Strengthening Human Performance in the Control …...1 Strengthening Human Performance in the...

Strengthening Human Performance in the Control Room

Mike Legatt, Ph.D., CPT

WECC Human Performance Conference

“Lighting the Path”

October 24, 2017

Core Philosophy:

“All organizations are perfectly alignedto get the results they get.”

Arthur W. Jones

Photo: J. Merlo, NERC

Core Philosophy:

In many ways, human beings are like componentson the grid. They each have their tolerances andoptimal ranges of function.

If you interconnect them well, you can build astrong, reliable and self-healing system. Conversely,you can create sub-synchronous resonances byincorrectly interconnecting them: in this you createinefficient circuits that waste energy and time, andcreate heat, risk and cost.

Managing people is no more and no less than beingan organizational reliability coordinator.

Please Think About…• A great deal of information in this and past Human Performance conferences

• Just culture

• High Reliability Organizational Culture

• Situation awareness

• Circadian rhythms, fatigue & error

• Visual attention, sustained vigilance

• Physiology and Psychology

• User Experience

• Cause analysis

• How can we combine all these pieces to improve human performance in the control room?

Agenda• Reframing the Conversation• Introduction• The changing control room• A look into humans within the organization• Shift work, sleep, and food• Human visual and attentional systems• Looking for meaning• Situational awareness• What are humans, and what is human error?• Cognitive biases• High reliabilty organizational culture• Just culture• Collaboration in emergencies• Near miss reporting• Wrap-up

Examples• Please think of an example of where you saw these occur / not go well:

• Operator error in the control room

• Management error in the control room

• A change in a process or procedure

• Adding a new user interface to an operator’s screen

• Promoting a person to management and training them to be successful.

• Emergency response to a dynamic, unanticipated situation

• Human resources events in the control room

• Operator injury as a result of a vehicle accident, fatigue, etc.

Reframing the Conversation

Reframing

Society

Regulators

Organizations

People

IT Systems

In-the-field devices,

regulated assets

Habits Expectations

• Like much of power systems engineering involves applying knowledge from physics, so does human factors engineering apply knowledge from psychology, sociology & anthropology.

• New view of a power system: humans and technology intertwined into a larger system.

• Humans enhance (not threaten) reliability.• Thus, co-optimizing both each part and their interaction is a key goal --

engineering for success.

Human Factors Engineering

• A great many human factors influence the overall reliability of the system, for example:

Exercise Visual system function

Sleep Cognitive biases

Corporate culture Mood

Genetic factors Training

Self-monitoring Abstract reasoning, empathy

Diet Self-actualization

Stress & fear Positive thinking

Perceived safety Key performance indicators / HR metrics

Human Factors Engineering

Reliability, Resiliency, and Robustness

– Reliability: “Is it working now?”

• Evaluating the consistency of service in real-time, often measured by interruptions (Clark-Ginsberg, 2016)

– Resiliency: “How well/quickly can it bounce back/transform from an adverse event?”

• Evaluating the ability of the system to reduce the magnitude and/or duration of disruptive events…depends upon its ability to anticipate, absorb, adapt to, and/or rapidly recover from a potentially disruptive event” (NIAC, 2009)

– Robustness: “How much can it absorb/withstand disturbances and crises before they become adverse events”?

Reliability, Resiliency, and Robustness– Critical infrastructure resiliency: both physical infrastructure, and the

human components

– Resiliency Engineering: Humans are the primary source of resiliency for an infrastructure

• This is especially true as growing infrastructure nexus challenges occur (e.g., electric-natural gas)

– Therefore, to strengthen an organization’s resiliency, you need:

• Strong ways of measuring resiliency

• Creating the optimal environment for human resiliency– High Reliability Organizational Culture

– Just Culture

– “Team of Teams” approaches

• Building habits of resiliency, rather than unprepared emergency response

Introduction

Who Am I?

What do I do?

Nonlinear Contrast Gain Control

What do I do?

TechnicalSocio-

Emergency OpsNormal Ops

Does It Work?

What do I do?

