doe human performance course earl carnes – doe-hq [email protected] (301)...
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DOE Human Performance
Course
Earl Carnes – DOE-HQ [email protected] (301) 903-5255
Brian Baskette - INPO [email protected] (770) 644-8601
T. Shane Bush – INEEL [email protected] (208) 526-7976
To proactivelyprevent eventstriggered by human error
Events
Purpose of Course
Strategic Framework
Jobsite Tools & Error-likely Situations
Organizational Improvement
Leadership Opportunities
Course Goals Proactive Mental
Framework
Managing Human Performance
Significant EventsAnnual Industry Averages
2.38
1.66
0.85 0.880.77
0.460.28
0.08 0.04 0.03
0.30 0.300.21
0.1 0.07
0.0
0.5
1.0
1.5
2.0
2.5
3.0
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Sig
nifi
can
t Eve
nts
pe
r U
nit
Data Source: U.S. Nuclear Regulatory Commission
(Core Damage Potential)
Is 99.9% Good Enough?
Year No. Ev. No. HU %
1995 66 44 67
1996 44 34 77
1997 26 21 81
1998 26 22 85
1999 19 16 84
Totals 181 137 76%
44
Significant Events 1995 through 1999
(Potential Personnel Injury)
0
1000
2000
3000
4000
5000
6000
1995 1996 1997 1998 1999 2000
OccurrenceReportsOccurrences
90% Involve Human Behavior(National Safety Council)
DOE Occurrence Reports and Occurrences 1995-2000.
21 out of 26 fuel-damaging accidents due to human error
Three out of four significant events due to human error
Greatest contributor to costs ?
70 percent of causes due to weaknesses in Organization
Why Human Performance?
Industry Event Causesdue to human performance
Source: INPO, Event Database, March 2000. For all events during 1998 and 1999.
215
26 3988
192
654
9 20
160
82
806
73118
0
100
200
300
400
500
600
700
800
900
Num
be
r o
f C
ause
s
1,676 = Org behavior (68%)
806 = Individual behavior (32%)
Principles1. People are fallible, and even the best make mistakes.
2. Error-likely situations are predictable, manageable, and preventable.
3. Individual behavior is influenced by organizational processes and values.
4. People achieve high levels of performance based largely on the encouragement and reinforcement received from leaders, peers, and subordinates.
5. Events can be avoided by understanding the reasons mistakes occur and applying the lessons learned from past events.
Counting F’s
Aoccdrnig to rscheearch at an Elingsh uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are, the olny iprmoetnt tihng is taht the frist and lsat ltteer is at the rghit pclae. The rset can be a toatl mses and you can sitll raed it wouthit porbelm. Tihs is bcuseae we do not raed ervey lteter by it slef but the wrod as a wlohe.
Human Performance
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Target No.1Target No.1 Target No.2Target No.2
Two Kinds of Error
Active Error
Latent Error
Anatomyof an Event
Event
ErrorPrecursors
Vision, Beliefs, &
Values
LatentOrganizationalWeaknesses
Mission
Goals
Policies
Processes
Programs
FlawedDefenses
InitiatingAction
Vision, Beliefs, &
Values
The Beginning – February 20, 1986The Beginning – February 20, 1986
• In orbit for 15 years
• Visited by over 100 cosmonauts & astronauts
• Two long duration space records
J. M. Linenger, M.D., M.S.S.M., M.P.H., Ph.D. (Captain, Medical Corps, USN) Highly experienced and trained astronautwith several hours of experience aboard US shuttles. Completed both detailed cosmonaut and astronaut training.
J. M. Linenger, M.D., M.S.S.M., M.P.H., Ph.D. (Captain, Medical Corps, USN) Highly experienced and trained astronautwith several hours of experience aboard US shuttles. Completed both detailed cosmonaut and astronaut training.
Alexander “Sasha” Lazutkin – Flight Engineer Highly trained cosmonaut on his first assignmentaboard MIR. Became skilled by “learning as yougo” when repairing failing systems aboard the station during the mission.
Alexander “Sasha” Lazutkin – Flight Engineer Highly trained cosmonaut on his first assignmentaboard MIR. Became skilled by “learning as yougo” when repairing failing systems aboard the station during the mission.
Vasily Tsibliev - Commander and pilot of Progress in coming vessel.Highly experienced and trained cosmonaut with previous tour aboardMIR.
