Management Overview on Human Performance Improvement
Facilitators:Shane Bush, INL Brian Baskette, INPO
Purpose of Workshop
• Provide an overview of the principles, concepts, and benefits of Human Performance Improvement, or HPI (morning session, 9:00-12:00 noon)
• Provide an overview of the bases of HPI, and practical tools for implementing HPI (afternoon session, 1:00-4:30 pm)
Minimize the frequency and severity of events (i.e., occurrences)
Events
Purpose of Human Performance Improvement
21 out of 26 fuel-damaging accidents due to human error
Three out of four significant events due to human error
Greatest contributor to costs ?
70 percent of causes due to weaknesses in Organization
Why HPI in commercial nuclear?
Significant Events(commercial nuclear) Annual Industry Averages
2.38
1.66
0.85 0.880.77
0.460.28
0.08 0.04 0.03
0.30 0.300.21
0.1 0.07
0.0
0.5
1.0
1.5
2.0
2.5
3.0
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Sig
nifi
can
t Eve
nts
pe
r U
nit
Data Source: U.S. Nuclear Regulatory Commission
(Core Damage Potential)
Is 99.9% Good Enough?1 hour of unsafe drinking water per month
2 unsafe landings per day in Atlanta, GA.
50 dropped babies per day
116,000 lost pieces of mail per hour
20,000 incorrect drug prescriptions per year
22,000 checks deposited in wrong accounts per hour
0
1000
2000
3000
4000
5000
6000
1995 1996 1997 1998 1999 2000
OccurrenceReports
Occurrences
90% Involve Human Behavior(National Safety Council)
DOE Occurrence Reports and Occurrences 1995-2000.
• Dateline clip on medical mistakes
What do you Manage?
• Assets: people & the plant
• Hazard: human error
• Exposure: “People touching equipment”
• Risk: probability and consequences
• Control: error rate and defense-in-depth
Principles1. People are fallible, and even the best make mistakes.
2. Error-likely situations are predictable, manageable, and preventable.
3. Individual behavior is influenced by organizational processes and values.
4. People achieve high levels of performance based largely on the encouragement and reinforcement received from leaders, peers, and subordinates.
5. Events can be avoided by understanding the reasons mistakes occur and applying the lessons learned from past events.
Studies of Visual Awareness
[ Video Exercise ]
Defining Human Performance
5 443 32 2 11
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Target No.1Target No.1 Target No.2Target No.2
Two Kinds of Error
Active Error
(leading to latent conditions)
Latent Error
Anatomy of an Event
Event
Vision, Beliefs, &
Values
LatentOrganizationalWeaknesses
Mission
Goals
Policies
Processes
Programs
FlawedDefenses
ErrorPrecursors
InitiatingAction
Vision, Beliefs, &
Values
Insert DOE Example to illustrate Anatomy
Strategic Approach
1. Anticipate and prevent active error (Re) at the job-site.
2. Identify and eliminate latent organizational weaknesses (Md).
Re + Md ØE
Examples of Error-prevention Techniques
Turnover
Supervision
Placekeeping
Questioning attitude
Self-checking
Peer-checking
Three-way communication
Procedure use & adherence
Stop when unsure
Pre-job briefing
Examples of Defenses
• Training• Self assessment• Procedures• Planning and
Scheduling• Management
oversight• Regulatory oversight• Problem reporting
• Engineered safety features
• Personnel protective equipment
• Containment• Review and
approval• Performance
indicators
1. Facilitate open communication
2. Promote teamwork
3. Reinforce desired behaviors
4. Eliminate latent organizational weaknesses
5. Value prevention of errors
Leadership Practices
Q&AWrap-up
Welcome back!
[Add constant sorrow clip]
Job Site and the Individual
Inattention to Detail
[ Things Made in October ]
Traps of Human Nature 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 goal Fatigue
PARISIN THE
THE SPRING
BIRDIN THE
THE HAND
ONCEIN A
A LIFETIME
Phrase Recall Exercise
Source: Swain & Guttmann. Handbook of Human ReliabilityAnalysis with Emphasis on Nuclear Power Plant Applications.U.S. Nuclear Regulatory Commission (NUREG/CR-1278), 1983.