The Changing Control Room

Interconnected Critical SystemsOften, focus on:

– Electric power

– Natural gas

– Water

– Telecommunications

– CybersecurityBut, they all have in common:

– Humans

• Individuals

• Within-organization collaboration

• Between-organizations collaboration

• Human-computer interactions

What is energy consumption?Can view as the aggregation of:

– Human behavior based on their needs

– Human behavior resulting from policy decisions and financial incentives

– Devices facilitating human behavior

– Human behavior in control rooms, policy decision making, and in the residential and consumer spaces.

– Technical changes to the system as understood by humans

Interconnected Critical Systems• Modes of operation:

– Compliance

– Reliability

– Resilience

– Robustness• Stress?

– Distress

– Eustress• Cascades in human error

A Dynamic Model of Stress and Attention, from Hancock & Warm (1989)

HumansIndividuals

– Humans responsible for building, testing, installing, and maintaining the physical and software components necessary for its function.

– Oftentimes, the interface between the humans and these systems are the fastest growing weakest link.

– Increased number and speed of telemetry devices in the field

• -> New systems or subsystems to handle additional data

• -> Additional UIs

• -> Additional monitors and wallboards

• -> Lowered situational awareness, increased misplaced salience

What are our new patterns?

• Standards &

Procedures

• Metcalf Substation

• Increased media

attention

• Faster news cycles

• Increased breadth and depth of data

• Increasingly dynamic systems

What are our new patterns?

• Our management,

culture, and

colleagues

• Praise from our

management

• Our management’s support of us

• Our mental models – what we believe is

what we see, and who we are is what

we’ve done (Fundamental Attribution Error)

A Look into Humans Within the Organization

Activating Better Habits

Use a positive psychology principal:• Ratio of positive to negative > 2.901 to 1• > Linked to higher performance, lower anxiety• > 7:1 for “superstar” teams• < associated with punitive / fear-based cultures.

Activating Human Performance Improvement

1) What are we creating inside our organizations? Learned helplessness or learned optimism?

2) What are we fighting for inside our organizations? Control or excellence?

3) Are we making it easier for people to do the right things, and harder to do the wrong things? Have we set

them up to be successful?

Unintended Consequences

The Cobra Effect

Unintended Consequences

In the Workplace

Habits of Human Performance

Cue -> Routine -> Reward -> Cue…

– Patterns unfold automatically – brain spends resources on other tasks

– Much (> 40%) of what we do each day not a decision, rather a habit.

Effectiveness of Habits

Brushing vs. Flossing

Images: Colgate & Dentist4Kidz

Creating / Changing HabitsTakes a signifiant amount of willpower.

(Put another way, willingness and ability for self-control).

Self-control as a muscle?

Ego Depletion

In Chemistry, activation energy is what’s needed to make a reaction happen; without it, the reaction won’t occur.

In Psychology, it’s the motivation needed to start a task.

From http://www.nature.com/scitable/content/enzymes-and-activation-energy-14711476

Shift Work, Sleep, and Food

• Slow-Wave Sleep (SWS)

• Rapid Eye Movement (REM) sleep

• The average person needs 7-8 hours

uninterrupted sleep

• Not just “falling asleep”, but “going through

the sleep process”

• Some areas especially susceptible to

interruption

Source: Nature

Circadian Rhythms

Source: Neuroscience Education Institute

Circadian Rhythms

• Slightly longer than 24 hour schedule

• Body temperature, blood pressure, heart

rate, blood chemistry, attention, error

rates, SWS, and others predictable.

• “Synchronized” vs. desynchronized

Source: FAA

Circadian Rhythms

• Time keepers (“zeitgebers”) – cues that

help set our internal clock

–Some of them are social (e.g., SRM-II-5):

Source: Schwartz, H.A. (2013)

Circadian Rhythms

Fatigue

• “After more than 100 years of research on fatigue, we do

not really know very much about it” - Hockley

• “A lack of sufficient steady-state energy to power physical

and/or cognitive work” – Hancock, Desmond & Matthews

• “Fatigue makes cowards of us all” – Vince Lombardi

Fatigue

• Stark & Ash (1917): “When an error occurs it is followed

immediately by other errors and more and more frequently

as the period of work continues”

• Fatigue is not boredom!

