Post on 02-Apr-2020
Predicting Errors using Human Performance Measurement Tools
T. Shane Bush
Peggy S. Bush
(208) 221-9378
2020 Stosich Lane
Idaho Falls, ID 83402
BushCo@cableone.net
Human Performance
Fundamentals (2017)
BushCo
To proactively prevent “Unwanted
Outcomes” triggered by human error.
Purpose of Course
Unwanted
Outcomes
But there is one small problem: The quote actually
originated not with the late poet and civil rights champion,
but with a children' book author Joan Walsh
Error?Un-intentional Deviation from a
Preferred Behavior
Error?
Something you didn’t intend to do!
Reducing Errors should not be the primary focus.
It should be reducing the consequences of errors!
HENCE ZERO IS ACHIEVABLE!!!!!
Reducing Errors should not be the primary focus.
It should be reducing the consequences of errors!
HENCE ZERO IS ACHIEVABLE!!!!!
Human Performance
Part One – Why A Human Performance Approach
Part Two – Individual
Part Three – Organization
Part Four – Leader
Part Five – Case Studies, Implementation, & Review
Objectives
1. Explain what constitutes an
unwanted outcome
2. Describe why the applications of
Human Performance are important
in reducing the frequency &
severity of unwanted outcomes
3. Explain how individual behavior
affects the frequency &
severity of unwanted outcomes
4. Explain how Organizational
Processes and Values
affects the frequency &
severity of unwanted outcomes
Unwanted
Outcomes
Objectives5. Explain how leader behavior
affects the frequency & severity
of unwanted outcomes
6. List the error prevention tools
available to help anticipate and
prevent error likely situations
7. Given a case study as a guide,
explain the attributes of a
successful Human Performance
Improvement Process
8. Explain what we can do
individually and as a company
to meet the objectives of this
course
Unwanted
Outcomes
Leadership
CEREBRAL
RIGHTLEFT
Analytical
Math
Compliance
Regulated
Mandatory
Text
Logical
Factual
Creative
Synergistic
Imaginative
Holistic
Contextual
Futuristic
Intuitive
Feelings
30%
100%
Discretion of Employee
Per
cent
of
Eff
ort
Discretionary Effort
50%
A Simple Model
Performance outcome Y is a
function of factors X.
PerformanceOutcome
Factors AffectingOutcome Y
Y = f (x)
Y = f (x1, x2, x3, x4, x5, … xn)
Positive effect on y
Little or no effect on y
The real challenge is to identify those factorsthat do and don’t drive performance.
Captain Marty McDonough
Negative effect on y
Four Most Common Ways to Reinforce Behaviors:
1.
2.
3.
4.
Positive
Negative
Extinction, Nothingness
Punishment
The Challenge: Identifying what factors affect people performance
Why a Human Performance Improvement Approach?
80% Human Error 30%
Individual
20% Equipment
Failures
Human Error
Unwanted Outcomes
70% Latent
Organization
Weaknesses
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
Cha
nge
Man
agem
ent
Env
ironm
enta
l Con
ditio
ns
Hum
an-m
achine
Inte
rface
Sup
ervis
ory Met
hods
Wor
k O
rgan
izat
ion/
Plann
ing
Writ
ten
Proce
dure
Res
ourc
e Man
agem
ent
Wor
k Sch
edule
Tra
ining/
Qua
lifica
tion
Ver
bal C
omm
unicat
ions
Wor
k Pra
ctic
es
Man
ager
ial M
etho
ds
Oth
er/U
nkno
wn
Num
be
r o
f C
ause
s
1,676 = Org behavior (68%)
806 = Individual behavior (32%)
December 20, 2015
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 weaknesses in the organization, not lack of skill or knowledge
• Error rates can never be reduced to zero
• Consequences of errors can be eliminated
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.
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.
MEDICAL ERRORS AND MISTAKES
Plant
Worker
Processes Values
Individual
• 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 Precursorsshort list
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
Human Information Processing
Source: Wickens, 1992
Shared
Attention
Resources
ThinkingSensing Acting
Information
Flow Path
Organization
Human Performance Fundamentals
Victims of our own Success
Human Performance Fundamentals
Defenses
• Hard -
• Soft -
Two Kinds of Error
Active Error
Latent Error
Was the behavior
intended?
