Transcript
Siemens Human Performance
HuP Refresher
Keith Dean, Field Service EHS Manager
Objectives
• Review Human Error Fundamentals and discuss concepts in-depth
• To ensure that each MW is committed to reducing or eliminating Safety &
Quality losses at every Siemens Energy jobsite
• Enable course participants to use Human Performance techniques at their
jobsites to reduce or eliminate Safety & Quality Incidences.
The Connection between Human Error and Loss
• By reaching our Human Performance
targets through improved
Safety – Quality – Productivity
we can meet the concerns of all our
customers
• The purpose of Human Performance is to
reduce losses and financial impact
associated with safety, quality, and
productivity errors
• Human performance is a program that
uses specialized tools and practices to
reduce the impact of human error and
violation
“… this in turn increases customer satisfaction
and increases our value added to the customer.”
Customer Satisfaction & Future Business
“HuP is the basis for improving Safety, Quality and
our Overall Performance on jobsites…”
“This increases our chances of obtaining future
business and keeps us all employed.”
Why Siemens believes in HuP?
Vocabulary
• Error – refers to the cognitive act
• Event – the outcome
• Incident – unintended or undesired outcome
• Human Violation – an intentional or willful act
• Human Performance – the series of actions to
prevent incidents by managing precursors to
incidents
• Organization is the business - from senior
management to the turbine deck supervision,
that directs the activities of MW’s performing the
work.
HuP involves both the individual and the organization
Why do people do
what they do?
HuP Introduction Discussion
Performance Modes | Error Rates
Error RateKey WordsPerformance Mode
1 in 2
TO
1 in 10
(quite
often)
You don’t know
WHAT
you don’t know!
• Using analytical processes and stored knowledge
• You are uncertain how to proceed
• Has NOTHING to do withhow smart you are!
Knowledge
Based
1 per 100
(infrequent)
There is a rule, and
I KNOW there is a
rule
• Rules accumulated via experience and training
• Can be written or verbal
Rule
Based
1 per
10,000 (very
infrequent)
HABIT
Familiar (done it
more than 50 times)
Not Thinking
• Stored patterns of pre-programmed actions
• Acting out of habit withoutconscious thoughts
Skill
Based
Results in a task or system outside of acceptable limits, or whose result is outside of established rules / standards
Failure of actions to
achieve desired goal
What is Human Error?
Results in an undesirable or unwanted condition
An unintentional deviation from an
approved behavior
Human Error is an action or behavior (active or latent) that
unintentionally...
Blame
Culture
(cycle)
Individual counseled
and/or disciplined
(unwarranted)
More flawed
defenses and
error precursors
Latent organizational
weaknesses persist
Management less aware
of jobsite conditionsLess
Communication
Reduced Trust
Human
Error
Blame Culture vs. Reporting Culture
A Blame Culture and a Reporting Culture CANNOT co-exist!
HuP Loss “Incidents”
Examples of Major Financial Loss Incidents
Fuel lines were crossed during installation
Misread micrometer on critical rotor dimension
Loss = $1,500,000
Loss = $4,000,000
Human Error: Active vs. Latent
Errors that change equipment,
system or product triggering
immediate undesired
consequences
LatentActive
Errors resulting in undetected
organizational-related or
equipment flaws that lie dormant
until challenged
Vs.
Human Error Discussion
• Errors happen frequently
(every day, every shift); they are universal
and inevitable
• Errors will always occur as long as
humans are doing the work
• Humans, on average, make 10-12 errors
per hour
• Errors are a part of human nature. You
cannot change the human condition, but
you can change the conditions in which
humans work
• Most errors have minimal consequences
• Making an error is not always a bad thing
Can we have an
error-free
workplace?
HuP Introduction Discussion
?
HuP Introduction Discussion
No we will not.
We NEVER will.
It is impossible.!
HuP Introduction Discussion
Because it is impossible to have an error-free workplace,
does that mean it is impossible to have an
incident-free workplace??
Because it is impossible to
conduct an “error-free”
workplace, Siemens uses
Human Performance tools
to identify, manage, and
control errors
• Human performance as it applies to the individual is a series of
behaviors executed to accomplish specific task objectives.
• Organizationally, Human Performance is the “aggregate system” of
the Organization’s Culture, Priorities and Influences, the
Organization’s processes and procedures, and the resultant
Behaviors of the workers. All of this manifest itself as the results in
the workplace.
Definition of Human Performance
What is Human
Performance ?
(HuP)?
Human Performance
Goal of Human Performance (HuP)
What is the Goal of
HuP?• Prevent events related to human performance
• Reduce impact of human error
• Continuously improve human performance, inside or outside
of work
5 Principles of HuP Excellence
People are
fallible, and even
the best make
mistakes.
Error-likely situations are
predictable, manageable,
and preventable.
People achieve high levels of
performance based largely on
encouragement and
reinforcement received from
leaders, peers & subordinates
Individual behavior
is influenced by
organizational
processes and
values.
An understanding of the reasons mistakes occur, and application
of the lessons learned from past incident, can avoid future
incidents.