• Every hour awake after 10 hours, the equivalent of .004%

BAL decrease in reaction time (Dawson & Reid, 1997).

• Increased error risk, lowered self-monitoring.

Fatigue Research

• Thorndike (1900): “An emotional repugnance to the idea of mental work”

• Bills (1931): Lapses in attention• WWII: Polygraphs of pilots in

flight• Drew, Bartlett & Davis (1948):

Cambridge Cockpit• Eddy (2000): Fatigue

Avoidance Scheduling Tool

• Serotonin is a neurotransmitter (traveling between nerve cells)

• Low serotonin levels lead to clinical depression

• Excessive serotonin leads to extreme feelings of well-being and happiness

– Serotonin syndrome

– Serotonergic neurotoxicity

Serotonin

Image Sources: Wikipedia

• Digesting carbohydrates increases blood sugar, and the body in turn produces more insulin.

• Type 2 diabetes begins when muscle and other cells stop responding to insulin, and eventually insufficient insulin is produced and blood sugar levels stay too high.

Carbohydrates

Image Source: Harvard School of Public Health

• Vigilance is: The ability to maintain attention over long periods of time• Vigilance can decrease due to:

– Memory load

– Event rate

– Adverse environmental factors

– Changes in motivation• Maintaining vigilance is stressful, and exhausting (ego depleting), especially

under high stress

Vigilance over time

• Ford Motor Company (1917) found two 10-minute breaks every day produced greater worker output over the whole day.

• Fatigue is not “one size fits all”:

• Fatigued extroverts perform better in stimulating environments around people, worse in quiet steady-state environments

• The opposite effect is observed for introverts

Studies on fatigue

• Chances of getting acquitted in a criminal trial is higher right after lunch, lower right before (Danziger, Levav & Avnaim-Pesso, 2011).

• Some cultures incorporate early afternoon / post-lunch rest / nap (siesta) to insulate against heat & fatigue.

• In the medical field, a higher probability of human error in the early afternoon (often on long shifts) as opposed to the beginning of a shift.

Time of day

Many drugs used to treat depression are SSRIs – they lead to more serotonin in the brain95% of serotonin is secreted in the gut in response to foodUnder stress, most people tend to increase “snack food” intake, reduce “meal food” intake (Oliver & Wardle, 1998).

Diet and Stress

Experimentally, stress tends to shift people towards higher saturated fat, sugar and calorie foods (Zellner et al, 2006).

– After eating these foods, participants reported feeling better for a short while.

– People already dieting reported much higher levels of stress during these times.

– Suppressing the impulse to eat fatty foods, especially under stress, may increase the risk of ego depletion!

Diet and Stress

• There is a well-known relationship between what you eat and how tired you feel.

• Eating high-carbohydrate foods can lead to hyperinsulemia (excessive insulin)• For people engaged in strenuous exercise, high-carbohydrate foods 3-4 hours

prior lead to reduced fatigue.• For people not engaged in strenuous exercise, high carbohydrate foods are

associated with lightheadedness, fatigue, and occasional fainting.• Fatigue is not just physical; people can also become fatigued mentally.• The brain uses sugar as a fuel source.• Complex mental problems (including vigilance and self-control) require

increased use of sugar in the brain.• People given complex mental puzzles tend to also search out high fat / sugar

/ calorie snacks, compared to people given simple mental puzzles.

Diet and Fatigue

• Large food intake requires more blood flow to the gut, in order to support digestion & absorption.

• Carbohydrate intake also leads to decreases in blood pressure.

Diet and Blood Pressure

Central fatigue hypothesis: Increased serotonin in the brain can lead to decreased sport/exercise performance (Davis, 1996).