Error-likely Situation The Devil in the Details
Degree of mismatch due to:
Error likely Situation
Unintentionaldeviation frompreferred behavior
Job-Site Conditions:• Task• Individual
error precursors
Error Precursors
Task DemandsTask Demands
Individual Individual CapabilitiesCapabilities
Work Work EnvironmentEnvironment
Human NatureHuman Nature
• Limited short-term memory• Personality conflicts
• Mental shortcuts (biases)• Lack of alternative indication
• Inaccurate risk perception• Unexpected equipment conditions
• Mind-set• Hidden system response
• Complacency / Overconfidence• Workarounds / OOS instruments
• Assumptions• Confusing displays or controls
• Habit patterns• Changes / Departures from routine
• Stress• Distractions / Interruptions
Human NatureWork Environment
• Illness / Fatigue• Lack of or unclear standards
• “Unsafe” attitude for critical tasks• Unclear goals, roles, & responsibilities
• Indistinct problem-solving skills• Interpretation requirements
• Lack of proficiency / Inexperience• Irrecoverable acts
• Imprecise communication habits• Repetitive actions / Monotony
• New technique not used before• Simultaneous, multiple tasks
• Lack of knowledge (mental model)• High Workload (high memory requirements)
• Unfamiliarity w/ task / First time• Time pressure (in a hurry)
Individual CapabilitiesTask Demands
Error Precursors
OOS – out of service
Hazardous Attitudes
Pride - “Don’t insult my intelligence.”
Heroic - “I’ll get it done, hook or by crook.”
Invulnerable - “That can’t happen to me.”
Fatalistic - “What’s the use?”
Bald Tire - “Got 60K miles and haven’t had a flat yet.”
Summit Fever - “We’re almost done.”
Pollyanna - “Nothing bad will happen.”
Performance Modes
KBPatterns
RBIf - Then
SBAuto
Familiarity (w/ task)Low High
High
Low
Att
enti
on
(to
task
)
Inattention
Misinterpretation
Inaccurate Mental Picture
Sou
rce:
Jam
es R
easo
n. M
anag
ing
the
Ris
ks
of O
rgan
izat
iona
l Acc
iden
ts,
1998
.
Error-prevention TechniquesFlagging
Concurrent verification
Independent verification
Problem-solving
Conservative decision-making
Two-minute rule
Turnover
Supervision
Self-checking
Peer-checking
Three-way communication
Procedure use & adherence
Stop when unsure
Pre-job briefing
Questioning attitude
Placekeeping
Engineer Human Performance Techniques
Pre-job briefing / Task Assignment
Procedure use & adherence
Questioning attitude
Review and Verification
Problem-solving & Decision-making
Design review meetings
Signature
Supervisor Techniques
• Work planning
• Walkdown
• Task assignment
• Pre-job briefing
• Observation
• Performance management
• Post-job review
Team Errors “social loafing”
Halo Effect
Pilot / Co-pilot
Free Riding
Groupthink
Risky Shift
The Organization
To facilitate the accomplishment of the organization’s missionmission in accordance with its norms, values, and strategies.
SafetyTo consistently searchsearch for and eliminateeliminate conditions that provoke human error while reinforcing defenses.
Dual Purposes
Defenses
• Create Awareness• Detect and Warn• Protect• Recover• Contain• Enable Escape
Physical Administrative
Flawed defenses allow active errors or their consequences to occur.Source: Maurino (1995)
MANAGERIAL METHODS
TRAINING
WORK SCHEDULEWORK ORGANIZATION OR
SUPERVISORY METHODS
WRITTEN COMMUNICATIONS
CHANGEIMPLEMENTATION
VERBALCOMMUNICATIONS
DESIGN
WORK PRACTICES
ChallengesChallengesTo the PlantTo the Plant
ENVIRONMENTALFACTORS
EVENTS
Defense-in-
Depth
LeadershipProper Reactions
High Standards Reinforcement
Coaching
Questioning Attitude
Respectfor Others
Open & HonestCommunication
CompellingVision
HealthyRelationships
Courage &Integrity
Motivation
Example
Communication Practices / Plan
Reviews & Approvals
Change Mgmt.