HuP Introduction Discussion
A quote from the first page of
Managing
Maintenance Error
By
James Reason and Alan Hobbs
“If some evil genius were given the job of creating
an activity guaranteed to produce an abundance
of errors, he or she would probably come up with
something that involved the frequent removal and
replacement of large numbers of varied
components, often carried out in cramped and
poorly lit spaces that are rarely at ground level, and
usually under severe time pressure…the people that
wrote the manuals and procedures rarely if ever
carried out the activity under real-life conditions…
HuP Introduction Discussion
HuP Introduction Discussion
1 J. Reason and Alan Hobbs,
Managing Maintenance Error
Those who started a job need not necessarily be the
ones required to finish it…(and) a number of different
groups work on the same piece of equipment either
simultaneously or sequentially…” 1
Opposing Views of Human Error
Old View of Human Error
• Human error is the cause of many
accidents.
• The system in which people work is
basically safe; success is intrinsic. The
chief threat to safety comes from the
inherent unreliability of people.
• Progress on safety can be made by
protecting the system from unreliable
humans through selection, procedure
creation, automation, training and
discipline.
Opposing Views of Human Error
New View of Human Error
• Safety is not inherent in systems. The
systems themselves are contradictions
between multiple goals that people must
pursue simultaneously. People have to
create safety.
• Human error is a symptom of trouble
deeper inside the system.
• Human error is systematically
connected to features of people, tools,
tasks and operating environment.
Progress on safety comes from
understanding and influencing these
connections.
What we learned from Industry and Academia
• You can’t stop Human Error
(the cognitive act)
• You can intervene between error
and incident
• You can learn to recognize
error-likely situations
• Human Performance includes
violation recognition and
management as well
• Understanding these fundamentals
opens opportunities
The “Bathtub” Chart
“Likelihood for Error”
vs.
“Years of Service”
Where are the Human Error Events?
Human Error Significant Events
by Time with Company
High potential for
Human Error Incidents
High potential for
Human Violation Incidents
Error-Likely Situations*
A work-related situation in which there is
a greater opportunity for error when
performing a specific action or task due
to the existence of error precursors
Definition: Error-Likely Situations
*The 3W (Work, Worker, Workplace)
HuP Tool addresses Error-Likely Situations
Error Prevention Tools provide a means to identify error-likely situations
Definition: Error Precursors & Error-Likely Situations
Error Precursors
Unfavorable prior conditions that
reduce the opportunity for successful
behavior and performance of a task
Error-Likely Situations
A work-related situation in which there
is a greater opportunity for error when
performing a specific action or task due
to the existence of error precursors
How do we prevent events?
Employs tools to help identify error-likely situations
and
Allows for the placement of adequate
defenses to either:
• prevent the error or violation
• reduce the magnitude of the error
or consequences
• and / or correct the error
Human Performance
HuP Error Prevention Tools
Human PerformanceMinimizing human error is essential to our continued success. Human
Performance tools such as Pre-Job Briefing and Three Way
Communication provide an effective means to reduce your potential for
human error. By using these tools uncompromisingly, you will minimize
your potential for making a mistake
Pre-Job Briefing – Take 5
Self-Check (STAR)
Procedure Use and Adherence
Three-Way Communication
(or ”Three-Part” Communication)
Questioning Attitude
Peer-Check
Work, Worker, Workplace (3W)
OPPS – Out Process / Procedure -
STOP
Write Down this Date :
11/8/2016
It will be a question on the Test
And it shows you paid careful
attention to the info in thuis
presentation.
HuP Tools: OOPPS –
Out of Process / Procedure - STOP
Why ?
▪ To prevent errors that could result in injury or equipment damage
When ?
▪ Anytime a Task that you are performing is not going as you planned in the
Take 5 Pre-job Brief. Your Plan is the Process
▪ Anytime while you are performing a Task that you become unsure of the
next step in the procedure.
▪ Anytime you observe a Task or Action that you think could result
in Injury or Equipment damage, “STOP the Work” and get a
Supervisor.
HuP Tools: Procedure Use
HuP Tools: 3W Work, Worker, Workplace
12 Primary HuP Traps
Human Performance Traps / Error PrecursorsConditions, circumstances or occurrences that increase the potential for human error
1. Time pressure (in a hurry)
2. Distractions / interruptions
3. Unfamiliarity with task
4. Stress
5. High workload
(memory requirements)
6. Changes / departure from routine
7. Lack of knowledge
8. Habit patterns
9. Simultaneous, multiple tasks
10. Confusing displays / controls
11. New techniques
12. Assumptions
Hazards
Losses
Successive Layers of Defenses
Some holes are due to
Active Failures; some are
due to Latent Conditions
Awareness of hazards and good HuP techniques
Drawings & procedures
Alarms and support systems
Containment and barriers
(errors, equipment
failures, etc.)
(events)
Losses (Negative Events) are caused by a Failure of
multiple layers of Defenses
Events don’t typically occur because of one single error...
By having Successive Layers of Defense – you can prevent an
error from becoming a LOSS !!
Flawed Defenses
Initiating
ActionsONE WAY
ErrorPrecursors
LatentOrganizational
Weaknesses
Anatomy of an Event – Typically it is :
20% is on the Person
80% is Organizational
Event
80% 20%
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