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Human Performance for Safety Professionals

“Taking Science to Application”

John Wellisch MTD Master Trainer

Human Performance Improvement

(208) 351-4523

[email protected]

"There was an error in the Dear Abby

column that was published on Monday.

In the fifth paragraph, the second

sentence stated that Charlie's hiccups

were cured temporarily through the use

of carbon monoxide. It should have read

carbon dioxide.“

--Anchorage Daily News

BOTH WILL STOP HICCUPS

To proactively prevent “Unwanted

Outcomes” triggered by human error.

Purpose of Human Performance Improvement

Unwanted

Outcomes

Why a Human Performance

Improvement Approach?

80% Human Error 30%

Individual

20% Equipment

Failures

Human Error

Unwanted Outcomes

70% Latent

Organization

Weaknesses

DOE 1-10

Constant Sorrow

DOE1 1-19

HPI Principle 1 • People are fallible, and even the best make mistakes.

HPI Principle 2 • Error-likely situations are predictable, manageable, and

preventable.

HPI Principle 3 • Individual behavior is influenced by organizational

processes and values.

Cheering

HPI Principle 4 • People achieve high levels of performance based largely

on the encouragement and reinforcement received from

leaders, peers, and subordinates.

HPI Principle 5 • Events can be avoided by understanding the reasons

mistakes occur and applying the lessons learned from

past events.

Meet Kenny

“Events are not so much the result

of error-prone workers as they are

the outcome of error-prone tasks

and error-prone work

environments, which are

controlled by the Organization.”

James Reason, Managing the Risks of Organizational Accidents

Dr. Lucian Leape

Question:

Very tricky math! Note: This must be done in your

head only. Do NOT use paper and pencil or a calculator. Try it.

Take 1000 and add 40 to it. Now add

another 1000. Now add 30. Add another

1000. Now add 20. Now add another 1000

Now add 10. What is the total?

Answer: The correct answer is actually 4100.

“Punishing people for their errors

is emotionally satisfying but

remedially useless.”

James Reason, Managing Maintenance Error, pg 97

DOE2 96-97

Blame Cycle

Human

Error

Less

communication

Management less

aware of jobsite

conditions

Reduced trust Latent organizational

weaknesses persist

Individual counseled

and/or disciplined

More flawed defenses

& error precursors

DOE1 4-23

Who makes the worst mistakes?

• Front-line workers

• Technical Staff/Knowledge

Workers

• Supervisors

• Managers

• Directors

• Corporate

Two Kinds of Error

Active Errors

Latent

Errors

DOE1 2-8

• Limited short-term memory • Personality conflicts

• Mental shortcuts (biases) • Lack of alternative indication

• Inaccurate risk perception (Pollyanna) • Unexpected equipment conditions

• Mindset (“tuned” to see) • Hidden system response

• Complacency / Overconfidence • Workarounds / OOS instruments

• Assumptions (inaccurate mental picture) • Confusing displays or controls

• Habit patterns • Changes / Departures from routine

• Stress (limits attention) • Distractions / Interruptions

Human Nature Work Environment

• Illness / Fatigue • Lack of or unclear standards

• “Hazardous” attitude for critical task • Unclear goals, roles, & responsibilities

• Indistinct problem-solving skills • Interpretation requirements

• Lack of proficiency / Inexperience • Irrecoverable acts

• Imprecise communication habits • Repetitive actions, monotonous

• New technique not used before • Simultaneous, multiple tasks

• Lack of knowledge (mental model) • High Workload (memory requirements)

• Unfamiliarity w/ task / First time • Time pressure (in a hurry)

Individual Capabilities Task Demands

Error Precursors short list

DOE1 2-32

Anatomy of an Event

DOE1 1-14

True or False 1. __ If there are no events, there is no human

performance problems

2. __ Training is the solution to performance

problems

3. __ Self-checking means good human

performance

4. __ Accountability is all that is necessary

5. __ Event significance determines culpability

6. __ Experienced workers make mistakes

7. __ Errors cause significant events

8. __ Errors are a fact of life

Facts about Human Error • It thrives in every industry

• It is a major contributor to events and unwanted

outcomes

• It is costly, adverse to safety, and hinders

productivity

• The greatest cause of human error is weakness in

the organization, not the lack of skill or knowledge

• Error rates can never be reduced to zero

• Consequences of errors can be eliminated

Common Traps of Human Nature 1. Stress

2. Avoidance of mental strain

3. Limited working memory

4. Limited attention resources

5. Mind set

6. Difficulty seeing own errors

7. Limited perspective

8. Susceptible to emotion

9. Fatigue (Sleep Deprivation)

10. Presenteeism

4+ 5 8 DOE1 2-1

22

PARIS

IN THE

THE SPRING

BIRD

IN THE

THE HAND

ONCE

IN A

A LIFETIME

Phrase Recall Exercise

23

Phrase Recall Exercise

ONCE

IN A

A LIFETIME

PARIS

IN THE

THE SPRING

BIRD

IN THE

THE HAND

Critical Steps If done incorrectly will take a significant

amount of time and money to recover from.

Human Performance Tools

• Task Preview

• Job Site Review

• Questioning Attitude

• Pause when Unsure

• Self Checking

• Procedure Use and Adherence

• Place Keeping

• Do Not Disturb Sign

• Pre-Job Briefing

• Flagging

• Turnover

• Post Job Review

• Project Planning

• Benchmarking

• Observations

• Performance Indicators

• Independent Oversight

• Investigating Events

Triggered by Human Error

• Change Management

• Culpability Decision Tree

See DOE Book 2 Checklists

How You React to Failure Will Influence What You

Know About Failure • Listen First

o Shut Up!

• Repeat back to ensure understanding

• Focus on actual behavior rather than judgment

and evaluation

People or Process? • Learn from error or punish?

Leadership • Observe free of judgement and evaluation

Feelings and Needs • Recognize feelings

• Feelings are tied to needs

Requests • Make requests, not demands

o Use positive action language

o Leave their autonomy intact

o Would you be willing?

When a person hears a demand from us, they see two options: to submit or to rebel. Marshal Rosenberg

The man who is bigger than his job

keeps his cool. He does not lose his

head, he refuses to become rattled, to

fly off in a temper. The man who

controls others must first be able to

control himself. There is something

admirable, something inspiring,

something soul-stirring about a man who

displays coolness and courage under

extremely trying circumstances

B.C. Forbes

Questions?

“We ought not to look back unless it is

to derive useful lessons from past

errors, and for the purpose of

profiting by dear-bought

experience.”

George Washington

1732-1799

“I told you guys to slow down and

take it easy or something like this

would happen”