have not done this task in over 6 months Tools –Step-By-Step and Seek-Out

65. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 64 5 Procedure Error traps to look for… Field Decisions Difficulty / Burden Vague or Misleading Information Conflicting Information Multiple or Embedded Actions

66. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 65 Field Decisions The procedure user must make a decision with little or no guidance for making that decision. Things to look for include: –IF…THEN statements without adequate criteria, –As Required, –As Desired, –As Appropriate, –If Needed. Any of these statements are a sign of a Field Decision

67. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 66 Difficulty / Burden Mental… –Taught once - must apply now –Stated earlier - must remember now Physical –Difficult tasks –Unnecessary or unreasonable tasks –Easy to shortcut –Contact with other organization –Has to stop and do something else or change procedures

68. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 67 Vague or Misleading Information Vague… –Vague Terms include abstract verbs, adjectives, and phrases. Certain terms that are normally considered vague may be acceptable, if the term has specific, defined meanings to the users Misleading Information… –Information that is incorrect; however it is difficult to detect due to its nature. –The most effective methods of discovery are walk-through and full scope verification. Other questions that you can ask include: –What does this step/title/chart mean? – Where does this information come from and is it the correct application?

69. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 68 Conflicting Information Actions that are required by procedural steps, but are contrary to the normal actions expected by the user. Conflicting instructions include inconsistent: –format, –words, –expressions, and –actions. This includes both internal to the procedure (same component with different names) and external to the procedure (referred to differently from procedure to procedure). Reverse acting valves and controls are also examples of conflicting instructions.

70. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 69 Multiple / Embedded Actions Multiple Actions include 3 or more discrete actions Embedded actions are those actions hidden in: –Notes, –Cautions, –Warnings, –Precautions & Limitations

71. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 70 Basic Problem Solving Approach 1.Define the problem 2.Identify possible causes 3.Collect and verify the data 4.Identify possible solutions 5.Determine the best solution 6.Implement the best solution

72. Fisher Improvement Technologies Make it F.I.T! www.fisherit.com 71 Objectives Check… Did We? Increase our understanding of… Human performance fundamentals, Identifying the Traps & Triggers that affect performance and the Tools used to prevent error and how to apply them, Improve our ability to… Recognize error traps, error-likely situations and error precursors, Reduce the errors that affect facility events, and Communicate human performance issues with other workers and management.