Problem Solving
Scheduling / Sequencing
Clear Expectations
Role Models
Safety Philosophy
Task Allocation
Meetings
Rewards & Reinforcement
Trend Analysis
OE
Training
Handoffs
Accountability
Simple/effective Process Philosophy
Procedure Revisions
Work Planning
Corrective Action
Self-Assessment
Benchmarking
Equipment Labeling & Condition
Procedure / Work Package Quality
Worker Knowledge,Skill, & Proficiency
Fitness-for-Duty
Wary Attitude
Equipment Ergonomics & Human Factors
Tool Quality & Availability
Roles &Responsibilities
HousekeepingEnvironmentalConditions
Foreign Material Exclusion
Lockout / Tagout
Personal Motives
Intolerance for Error Traps Self-Checking Place-Keeping
3-Part Communication
DoubleVerification
Procedure Use& Adherence
Supervision
Management Monitoring
Stop WhenUncertain
Critical Parameters
Problem-SolvingMethodology
ConservativeDecision-Making
Team Skills
Peer-Checking
Safeguards Equipment
Reactor Protection Systems
Containment
QC Hold Points
Independent Verification
InterlocksPersonal Protective Equipment Alarms
Forcing Functions
Postjob Reviews
Problem Reports
Root Cause Analysis
Performance Indicators
PLANTRESULTS
JOB-SITECONDITIONS
ORGANIZATIONPROCESSES
& VALUES
WORKERBEHAVIOR
Pre-jobBriefing
Just-in-time Operating Experience
Task Preview
Turnover
Clearance Walkdown
Walkdowns
Performance Feedback
Task Assignment
HP Surveys
Task Qualification
Performance Model
RECALL: Anatomy of an Event
Event
Vision, Beliefs, &
Values
LatentOrganizationalWeaknesses
Mission
Goals
Policies
Processes
Programs
FlawedDefenses
ErrorPrecursors
InitiatingAction
Vision, Beliefs, &
Values
Latent Organizational Weaknesses (sources)
Values (relationships) Priorities Measures & controls Critical incidents Coaching & teamwork Rewards & sanctions Reinforcement Promotions &
terminations
Processes (structure) Work control Training Accountability policy Reviews & approvals Equipment design Procedure
development Human resources
Finding Latent Organizational Weaknesses
Self-Assessments Benchmarking Post-job Reviews Trending Document Reviews Surveys and Questionnaires Observations Root Cause Analysis
Leadership
LeadershipProper Reactions
High Standards Reinforcement
Coaching
Questioning Attitude
Respectfor Others
Open & HonestCommunication
CompellingVision
HealthyRelationships
Courage &Integrity
Motivation
Example
Communication Practices / Plan
Reviews & Approvals
Change Mgmt.