Vasily Tsibliev - Commander and pilot of Progress in coming vessel.Highly experienced and trained cosmonaut with previous tour aboardMIR.
MIR
Spektr ModuleSpektr Module
Has four solar arrays and can carry >1600 lbs of US scientific equipment
Purpose: scientific study such as Earth observation, specifically natural resources and atmosphere, US astronaut living quarters
Launched - 1995
Has four solar arrays and can carry >1600 lbs of US scientific equipment
Purpose: scientific study such as Earth observation, specifically natural resources and atmosphere, US astronaut living quarters
Launched - 1995
Progress
Progress
Contains fresh food, supplies and parts when arriving, trash and laundry when departing
Purpose: unmanned supply transport First to be launched - 2/1986
Contains fresh food, supplies and parts when arriving, trash and laundry when departing
Purpose: unmanned supply transport First to be launched - 2/1986
SoyuzSoyuz
Russian manned spacecraft that ferries cosmonauts & astronauts to and from MIR.
Serves as an escape “lifeboat” in the event MIR should experience a life threatening event.
Max crew - 3
Russian manned spacecraft that ferries cosmonauts & astronauts to and from MIR.
Serves as an escape “lifeboat” in the event MIR should experience a life threatening event.
Max crew - 3
Task: Manually dock Progress with MIR using TORU system
TORU
Progress Manual Docking Instrumentation and Controls
Sasha and Jerry were positioned in opposite modules to yell out information to help Vasily find the Progress.
Video: “Terror in Space” a NOVA / BBC Production
Using the Anatomy of an Event, identify following factors in the mishap:
Flawed Defenses
Error Precursors
Organizational Weaknesses
The Near Collision – March 4, 1997The Near Collision – March 4, 1997
An experiment, called
“The TORU Test’ results in an
uncontrolled fly-by of the
Progress spacecraft within 200 meters of MIR.
Video: “Terror in Space” a NOVA / BBC Production
Using the Anatomy of an Event, identify following factors in the mishap:
Flawed Defenses
Error Precursors
Organizational Weaknesses
The Handoff
J. M. Linenger, M.D., M.S.S.M., M.P.H., Ph.D. (Captain, Medical Corps, USN) Highly experienced and trained astronautwith several hours of experience aboard US shuttles. Completed both detailed cosmonaut and astronaut training.
J. M. Linenger, M.D., M.S.S.M., M.P.H., Ph.D. (Captain, Medical Corps, USN) Highly experienced and trained astronautwith several hours of experience aboard US shuttles. Completed both detailed cosmonaut and astronaut training.
Michael Foale – Astronaut Highly experienced and trained astronautwith several hours of experience aboardUS shuttles. Completed both detailedcosmonaut and astronaut training.
Michael Foale – Astronaut Highly experienced and trained astronautwith several hours of experience aboardUS shuttles. Completed both detailedcosmonaut and astronaut training.
Video: “Terror in Space” a NOVA / BBC Production
Using the Anatomy of an Event,identify key factors in the mishap:
Who / what could have prevented the mishap?
Role of cosmonauts and astronauts?
Role of Russian mission control?
Role of NASA?
The Accident – June 25, 1997The Accident – June 25, 1997
During a manual docking test of a Progress re-supply ship, the craft collided with the Spektr Remote Sensing Module.
The Damage
Video: “Terror in Space” a NOVA / BBC Production
Using the Anatomy of an Event,identify key factors in the mishap:
Who / what could have prevented the mishap?
Role of cosmonauts and astronauts?
Role of Russian mission control?
Role of NASA?
Why did they try it again?
• Money
Pressure
Time
Politics
Strategic Approach
1. Anticipate and prevent active error at the job site.
2. Identify and eliminate latent organizational weaknesses.
Desired Outcomes High-Reliability Organizations
Uneasiness & Intolerance
Error-prevention tools
Communication
Structured mental framework
Training Techniques
• Using Case Studies
• Conducting Needs Assessment
• Establishing the ‘Why” to HU training
Human Human PerformancePerformance
Individual
Key terms
Fallibility & vulnerability
Error-likely situations
Performance modes and error modes
Error-prevention
Team Errors
Objectives
Plant
Worker
Processes Values
Strategic Framework for Human Performance
Human Fallibility
“Machines are fast, accurate,and dumb.
Humans are slow, sloppy,and brilliant.”