Diet and Exercise

Assessment and Monitoring

• Relieve work, or boost performance

• Manage risks of chronic fatigue

• Adaptive automation

• On-task efficiency, vs. driving home

Circadian Rhythm Disorders

• Loss of synchronization between internal

clock and external cues

• Sleep/wake schedules out of phase with

circadian rhythms

• Advanced sleep phase rhythms (early to

bed / early to rise)

• Delayed sleep phase rhythms (late to bed

/ late to rise)

Shift Work Disorder

• Early morning shifts may be associated

with difficulty falling asleep and waking up

• Frequent evening shifts may be

associated with difficulty falling asleep

• Reduced alertness may be associated

with reduced performance and increased

risk, even outside shift hours

• Major portions of free time may be spent

compensating for sleep loss.

Shift Work Disorder

• Most common symptoms:

–Not enough sleep (avg. 5.5 hours)

–Tendency to doze at work

–Reporting low-quality sleep

–Low feelings of well-being

–Decreased physical and mental well-being

– Insomnia (53%), excessive sleepiness (36%)

or both (23%)

Shift Work Disorder

• Social Rhythm Disruption is also

something to consider:

–Loss of social cues predicts a bipolar event

more than general psychological stress

–Social support may be lacking

–Spending time with loved ones and friends

may be harder on night shift rotations, etc.

–Even outside shiftwork, social media doesn’t

make people feel as connected as in-person

interactions

Source: Schartz, H. (2013)

Diet and Fatigue

• Maintaining a fairly constant blood sugar

level helps maintain energy levels

–Eat within an hour of waking, snack every 2-4

–Make sure strong fiber (soluble and insoluble)

in diet, especially at breakfast

• Fruits and vegetables great, but some

better than others

–Broccoli, kale, brussel sprouts, cauliflower

–Less processed generally better

Source: Schartz, H. (2013)

Three-Mile Island (1979)

• Significant increase in reported fatigue

after event at Three-Mile Island.

• 0400: High variability in performance,

operator misinterpreted value.

Source: FAA

• The ones who identified and prevented the tragedy were better rested, newly on-shift.

Three-Mile Island (1979)

• Additional human

factors failures:

hidden indicator

light, ambiguous

indicators

Source: FAA

Tracking sleep

• Take a sleep history! Track:

–Your work schedule

–Your sleep/wake schedule (what times, and

what quality)

–Any snoring, sleep apneas, etc.?

–Use of drugs and medications

–Quality of your surroundings – supportive of

sleep?

Tracking health

• Keep a close eye on:

–Body-mass index (BMI)

–Cholesterol and triglycerides levels

–Blood pressure

–Mood

–Perceived quality of sleep, physical and

mental health

Making shiftwork work

• When sleeping:

–Avoid bright light: sunglasses, dark room, etc.

–Keep your bedroom cool

• Strategically use caffeine in the first half of

a shift, no stimulants in the second half if

possible

• Plan naps

• Avoid working late after a shift end, if

possibleSource: Neuroscience Education Institute

Making Shiftwork Work

• Making social rhythms – within your team,

other friends who have shift work

• Make sure to be “finely tuned”

–Diet

–Exercise

–Social contact

–Quality of sleep

–Low-stress

–Regular physical examsSource: Neuroscience Education Institute

Making shiftwork work

• Bright Light: 10k lux for 30 minutes a day

• Dawn simulation: at end of sleep cycle,

light slowly brightens

Melatonin

• Melatonin in the evening advances the

circadian rhythm – helps make falling

asleep earlier.

• If given early in the morning, it doesn’t

help the person feel sleepy until later.

• Recommended use at 03:00 (circadian

rhythm low)

Sleep aid medications

• Benzodiazepine Hypnotics

–Greater risk of tolerance and withdrawal

–Estazolam, Flurazepam, Quazepam,

Temezepam, Triazolam

• Non-benzodiazepine hypnotics

–Eszopiclone, Zaleplon, Zolpidem

Awake aid medications

• Modafinil and Armodafinil

–Activates areas in the brain that control

wakefulness (the hypothalamus, prefrontal

cortex and anterior cingulate cortex)

–Side effects may include headache, nausea,

dizziness and insomnia

–Modafinil both short- and long-acting,

Armodafinil only long-acting.

