unclassified human performance improvement principles for managers
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Unclassified
Human Performance Improvement
Principles for Managers
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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
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When Good Pets Go Bad
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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
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What is Human Performance?
An individual…
working within organizational systems…
to meet expectations set by leaders.
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How to Improve Human Performance
Address limitations of human nature
Remove error traps
THIS WAY OUT
THIS W
AY OUT
Create error-tolerant systemsTHIS W
AY OUT
THIS W
AY OUT
Reinforce desired behaviors
Individual
Organization
Incentives to meet leader’s expectations
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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
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HPI Principles
1. People are fallible
2. Error-likely situations are predictable
3. Individual behaviors are influenced
4. Operational upsets can be avoided
5. People achieve high levels of performance based encouragement and reinforcement.
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The Individual
HPI Principle #1:
People are fallible, and even
the best make mistakes.
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10%
90%30%
70%
Origins of Human Error
Human Error
Slip, trip or lapse
Equipment Failures
Human Errors
Operational Upsets
System Induced Error
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Basketball
• Count the number of passes between white-shirted players
• You MUST be accurate
• PAY ATTENTION!
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Limitations of Human Nature
Mistakes arise directly from the way the mind handles information, not through
stupidity or carelessness.
— Dr. Edward de Bono
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Limitations 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 the goal• Fatigue
See page 4 in your Concepts Guide
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Hazardous Attitudes
• 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.”
See page 6 in your Concepts Guide
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Risk
“Risks that you can control are much less a source of outrage than
risks you can NOT control.”— Peter Sandman
… in other words, the risks that scare people and the risks that actually kill people are very different
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Performance ModesLo
w
Atte
ntio
n to
Tas
k
H
igh
Low Familiarity with Task High
Inattention
Misinterpretation
Inaccurate Mental Picture
Knowledge-Based
Rule-Based
Skill-Based
Patterns
If-Then
Auto
1/1,000
1/10,000
50/50 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.
See page 7 in your Concepts Guide
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Error Traps
HPI Principle #2:
Error-likely situations are predictable, manageable, and
preventable.
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Saw StopTM
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Error Precursors
• 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
• 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)
Task Demands Individual Capabilities
Work Environment Human Nature
See page 18 in your Concepts Guide
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Error Prevention Tools
• 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
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The Organization
HPI Principle #3:
Individual behavior is influenced by organizational processes and
values.
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New vs. Old View of Human Error
• 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.
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The Dryden Event
Air Ontario Flight 363 Fokker F28Dryden, CanadaMarch 10, 1989
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Types of Error
• 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.
See page 12 in your Concepts Guide
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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
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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
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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.
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Defenses in Depth
• Redundancy: many layers of protection.
• Diversity: many different varieties of protection.
• Independence: separate/autonomous layers of protection.
See page 14 in your Concepts Guide
Operational Upset
Active Error
Verbal & Written Communication and
Procedures
Equipment Design
Training & Work Practices
Protective Equipment & Shielding
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Traditional Heisenberg Model
• 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
600
30
10
1Major Accidents
Near Misses
Significant Events
Nonconsequential Errors
See page 16 in your Concepts Guide
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New View of Heisenberg Model
Major Accidents
Significant Events
Near Misses
Nonconsequential Errors
Proactive
Reactive• 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
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Zero Operational Upsets
Re + Md Re + Md → → OOUUReducing Error AND Managing Defenses
leads to Zero Operational Upsets
See page 20 in your Concepts Guide
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Medical Mistakes
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Organizational Values
HPI Principle #4:
Operational upsets can be avoided by understanding the reasons
mistakes occur and applying the lessons learned from past events.
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Blame Cycle
Reduced trustLatent
organizational weaknesses persist
Management less aware of
jobsite conditions
Less Communication
Individual counseled and/or disciplined
Human Error
More flawed defenses and
error precursors
See page 23 in your Concepts Guide
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Culpability Decision TreeWas the behavior
intended?
YES
Did the employee have
medical restrictions?
Were the consequences
intended?
Intentional sabotage
YESNO
Were restrictions communicated
and clearly understood?
YESDid the employee knowingly violate a requirement?
NO
Possible intentional violation
System-induced violation
YES NO
NO
Were the requirements
available, workable, intelligible, and
correct?
YES
Did the employee pass the
substitution test?
NO
Were there deficiencies in
training, selection or inexperience?
YES NO
Negligent error or intentional
violation
System-induced error
Possible intentional violation
System-induced violation
YES NO
YES NO
Did the employee have a history of
unsafe acts?
Corrective measures indicated
System-induced error or
blameless error
YES NO
See page 26 in your Concepts Guide
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Accountability vs. Culpability
Accountability Culpability
The power to accomplish performance objectives
The blame for failure vs.
A starting point for improvements
A dead end that discourages reportingvs.
Arises from empowerment and partnership
Is disempowering and divisivevs.
See page 40 in your Concepts Guide
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Performance Culture
• 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
See page 28 in your Concepts Guide
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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
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Human to Systems Interface
Organizational Systems:
Values
Systems in PracticeSystems in Practice Organizational Systems:
Processes
Organizational Systems:
Processes
Organizational Systems:
Values
• 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
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The Leader
HPI Principle #5:
People achieve high levels of performance based largely on the encouragement and reinforcement received from peers, leaders, and
subordinates.
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Fallacy of Competing Resources
BANKRUPTCY
CATASTR
OPHE
PR
OT
EC
TIO
N
PRODUCTION
Unrealized Potential
Optimization
Better defenses
converted into increased production
Operat
ional
Upset
See page 31 in your Concepts Guide
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How Leaders Influence Protection vs. Production
• 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.
See page 33 in your Concepts Guide
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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.
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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
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