PARISIN THE
THE SPRING
BIRDIN THE
THE HAND
ONCEIN A
A LIFETIME
Phrase Recall Exercise
Limitations of Human Nature
Avoidance of mental strain Inaccurate mental models Limited working memory Limited attention resources Pollyanna effect Mind set Difficulty seeing own errors Limited perspective Susceptible to emotion Focus on goal
Job Site Conditions the link between organization and the jobsite
Task
Information
Resources
Incentives
Source: Dean & Ripley. Performance Improvement Pathfinders, Models for Organizational Learning. 1997, p54.
Individual
Knowledge
Readiness
Motives
JENGA
Source: Swain & Guttmann. Handbook of Human ReliabilityAnalysis with Emphasis on Nuclear Power Plant Applications.U.S. Nuclear Regulatory Commission (NUREG/CR-1278), 1983.
Error-likely Situation The Devil in the Details
Degree of mismatch due toerror precursors
Error likely Situation
Unintentionaldeviation frompreferred behavior
Job Site Conditions• Task• Individual
Error Precursors
Task DemandsTask Demands
Individual Individual CapabilitiesCapabilities
Work EnvironmentWork Environment
Human NatureHuman Nature
Error-likely Situation
Wor
k
Enviro
nmen
t
precursors
TaskDem
ands
precursors Hum
an
Natur
eprecursors
Individual
Capabilities
precursors
An error aboutto happen due toerror 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
Human NatureWork 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 CapabilitiesTask Demands
Error Precursors short list
Task Demands Individual Capabilities
Work Environment Human Nature
Hazardous Attitudes
Pride - “Don’t insult my intelligence.”
Heroic - “I’ll get it done, hook or by crook.”
Invulnerable - “That can’t happen to me.”
Fatalistic - “What’s the use?”
Bald Tire - “Got 60K miles and haven’t had a flat yet.”
Summit Fever - “We’re almost done.”
Pollyanna - “Nothing bad will happen.”
Human Information Processing
Source: Wickens, 1992
SharedAttentionResources
ThinkingThinkingSensingSensing ActingActing
InformationFlow Path
Knowledge-Based
Patterns
Rule BasedIf - Then
Skill-BasedAuto
Performance Modes--Attending Problems
Familiarity (w/ task)Low High
High
Low
Att
enti
on
(to
task
)
Sou
rce:
Jam
es R
easo
n. M
anag
ing
the
Ris
ks
of O
rgan
izat
iona
l Acc
iden
ts,
1998
.
Inattention
Misinterpretation
Inaccurate Mental Picture
Error Prevention at the jobsite
Machine
Other People
Myself
At-Risk Behavior
Two-handed manipulations Hurrying Performing one task with
several procedures Cookbooking a procedure Reading while controlling a
process in manual
Error-prevention Techniques @ jobsite
Conservative decision-making
Change management
Three-way communication
Concurrent verification
Independent verification
Meetings
Peer-checking
Placekeeping
Prejob Briefing
Problem-solving
Procedure use & adherence
Questioning attitude
Self-checking
Stop & collaborate
Two minute walkdown
Source: Edward de Bono, Practical Thinking. 1971, p166.
WHAT?
WHEN?
WHERE?
What?
When?
Where?
Error
Desired
Inattention to detail?
STAR – 3W targeted attention management
Team Errors “social loafing”
Halo Effect
Pilot / Co-pilot
Free Riding
Groupthink
Risky Shift
Competence vs. Control
Uncerta
in/
Unsure
Healthy Uneasiness/Wariness
Too Certain/
Too Sure
Questioning Attitude Meter
Excellence inHuman
Performance
The Goal
Events
Human Human PerformancePerformance
Organization
Objectives
Organization purposepurpose
Organizational impact
DefenseDefense functionsfunctions and their reliability
Precursor and flawed defense to organizational weakness relationshiprelationship
Organizational toolstools for making latent failures visible
Sources of latent organizational weaknesses.
Source: Tuli, Apostolakis, and Wu. “IdentifyingOrganizational Deficiencies Through Root-Cause Analysis.”Nuclear Technology (vol. 116), Dec. 1996.
Purpose of Organization Dual Influences
Organization
Divisionof Labor
Coordinationof Effort
Work Processes(formal)
Culture(informal)
TaskBehaviors
OrganizationalProcesses& Values
PlantResults
WorkerBehavior
The Performance Model
Job SiteConditions
To facilitate the accomplishment of the organization’s missionmission in accordance with its norms, values, and strategies.