Yes
Were the
consequences
intended?
Yes
Intentional,
sabotage,
Medical
Restrictions?No
No
Were they
communicated
and clearly
understood?
Yes
System
induced
violation
No
Possible
intentional
violation
Yes
Did employee
knowingly violate
requirement?
No
Yes
Were requirements
available, workable
intelligible & correct?
Possible
intentional
Violation
Yes
System
induced
violation
No
Pass
substitution
test ?No-
Deficiencies
in training &
selection or
inexperience?
No
Possible
negligent
error
No Yes
System
induced
error
History
unsafe
acts?-Yes-
Corrective
training or
counseling
indicated
Yes
Blameless
error
No
(a)
(b)
(c)
(d)
(e)
(f) (g)
(h)
(i)
(j) (k)
(l)
(m)
(n)
(o)
(p)
(q)
(r)
g, j,
Culpability Decision Tree
Air Ontario Flight 363 Fokker F28Dryden, CanadaMarch 10, 1989
Performance Modes--Attending Problems
Familiarity (w/ task)Low High
High
Low
Att
en
tio
n (
to t
ask)
Sourc
e:
Jam
es R
eason.
Managin
g t
he R
isks
of
Org
aniz
atio
nal
Accid
ents
, 1998.
Inattention
Misinterpretation
Inaccurate
Mental Picture
Blame
Cycle
Human
Error
Less
communication
Management less
aware of jobsite
conditions
Reduced trustLatent organizational
weaknesses persist
Individual counseled
and/or disciplined
More flawed defenses
& error precursors
The Blame Cycle
Human Performance Tools
• Critical Steps
• Enhanced Pre-Job Briefing
• Peer Check
• Self Check
• Independent Verification
• Error Traps
• Just Culture
• Effective Communication
• Questioning Attitude
• Feeling of Uneasiness
• Enhanced Turnover
• 3 way communication
• Error Precursors
• Performance/Error Modes
• Devils Advocate
• Place keeping
• Poka Yoke
• SAFE Dialogue
• Discovery Clock
• STAR
• Training
What is the Organizations
Role?• Support the Education and
Implementation of the HPI
process
• Encourage Accountability and
the Development of a Just
Culture
• Encourage the use of the HPI
toolsWhat are the Employee’s
Responsibilities?• Have a Questioning Attitude
• Develop a strong sense of
Accountability
• Use of the HPI tools, Use the HPI
tools, Use the HPI tools
➢Stage 1: Obtain senior management commitment.
➢Stage 2: Establish a steering committee.
➢Stage 3: Perform a self-assessment of the current situation.
➢Stage 4: Develop a human performance improvement strategy and plan.
➢Stage 5: Communicate with and empower stakeholders.
➢Stage 6: Implement the strategy and plan.
➢Stage 7: Evaluate and improve the program.
➢Stage 8: Maintain the program.
HPI Implementation Plan
8 Initiative Areas1. Organization Structure
2. Expectations
3. Rewards and Reinforcement
4. Communication and Education
5. Training
6. Work Process & Incident Analysis
7. Assessments
8. Performance Monitoring
I. Error Rates
II. Discovery Clock Resets
III. Latent Condition Identification
IV. Error Precursor Trending
V. Re-work
VI. Culture Survey – Just Culture
VII. Critical Step Identification
VIII. Workforce Human Performance Education
IX. Enhanced Pre-Job Usage
X. Positive to Negative Reinforcement Ratio
XI. Human Performance Defense Usage
Human Performance Fundamentals
Leading Indicators
Drill
into conduit
Fire
Hydrant
Electrical
Panel
Back Into
Power Pole
Root
Cause
Root
Cause
Root
Cause
Root
Cause
Error PrecursorsTime Pressure Stress
Habit Patterns
ChangesAssumptions
Repetitive Actions
Simultaneous
Hidden System Response
Workarounds
Complacency
New TechniqueHazardous Attitude
Interpretation
Unclear Goals
Latent Organization Weaknesses
The Dirty Little Secret of Root Causes