Problem Solving
Scheduling / Sequencing
Clear Expectations
Role Models
Safety Philosophy
Task Allocation
Meetings
Rewards & Reinforcement
Trend Analysis
OE
Training
Handoffs
Accountability
Simple/effective Process Philosophy
Procedure Revisions
Work Planning
Corrective Action
Self-Assessment
Benchmarking
Equipment Labeling & Condition
Procedure / Work Package Quality
Worker Knowledge,Skill, & Proficiency
Fitness-for-Duty
Wary Attitude
Equipment Ergonomics & Human Factors
Tool Quality & Availability
Roles &Responsibilities
HousekeepingEnvironmentalConditions
Foreign Material Exclusion
Lockout / Tagout
Personal Motives
Intolerance for Error Traps Self-Checking Place-Keeping
3-Part Communication
DoubleVerification
Procedure Use& Adherence
Supervision
Management Monitoring
Stop WhenUncertain
Critical Parameters
Problem-SolvingMethodology
ConservativeDecision-Making
Team Skills
Peer-Checking
Safeguards Equipment
Reactor Protection Systems
Containment
QC Hold Points
Independent Verification
InterlocksPersonal Protective Equipment Alarms
Forcing Functions
Postjob Reviews
Problem Reports
Root Cause Analysis
Performance Indicators
PLANTRESULTS
JOB-SITECONDITIONS
ORGANIZATIONPROCESSES
& VALUES
WORKERBEHAVIOR
Pre-jobBriefing
Just-in-time Operating Experience
Task Preview
Turnover
Clearance Walkdown
Walkdowns
Performance Feedback
Task Assignment
HP Surveys
Task Qualification
Leader’s Role
Competing Resources
Source: James Reason. Managing the Risks of Organizational Accidents, 1997 (in press).
Pre
ven
tio
n
Productiont0
tn
new plant state
plant eventAcc
iden
t
Bankr
uptcy
1. Facilitate open communication
2. Promote teamwork
3. Reinforce desired behaviors
4. Eliminate latent organizational weaknesses
5. Value prevention of errors
Leadership Practices
Challenge to Communicate
Managers:
“Ask for what you need to hear, not for what you want to hear.”
Subordinates:
“Tell your boss what they need to hear, not what you think they want to hear.”
--Roger BoisjolyFormer chief engineer for Morton-Thiokol, Inc.
Four goals in any communication:• Have the message received.
• Have the message understood.
• To initiate action.
• To maintain or enhance the relationship.
“ I didn’t say she stole the money.”
Team Skills Ladder
Inquiry
Advocacy
Leadership
Conflict Management
Critique Performance
Difficulty increases as you “climb” the ladder!
TRUSTCOM
MUNIC
ATION
Reinforcement
Source: Daniels, Bringing Out the Best in People, 1989.
Consequences that Decrease Behavior
Behavior
BEHAVIOR INCREASES
Consequences that Increase
Behavior
1. GET SOMETHING YOU WANT1. GET SOMETHING YOU WANT
2. AVOID SOMETHING YOU DON’T 2. AVOID SOMETHING YOU DON’T WANTWANT
1. GET SOMETHING YOU DON’T 1. GET SOMETHING YOU DON’T WANTWANT
2 . LOSE SOMETHING THAT YOU 2 . LOSE SOMETHING THAT YOU HAVEHAVEBEHAVIOR DECREASES
Insert Terry Tate clip
Behavior can be:
• Desirable; want more of it – the Good
• Acceptable or unacceptable; improvement is wanted – the Badthe Bad
• Unsafe, at-risk, or unsatisfactory; want it to stop now – the Ugly
What does excellence require?
BlameCycle
HumanError
Lesscommunication
Management lessaware of jobsiteconditions
Reduced trustLatent organizationalweaknesses persist
Individual counseled and/or disciplined
More flawed defenses& error precursors
Source: Reason, Managing the Risks ofOrganizational Accidents, pp.127-129.
Eliminating Latent Organizational Weaknesses
Solicit and act on feedback from workers
Determine fundamental causes
Monitor trends
Observe work in the field
Conduct surveys and use questionnaires
Perform process mapping
Conduct task analysis
Perform benchmarking
Behaviors that influence values & beliefs
1. What leaders pay attention to, measure, or control
2. Reactions to critical incidents or crisis
3. Criteria used to allocate scarce resources
4. Deliberate attempts at role modeling, teaching, and coaching
5. Criteria for reinforcement and discipline
6. Criteria used to select, promote, or terminate employees
Source: Schein, Edgar H. Organizational Culture andLeadership, Jossey-Bass, 1992, p231.
Q&A Wrap-up
Thanks!