SafetyTo consistently searchsearch for and eliminateeliminate conditions that provoke human error while reinforcing defenses.
Dual Purposes
Mission Vision
Goals Beliefs
Processes Values
Results
Behavior(Production)
Behavior(Prevention)
Source: Tosti, D. and Jackson, S. “Alignment: How it Works and Whyit Matters.” Training, 31(4), 58-64 (1994).
Competing Behaviors?
Competing Resources
Source: James Reason. Managing the Risks of Organizational Accidents, 1997 (in press).
Pre
vent
ion
Productiont0
tn
new plant state
plant eventAccid
ent
Bankr
uptcy
Defenses
• Create Awareness• Detect and Warn• Protect• Recover• Contain• Enable Escape
Physical Administrative
Flawed defenses allow active errors or their consequences to occur.Source: Maurino (1995)
MANAGERIAL METHODS
TRAINING
WORK SCHEDULEWORK ORGANIZATION OR
SUPERVISORY METHODS
WRITTEN COMMUNICATIONS
CHANGEIMPLEMENTATION
VERBALCOMMUNICATIONS
DESIGN
WORK PRACTICES
ChallengesChallengesTo the PlantTo the Plant
ENVIRONMENTALFACTORS
EVENTS
Defense in Depth
The Performance Model
ORGANIZATIONALPROCESSES
& VALUES
PLANTRESULTS
WORKERBEHAVIOR
JOBSITECONDITIONS
Defenses
Defenses
Defenses
Defenses
DefensesDefenses
DefensesDefenses
“…assume that mistakes will happen
and have in place procedures [barriers,
and practices] that will catch and
correct them before they snowball.”
— Vincent Czaplyski, Boeing 727 Check Airman
Defense-in-Depth Operations
Self-Checking Place-Keeping
3-Part Communication
Double (dual)Verification
Procedure Use & Adherence
Supervision
Management Monitoring
Stop WhenUncertain
Critical Parameters
Problem-solvingMethodology
ConservativeDecision-Making
Team Skills
Peer-Checking
RecognizingError Traps
Rigor of Execution
Challenge
Flagging
Communication Practices & Plan
Reviews & Approvals
ChangeMgmt.
Problem- Solving
Scheduling / Sequencing
Clear Expectations
RoleModels
Safety Philosophy
Task Allocation
Meetings Rewards &Reinforcement
Trend Analysis
OE
Training
Handoffs
Accountability
Simple / Effective Processes
Procedure Revisions
Work Planning
Corrective Action Program
Self-Assessment
Benchmarking
CompatibleGoals & Priorities
Strategic HU Plans
Management Practices
Safeguards Equipment
Reactor Protection Systems
Containment
EquipmentReliability
Equipment Labeling & Condition
Procedure / Work Package Quality
Worker Knowledge,Skill, & Proficiency
Fitness-for-Duty
Uneasy Attitude
Equipment Ergonomics & Human Factors
Tool Quality & Availability
Roles &Responsibilities
Housekeeping EnvironmentalConditions
Foreign Material Exclusion
Lockout / Tagout
Personal Motives
Intolerance for Error Traps
Morale
RWPs
Performance ModelPerformance Model w/ example defenses (10-08-02)
Leadership
Post-job Critiques
Problem Reporting
Root Cause Analysis
Performance Indicators
PLANTRESULTS
JOB-SITECONDITIONS
ORGANIZATIONPROCESSES
& VALUES
WORKERBEHAVIOR
Proper Reactions
High Standards
Reinforcement
Coaching
Questioning Attitude
Respectfor Others
Open & HonestCommunication
CompellingVision
HealthyRelationships
Courage &Integrity
Motivation
Example
Pre-jobBriefing
Just-in-time Operating Experience
Task Preview
Turnover
Clearance Walkdown
Walkdowns
Performance Feedback
Task Assignment
HP Surveys
Task Qualification
QC Hold Points
Independent Verification
InterlocksPersonal Protective Equipment
Alarms
Forcing Functions
FME
Questioning AttitudeWork-arounds & Inconveniences
Staffing
Labor Relations
Socialization
Design & Configuration Control
Values & Beliefs
Independent Oversight
New Paradigm
Re + Md Re + Md → → ØØEERe + Md Re + Md → → ØØEE
Minimum Minimum frequencyfrequency and and
severityseverity of plant events, with of plant events, with
high safety margins and high safety margins and
reliability and no fuel-reliability and no fuel-
damaging events.damaging events.