Awake aid medications

• Stimulants

–Caffeine (300 mg)

–Energy drinks (no evidence to support use,

plus noted associations with heart rhythm

issues with long-term use)

–Simulant use may lead to increased fatigue

when it wears off.

Positive Psychology

• Positive attitudes/perspectives linked with:

–Better immune system functioning

–Better creativity & building solutions

–Working memory (how many things you can

process at once)

–Positive attitudes lining up for success

–Positive feedback among team members

highly predictive of team success (Losada

Source: Achor, S. (2011)

Sports Psychology

• Visualizing success (Imagery)

• Goal Setting

–Measurable, written, tracked

• Self-Talk

–Phrases or cues that prompt you in to the

mood you want to be in

• Arousal Regulation

–Relaxation and energizing exercises

Source: AASP

Summary

• Shift-work is stressful (but is it

eustress/good vs distress/bad?)

• Any existing other conditions (e.g.,

depression, bipolar disorder, CVD) likely

exacerbated by shiftwork

• However – with tracking and self-

monitoring, you can perform far more

optimally

Summary

• At the end of the day, we appreciate you.

• You do something our society completely

relies on.

• So, we need to respect and support you in

your work – respect your need to sleep,

the hours of time you spend working, and

the sacrifices you make to do what you do.

Human Visual and Attentional Systems

Visual Attention

Simons & Chabris: Selective Attention Test (1999)

Starting Small…

• Eye to LGN to several areas of brain:

– “What” system

– “Where / how” system

–Both involved in visual attention

Starting Small…

• Magnocellular (large cells):

–Edges, motion, low contrast

– “Low resolution”

–10% of LGN area

–Fast processing

–Strong linkages to areas

involved in attention

–Nonlinear contrast gain control

system – speeds up visual

processing to high contrast

Source: Legatt, 2005

Starting Small…

• Parvocellular (small cells):

–Red/green color, form, high

contrast, slower processing

– “High resolution”

–80% of LGN area

• Koniocellular (“sand” cells)

–Yellow/blue color

–Recently discovered

–Hidden between LGN layers

82Source: Legatt, 2005

Signal Detection Theory

• Green & Swets (1966)– Ability to correctly identify

stimuli on a radar screen

• How accurately can you

detect stimuli?– Hit / False Alarm Proportion

– Accuracy (% correct)

– Sensitivity (accuracy)

– Response criterion (bias in

ambiguous situations)

Target Noise

Response Hit False Alarm

No Response Miss Correct Rejection

Measuring Visual Attention:

VC-CPT

• Take out a paper and pen

• When you see the next slide, write down exactly what you see on the slide.

• As soon as you’re done, raise your hand.

• The first person to complete this gets $20!

Starting with a Challenge

Jewelry is shiny

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Source: JMA Human Error Solutions

• How fast was that?

• How hard was it?

– Did any of you make any errors?

– Did any of you have any near misses?

• Now, let’s try that again, but this time do it differently.

• We’ll write out the same lines, • Except we’ll take turns, going between letters and numbers. For

example:

• The first person to complete this gets $20!

• How fast was that?

• How hard was it?

– Did any of you make any errors?

– Did any of you have any near misses?

• So, wait a minute… what just happened here?

How we make mistakes

Humans

Individuals

– “Multitasking” is a myth: switch-tasking / mental set-shifting

Sources: The Simpsons, Frontiers in Human Neuroscience

Change Blindness – Sometimes we don’t see changes in a scene or some critical detail

Problems with Visual Attention

“Multitasking” is the attempt to carry on two or more tasks or activities at the same time.But, really what is happening is both

– Habit / automation – learned behaviors being repeated with little thought

– Frequent “mental set shifting” / “context switching” which is computationally intensive and risky.

– Should something (e.g., driving a car) need a jump in attention, there may be insufficient resources available to help.

“Multitasking” or switchtasking

• Generally, we can do more than one thing, as long as:

– Only one thing requires our conscious attention – and the other tasks can be processed automatically

• e.g., Sending an email while chewing gum

– The task that is requiring our conscious attention can be immediately stopped without consequence and there is time to re-orient

• e.g., we can pause writing out the email when we start to choke on our gum, knowing we can pick up the email later.

