Human Performance Improvement

1. Human Performance Improvement Principles for Managers Unclassified

2. Course Objective • Management will be able to create an environment where workers can make good decisions by: • Recognizing the role of the individual and human fallibility in human performance • Identifying how organizational systems influence human behavior • Embracing the role of the leader to manage organizational systems and positively influence human behavior Unclassified

3. When Good Pets Go Bad Unclassified

4. Human Performance “People do not operate in a vacuum, where they can decide and act all-powerfully. To err or not to err is not a choice. Instead, people’s work is subject to and constrained by multiple factors”. — Sidney Dekker Unclassified

5. What is Human Performance? An individual… working within organizational systems… to meet expectations set by leaders. Unclassified

6. How to Improve Human Performance Address limitations of human nature Remove error traps Create error-tolerant systems Reinforce desired behaviors Individual Incentives to meet leader’s expectations Organization Unclassified

7. Definitions • Operational Upset: A condition that adversely affects, or may adversely affect, DOE or contractor personnel, the public, property, environment or the DOE mission. • Error: An unintentional deviation from an expected behavior. • Violation: Deliberate, intentional acts to evade a known policy or procedure requirement for personal advantage usually adopted for fun, comfort, expedience, or convenience Unclassified

8. HPI Principles • People are fallible • Error-likely situations are predictable • Individual behaviors are influenced • Operational upsets can be avoided • People achieve high levels of performancebased encouragement and reinforcement. Unclassified

9. The Individual HPI Principle #1: People are fallible, and even the best make mistakes. Unclassified

10. Origins of Human Error Human Errors System Induced Error Operational Upsets Slip, trip or lapse Human Error Equipment Failures Unclassified

11. Basketball • Count the number of passes between white-shirted players • You MUST be accurate • PAY ATTENTION! Unclassified

12. Limitations of Human Nature Mistakes arise directly from the way the mind handles information, not through stupidity or carelessness. — Dr. Edward de Bono Unclassified

13. Limitations of Human Nature See page 4 in your Concepts Guide • Stress • Avoidance of mentalstrain • Inaccurate mentalmodels • Limited working memory • Limited attention resources • Mind set • Difficulty seeing own errors • Limited perspective • Susceptible to emotion • Focus on the goal • Fatigue Unclassified

14. Hazardous Attitudes See page 6 in your Concepts Guide • Pride: “Don’t insult my intelligence.” • Heroic: “I’ll get it done, by hook or by crook.” • Invulnerable: “That can’t happen to me.” • Fatalistic: “What’s the use?” • Bald Tire: “Gone 60K miles without a flat yet.” • Summit Fever: “We’re almost done.” • Pollyanna: “Nothing bad will happen.” Unclassified

15. Risk “Risks that you can control are much less a source of outrage than risks you can NOT control.” — PeterSandman … in other words, the risks that scare people and the risks that actually kill people are very different Unclassified

16. Performance Modes See page 7 in your Concepts Guide When switching from one performance mode to another a worker is presented with a new situation but has only old information on which to base decisions. Unclassified

17. Error Traps HPI Principle #2: Error-likely situations are predictable, manageable, and preventable. Unclassified

18. Saw StopTM Unclassified

19. Time pressure (in a hurry) • Unfamiliarity w/ task / First time • High Workload (memory requirements) • Lack of knowledge (mental model) • Simultaneous, multiple tasks • New technique not used before • Repetitive actions, monotonous • Imprecise communication habits • Irrecoverable acts • Lack of proficiency / Inexperience • Interpretation requirements • Indistinct problem-solving skills • Unclear goals, roles, & responsibilities • “Hazardous” attitude for critical task • Lack of or unclear standards • Illness / Fatigue • Distractions / Interruptions • Stress (limits attention) • Changes / Departures from routine • Habit patterns • Confusing displays or controls • Assumptions (inaccurate mental picture) • Workarounds / OOS instruments • Complacency / Overconfidence • Hidden system response • Mindset (“tuned” to see) • Unexpected equipment conditions • Inaccurate risk perception (Pollyanna) • Lack of alternative indication • Mental shortcuts (biases) • Personality conflicts • Limited short-term memory Error Precursors See page 18 in your Concepts Guide Task Demands Individual Capabilities Work Environment Human Nature Unclassified

20. Self-checking Peer-checking Concurrent verification Independent verification Three-way communication STAR Pre-job briefing Post-job briefing Procedure use & adherence Problem-solving Questioning attitude Conservative decision making Stop & collaborate Error Prevention Tools Unclassified