[reducing error AND managing defenses leads to zero events][reducing error AND managing defenses leads to zero events]
Individual + organization & processes Individual + organization & processes >>>>>>>> Performance ImprovementPerformance Improvement
Disaster Pyramid
Source: Frank Bird, Jr., Practical Loss Control Leadership, Det Norske Veritas (formerly International Loss Control Institute), 1969.
600
1
3010Significant
events
MajorAccident
NonconsequentialErrors
NearMisses
Degree of DependabilityR
elia
bilit
y of
D
efen
se
Degree of Human Control
Low High
High
Self-checking
PPE
Interlocks
Reactor VesselShield Wall
Caution Tags
Supervision
Engineered Safeguards
Procedure Use
Document Reviews
Job Site Conditions the link between organization and the jobsite
Motives
Readiness
Knowledge
Individual
Incentives
Resources
Information
Task
Source: Dean & Ripley. Performance Improvement Pathfinders, Models for Organizational Learning. 1997, p54.
Latent Organizational Weaknesses (sources)
Values (relationships) Priorities Measures & controls Critical incidents Coaching & teamwork Rewards & sanctions Reinforcement Promotions &
terminations
Processes (structure) Work control Training Accountability policy Reviews & approvals Equipment design Procedure
development Human resources
“Warning Flags” Leading Indicators to
Long-term Plant Shutdowns
Overconfidence Isolationism Relationships Production priorities Operations vs. Engineering Change management Leadership Self-critical perspective
Integrating Human and Organizational Performance
• Human Performance• Operating Experience• Self Assessment• Observations• Root Cause & Trending• Corrective Action• Benchmarking• Training• Leadership & Organizational Development
Creating a High Performance Organization
• Alignment• Engagement• Measurement and
Feedback• Environment
Human Human PerformancePerformance
The Vision ofExcellence in
Human Performance
Leadership
Events
Objectives
Leader’s role
Behavior vs. position
Performance Model
Leadership enablers
Leadership tools
Source: Rummler and Brache. Improving Performance, 1990.
WorkerBehaviors
PhysicalPlantResults
• Mission & Goals• Business Plans• Programs & Policies
• Work Processes• Relationships• Values & Beliefs
• Preferred• At-risk• Error• Violation
(short cuts)• Personal
consequences
• WANO PIs• Efficiencies• Equipment
Performance & Materiel Condition
• Configuration• Trips & Transients
• Task Information• Resources• Incentives• Knowledge• Readiness• Motives
Performance Model a systems perspective
Org’lProcesses& Values
Job SiteConditions
Leadership
Source: Rummler and Brache. Improving Performance, 1990.
Performance Model a systems perspective
Org’lProcesses& Values
Job SiteConditions
WorkerBehaviors
PhysicalPlantResults
Supervisors and Managers
Source: Tosti, D. and Jackson, S. “Alignment: How it Works and Whyit Matters.” Training, 31(4), 58-64 (1994).
Competing Behaviors?
Leadership
Mission Vision
Goals Beliefs
Processes Values
Results
Behavior(Production)
Behavior(Prevention)
Attributes of a High-Performing Nuclear Station
TOPMANAGEMENT
TEAM
MIDDLEMANAGERS AND SUPERVISORS
WORKFORCE
KEY ELEMENTS
•
•
Well aligned around common direction, standards, and valuesEffective oversight
HORIZONTAL INTEGRATION
VERTICAL
ALIGNMENT
• Healthy coaching and accountability• Teamwork
• Critical self- assessment• Leadership development
• Self- critical• Engaged
Leadership Opportunities
1. Facilitate open communication
2. Promote teamwork
3. Reinforce desired behaviors
4. Eliminate latent organizational weaknesses
5. Value prevention of errors
Challenge to CommunicateManagers:
“Ask for what you need to hear, not for what you want to hear.”
Subordinates:
“Tell what they need to hear,not what you want to tell them.”
Roger BoisjolyFormer chief engineer for Morton-Thiokol, Inc.
BlameCycle
HumanError
Lesscommunication
Management lessaware of jobsiteconditions
Reduced trustLatent organizationalweaknesses persist
Individual counseled and/or disciplined
More flawed defenses& error precursors
Source: Reason, Managing the Risks ofOrganizational Accidents, pp.127-129.