• A circuit from Motivation -> Attention -> Memory.

– Therefore, weaknesses in attention mean we have weaknesses storing, holding on to, and recalling memories

– Ever find you had a conversation while driving and a critical detail you knew you needed to know, but couldn't recall?

• Abilities to multitask not significantly different by sex or generation.• It has been estimated $650 billion a year is wasted in the US business

sector due to multitasking: errors and loss of productivity

• When we’re mental set shifting,

– We need extra time every time we move from one task to another, to readjust.

– We lower our performance speed (tasks take between 1½ and 3 times as long

– Our chances of making a mistake grow significantly

– Our IQ temporarily drops by about 10-15 points (worse than a night of no sleep, alcohol, marijuana, or a stroke)

– Our bodies show signs of stress: increased blood pressure, salivary cortisol, heart rate

– We are more likely to cut corners on a task

http://business.tutsplus.com/tutorials/how-to-do-one-thing-at-a-time-and-stop-multitasking--cms-25159

However, this also may feel exciting, and even have addictive components

– More dopamine is released in the brain when we’re trying to multitask

High prolonged multitaskers tend to have smaller anterior cingulate cortex

– A region of the brain responsible for empathy, and mental/emotional control.

Multitasking in meetings and other social settings tends to relate to lower self- and social-awareness / lower EQ.

http://www.forbes.com/sites/travisbradberry/2014/10/08/multitasking-damages-your-brain-and-career-new-studies-suggest/2/

Drivers trying to talk and drive at the same time are both:

– Worse drivers

• 4x more likely to be in a vehicle accident

• Reacted more slowly to brake lights and stop signs

• Involved in more rear-end collisions

• Sped up and braked more slowly than intoxicated drivers (BAL = .08)

– Worse conversationalists

• More forgetful about what discussed

• Struggled to maintain the conversation – especially when it was complexWhether a handsfree device was used or no effect.Listening to audio books did not have a negative effect on driving performanceNew infotainment systems, GPS devices, etc., seem to have similar distracting properties

“Multitasking” or switchtasking: Cell Phones & Driving

http://www.apa.org/research/action/drive.aspx

“Super-taskers”

– About 2 – 3% of the population can perform better when multi-tasking than when uni-tasking. There is likely a genetic influence – they’re born with it, and you can only learn to improve slightly.

– However, people’s ability to gauge their own multitasking abilities is usually inaccurate.

Field of Vision

• Resolution on retina highest at center, lower towards periphery.

– Farther out, you can only detect motion & vague shapes.

– Motion in the periphery can be distracting

Source: Lean Valley

Area of Reach

• Lay out your workspace, and user interfaces so the most commonly-used interfaces and materials are in front of you, and less frequently used materials/interfaces are on the periphery.

Source: UN Enable

Blind Spot

• Close one eye and stare at the cross (if

right eye open) or dot (if left eye open).

Move your head back or forward

Ambient Lighting

Source: Lean Valley

• High contrast differentials between environment and your

screen/UI can cause stress

–Full brightness in the middle of the night

–Low brightness screen in direct sunlight

–Transitioning between the screen and other factors of the

environment can be frustrating, especially if you have to do it often

or in a high-stress situation.

Colors

• Color is a fascinating subject

–Cultural values associated with colors

–Evolutionary issues

• Favorite color blue (60% of men, 35% of women)

Source: Color Blindness Simulator

• Processing speed

increases when

large red objects

– In the eye, three

types of cones

process color

signals

Issues with color

• Color discriminability decreases both with

age and nicotine use

• Color deficiency / blindness

Source: Chroma: A wearable augmented reality…

Targeting our visual system

• Based on knowledge on the visual system:

– If colors are being used, critical information

should have strong red/green components

(but check users for color blindness)

–Motion captures attention – only use when

you want to capture attention

–Critical information should not have low

contrast differentials

Source: UN Enable

Information Organization

• Try to group UIs based on task, frequency

of use, and/or how critical its information

• Try to minimize redundant data across

multiple screens

• If possible, integrate information from

multiple sources to support operations

• If possible, stay involved in

development/vendor efforts; make sure

the screens you receive work for you.