21. The Organization HPI Principle #3: Individual behavior is influenced by organizational processes and values. Unclassified

22. Human error is a cause of accidents To explain failure, investigations must seek failure They must find people’s inaccurate assessments, wrong decisions and bad judgments Human error is a symptom of trouble deeper inside a system… To explain failure, do not try to find where people went wrong. Instead, find how people’s assessments and actions made sense at the time, given the circumstances that surrounded them. New vs. Old View of Human Error Unclassified

23. The Dryden Event Air Ontario Flight 363 Fokker F28Dryden, CanadaMarch 10, 1989 Unclassified

24. Types of Error See page 12 in your Concepts Guide • Active Errors change equipment, system or processes that trigger immediate undesired consequences. • Latent Errors result in undetected organization-related weaknesses or equipment flaws that lie dormant. Unclassified

25. Understanding Events • Incentives are the cornerstone of human behavior • Dramatic events often have distant even subtle causes • Conventional wisdom is often wrong • Knowing what to measure and how to measure it makes a complex world much less complicated Unclassified

26. Organizational Processes Workplaces and organizations are easier to manage than the minds of individual workers. You cannot change the human condition, but you can change the conditions under which people work. — Dr. James Reason Unclassified

27. The Value of Error Tolerance Error without consequence is a good thing — it shows that our systems are error-tolerant and that they are working. Unclassified

28. Defenses in Depth See page 14 in your Concepts Guide • Redundancy: many layers of protection. • Diversity: many different varieties of protection. • Independence: separate/autonomous layers of protection. Unclassified

29. Traditional Heisenberg Model See page 16 in your Concepts Guide • Number of errors is relative to the severity of consequences • For every major accident there are many errors • Leads us to assume that driving down errors will eliminate major accidents Unclassified

30. New View of Heisenberg Model • The consequence of error has no relationship to the number of errors • It is related to the number and integrity of defenses • Any error can lead to a major accident if defenses fail Unclassified

31. Zero Operational Upsets See page 20 in your Concepts Guide Re + Md → OU Reducing Error AND Managing Defenses leads to Zero Operational Upsets Unclassified

32. Medical Mistakes Unclassified

33. Organizational Values HPI Principle #4: Operational upsets can be avoided by understanding the reasons mistakes occur and applying the lessons learned from past events. Unclassified

34. Blame Cycle See page 23 in your Concepts Guide Unclassified

35. Culpability Decision Tree See page 26 in your Concepts Guide Unclassified

36. The power to accomplish performance objectives vs. The blame for failure A starting point for improvements A dead end that discourages reporting vs. Is disempowering and divisive Arises from empowerment and partnership vs. Accountability vs. Culpability See page 40 in your Concepts Guide Accountability Culpability Unclassified

37. Performance Culture See page 28 in your Concepts Guide • Encourage Reporting: Value errors as leading safety data • Create a Just Work Environment: Don’t try and punish errors out of the system • Flexibility: Prepare workers to adapt effectively to changing demands • Learning: Create opportunities for observation, reflection and feedback Unclassified

38. Barriers to a Learning Organization • 20 years of experience = 1 year of learning repeated 20 times • Experts use their informational advantage to reinforce their biases Unclassified

39. Human to Systems Interface • People will never perform better than what the organization will allow • If a system relies on people doing the right thing every time, it will fail • No working system remains in stasis Unclassified

40. The Leader HPI Principle #5: People achieve high levels of performance based largely on the encouragement and reinforcement received from peers, leaders, and subordinates. Unclassified

41. Fallacy of Competing Resources See page 31 in your Concepts Guide Unclassified

42. How Leaders Influence Protection vs. Production See page 33 in your Concepts Guide • What they pay attention to, measure, and control • Their reactions to critical incidents or crises • The allocation of resources • Their criteria for allocation of rewards and punishment • Their criteria for selection, advancement, and termination • Their deliberate attempts to coach or model behaviors. Unclassified

43. Reality Check • Safety values express how you desire safety to be in your organization. • Safety systems are real defenses and actionable programs that provide measurable safety data sets. Unclassified

44. Implementing HPI • HPI is not just training • It is a way of doing business that includes: • Behavioral observation and walk-arounds • Conduct of operations and work management • Systems development and re-engineering • Issues reporting, management and corrective actions • Event investigation and lessons learned • Performance management and assurance • Simulations and training Unclassified