Communication Plan
1. Values & beliefs
2. Target audience & settings
3. Key messages
4. What is said vs. what is done
5. Who & what to pay attention to
6. Critical incidents
Team Skills Ladder
InquiryInquiry
AdvocacyAdvocacy
LeadershipLeadership
Conflict ManagementConflict Management
Critique PerformanceCritique Performance
Reinforcement
Behavior
BEHAVIOR INCREASES
Consequences that Increase
Behavior
1. GET SOMETHING YOU WANT1. GET SOMETHING YOU WANT
2. AVOID SOMETHING YOU DON’T WANT2. AVOID SOMETHING YOU DON’T WANT
Consequences that Decrease Behavior
1. GET SOMETHING YOU DON’T WANT1. GET SOMETHING YOU DON’T WANT
2 . DON’T GET SOMETHING YOU WANT2 . DON’T GET SOMETHING YOU WANTBEHAVIOR DECREASES
Source: Daniels (1989)
Rewards & Reinforcement Plan
1. Results (key outcomes)
2. Target behaviors (expectations)
3. Opportunities (R+, R-, P, X)
4. Feedback (SSIP)
5. Celebrations (for results)
Eliminate Organizational weaknesses
Continuous improvement culture
Root Cause / Corrective Action
Self-evaluation
Benchmarking
Task analysis
Leader Tools influence on beliefs & values
1. What leaders pay attention to, measure, or control
2. Reactions to critical incidents or crisis
3. Criteria used to allocate scarce resources
4. Deliberate attempts at role modeling, teaching, and coaching
5. Criteria for reinforcement and discipline
6. Criteria used to select, promote, or terminate employees
Source: Schein, Edgar H. Organizational Culture andLeadership, Jossey-Bass, 1992, p231.
Change Leadership for Continuous Improvement
1. Champion
2. Steering committee
3. Vision & urgency
4. Strategy
5. Communicate
6. Empower
7. Implement
8. Short-term successes
9. EmbedSource: Kotter, J. Leading Change, 1996.
Desired Outcomes High-Reliability Organizations
Uneasiness & Intolerance
Error-prevention tools
Communication
Structured mental framework
“The longest distance to travel in human performance is the distance between the
head and the heart.”
-Tom Harrall, plant manager, McGuire
Ways to Achieve Buy-In
• Behavior Reinforcement• Significant Emotional Event• Alignment with personal values• WIIFM• Intrinsic Motivation
– Purposefulness– Progress– Control– Competence
Human Human PerformancePerformance
Structured Mental Framework
Errors Eventsand
Objectives
System-level framework
Job-level framework
Prejob briefing
Application: plant task
Post-job critique
System to Job Site
Dialogue
Job SiteConditions
PlantResults
WorkerBehavior
OrganizationalProcesses& Values
IndividualCapabilities
TaskDemands
HumanNature
WorkEnvironment Prejob
BriefingA Dialogue
Error-likelySituations
PotentialConsequences
FlawedDefenses
CriticalSteps
Worker &Supervisor Feedback
TaskPreviewBefore & During
PrejobBriefing
Task Preview
SAFE Dialogue
S – Summarize critical stepsA – Anticipate error trapsF – Foresee consequencesE – Evaluate defenses
IndividualCapabilities
TaskDemands
HumanNature
WorkEnvironment
Error-likelySituations
PotentialConsequences
FlawedDefenses
CriticalStepsTask
Preview
“SAFE” A Task Preview
Summarize critical steps
Anticipate error traps
Foresee consequences
Evaluate defenses
Review operating experience
Guidance for Level of Prejob Briefing
Simple or Repetitive
SAFE Conversation.
Preplanned Prejob Briefing Forms
Complex or Infrequent
Generic Prejob Briefing Checklist
Infrequently Performed Test or Evolution
Low-Risk High-Risk
Plus SAFE
Plus SAFE Plus SAFE
Post Job Critique
1. Purpose: Organizational improvement (OE)
2. Quick and easy
3. Production and Prevention
4. Management acknowledgement
5. Follow-through
Human Human PerformancePerformance
Where do I go from here?
• What’s my role in HU Excellence?
• What tools do I have to perform my HU role?
• What challenges will I need to overcome in my role?
• What support is available?
