Human Performance, the Event Free Clock & Breaking the Safety Cycle Introducing Leading Indicators to Break The “Safety Cycle”

Human Performance, the Event Free Clock & Breaking the Safety Cycle

Introducing Leading Indicators to Break The “Safety Cycle”

How To Measure Safety Performance?

Where to Focus Safety Efforts?

The Safety Cycle

Injuries

Time

Upper Limit

Lower Limit

TrainingRules

Discipline

Regulations

Safety Meetings

Pre-Job Brief

AwardsFewer

Accidents?

Safety Initiatives

Five Basic Facts

1. People are fallible and even the best will make mistakes.

2. All consequential errors that could lead to injuries are preventable.

3. No worker would intentionally injure themselves.4. If there is a method that could free a worker from

being injured without undue burden, they would adopt it.

5. Fast improvement can only be achieved in an open, non-punitive, and constant learning workplace.

Human Performance

Basic Human Performance concepts focus on identifying and improving:

• Human Errors– Reduce the chances of errors occurring, and– Reduce the effects of errors resulting in injury

and/or system disturbances• Failed or Insufficient Layers of Protection• Latent Organizational Weaknesses

Layers of Protection

Unwanted Outcomes (Events)

Equipment Failure – 20%

Human Errors - 80%

Individual Errors – 30%

Latent Organizational Weaknesses – 70%

Human Performance

• What is Human Performance? – A series of behaviors executed to accomplish specific tasks.

Human Performance

Improve Human Performance

&

YOU WILL

Improve Operational Performance

THE THREE TYPES OF HUMAN ERRORS ARE:

1. Knowledge-based Errors

• These tasks are new, unfamiliar or unique to the performer

• They depend heavily upon the performer’s fundamental knowledge, diagnosis, and analysis skills

• Best described as trial and error or literally “I don’t know”

THE THREE TYPES OF BEHAVIOR BASED ERRORS ARE:

2. Rule-based Errors

• These tasks are familiar to the performer

• Upon correct recognition of a situation or condition, the performer can apply a stored rule to steer towards a known end goal

• Tasks in this domain tend to follow if-then logic

3. Skill-based Errors •These tasks are comprised of very familiar actions

•Performed in comfortable surroundings

•The human being is, or is close to, being on autopilot

THE THREE TYPES OF BEHAVIOR BASED ERRORS ARE:

Task Error Model

Knowledge based – Rule based – Skill based

Error Mode:

Inaccurate Mental Model

Error Rate 1:10Error Mode:

Misinterpretation

Error Rate 1:100

Error Mode:

Inattention

Error Rate 1:1,000

Rules, Standards, Checklist,Written Procedures

Memorization, Practice

Error Traps

Error Trap Recognition (TAPE Method)

Time Specific Error Traps Activity Specific Error Traps

Daily Cycle (time of day) Inadequate Layers of Protection

Weekly Cycle (day of week) Time Pressure Task

Monthly Cycle (summer effects, etc.) Distractive Task

Holiday Effects First Time or Infrequent Task

Person Specific Error Traps Environment Specific Error Traps

Compromised Physical & Mental Conditions

Weather Conditions

Negative Personal & Age Effects Unproven, Unseen, & Unauthorized Walk Paths

Inexperience Sloping Footing/Terrain

Not Understanding or Complying with the Rules

Low Visibility

Some Human Performance Tools for Individuals

• Questioning attitude• Stop when unsure• Self-checking• Procedure use and adherence• Three-way communication• Phonetic alphabet• Place-keeping• Two Minute Drill• Conservative Decision Making

Some Human Performance Tools for Teams

• Pre-job briefing (Tailboard)• Peer check• Flagging• Turnover• Post-job review• Concurrent Verification

Some Human Performance Tools for Leaders and Management

• Observations & Feedback• Self-Assessments• Operating experience

What is an Event Clock?

– A real time Human Performance tool to effectively communicate current human performance status relating to safety and reliability.

– Qualifying Events reset the clock to zero

– Helps improve safety and reliability by being a vehicle to share lessons learned following Qualifying Events so that we engrain the HP tools into how we do business.

2012 Event Clock Criteria

– Fatalities– Amputations– Loss of Consciousness– Electrical Contacts with Injury– Arc Flashes with Injury– Fractures (non-dental)– Lost-time Injuries– Switching Order & Clearance Errors (resulting in an

event)

– Motor Vehicle Accidents greater than $5K damage– Unplanned Significant Outages (with feeder breaker

trip)– OSHA Violations with an event

Event Clock Resetting Types

Avoidable: Total # Events

FatalitiesLost Times 5

Fractures 2Amputations

Loss of ConsciousnessElectrical Contacts w/ Injury

Arc Flashes w/ InjurySwitching & Clearance Events 3

Motor Vehicle Accidents >$5,000 3

Unplanned Feeder Outages (@ Sub Breaker)

6

Events with OSHA Violations 1Total Event Clock Resets 20

ED/CS/RR Event Clock

Organization 2012 Resets 2012 Incentive Threshold

Energy Delivery 19  

Customer Service 1

Rates & Regulatory 0

Total 20 32

Days Since Last Reset 44  

Average Days Between Resets 18

Organization Days Since Last Reset

# 2012 EFC Resets

Last Resetting Event

Last Reset Date

Atwell - Tot Transmission Construction 70 3 32603 7/13/2012Lucas/Tetlow - Total ED Power Ops & Maint 68 11 32596 7/15/2012

Easterly - Total Rural AZ Delivery 37 3 32701 8/15/2012Smith - Total ED Asset Mgmt & Plng 1856 0 26223 8/23/2007McElmury - Total Safety&Perf Excellence 331 0 31796 10/26/2011

Daniel - Total Distribution Constr 60 2 32628 7/23/2012Froetscher - Total Energy Delivery 37 19 32701 8/15/2012Orlick - Marketing None 0 None None Goguen - Total Cust Svc Ops 795 0 30350 7/19/2010Loveridge - Total Meter Operations 146 1 32381 4/28/2012Casuga - Total Cmty Dev/Cust Offices 780 0 30393 8/3/2010

McLeod - Total Customer Service 146 1 32381 4/28/2012

Guldner - Total Rates & Regulation 1134 0 29162 8/14/2009Total ED/CS/RR 37 20 32701 8/15/2012

Breaking the “Safety Cycle”

Injuries

Time

Trend

Close Calls are a gift from God

Presented by: Chuck Thomack, CSP

Section Leader, Safety

(602) 371-7873

Charles.Thomack@aps.com

Date: September 28, 2012