Information Organization

• When possible, show as little “all good”

information – especially in complex

systems

• Provide straightforward paths to navigating

to detail and searching

• Whenever possible, test screens in

simulations under a variety of conditions

before deploying.

Information Processing

Source: Hancock & Warm (1989)

• Most difficult to

process information

under extreme

stress (reptilian

complex)Working memory

decreases under

stress (7±2 => 3-5

or lower w/ long

term damage)

User-Centered Design

• Organize around:

–User procedures and abilities

–The way we process information and make decisions

Source: Bernardo Malfitano

–Users understanding the

state of the system (e.g.,

avoid early auto-pilot

failures)

Focus on the message

• “This system is powerful”

Source: StackExchange

Source: Rudy Vessup

• “This system is powerful” + a lot going on

Source: Gizmodo

Source: YouTube

Source: Design Directions

“This system is powerful”

“This system is optimized so you

can quickly understand what is

going on”

Source: UN Enable

• “This system is trying to optimize SA”

Sources: SA Tech, DHS,

• Why “this system is powerful?”

–Dignitaries and others visiting control rooms

– “cool” / “wow” factor

• Why “Optimizing SA?”

– Important, mission critical systems

–Data that may be changing rapidly, and is of

importance

–Trust in core systems – show primarily the

exceptions, not all information

Source: UN Enable

Avoid Pitfalls

• Attentional narrowing – attention grabbed,

drawing focus away from critical

information

• Data overload – More/faster information

presented than a human can process

• Misplaced salience – Avoid the wrong

things standing and catching your

attention

Source: Endsley, 2011

Avoid Pitfalls

• Complexity Creep – Additions to a UI or

procedure may affect far more than one

screen

• Low operator confidence in systems

• Uncertainty in data not represented to

Avoid Pitfalls

• Alarm screens

– “Alarm storms” – critical information scrolling

off the screen due to other important alarms

– “Dust storms” – critical information scrolling off

the screen due to unimportant alarms

Watch for Data Context &

Misinterpretation Risk

Source: J. Merlo

Watch for Data Context &

Misinterpretation Risk

Source: J. Merlo

Focus On What’s Important

Source: J. Merlo

Focus On What’s Important

Source: J. Merlo

Looking for Meaning

Why does corporate culture matter?

Esteem Needs

Belongingness and Love Needs

Safety Needs

Physiological Needs

SelfActualization

Why do we need good corporate culture?

Job market transparency employee expectations

Employees are becoming less engaged and satisfied (less than30%, despite education gains, >$500B losses –Gallup, 2012)

The trend toward education over hands-on experience

“What happens on the internet stays there… forever.”

Social media is changing communications and introducingboth benefits and risks

Existing sources of pressure and risk are growing

What makes for good management?

Google Oxygen ProjectManagers are successful who:

1) Are good coaches2) Empower their teams and don’t micromanage3) Express interest in team members’ success and personal well-being4) Are proactive and results-oriented5) Are good communicators and listen to their team6) Help their employees with career development7) Have a clear vision and strategy for the team8) Have key technical skills so they can help advise the team

Managers are NOT successful when they:1) Fail to recognize that managing is different than individually contributing2) Are inconsistent in performance management and career development3) Spend too little time managing and communicating

Mike Legatt

The How and Why of Why

The Emerging field of Positive Psychology

Corporate culture and employee engagement are key

Fear suppresses

– Creativity

– Motivation

– Positive ownership

Employee management is a skill, not just the next titlechange or compensation strategy

Need for cost reductions: health care, PTO, other risks

Fredrick Winslow Taylor– Mechanical engineer who sought to improve industrial efficiency

– One of the first management consultants

– Wrote The Principles of Scientific Management:

• Replace “rule-of-thumb” methods with those based on scientific study

• Actively select, train, and develop each employee

• Provide detailed instruction and supervision of each worker in the performance of that worker’s discrete task

• Divide work between managers and workers: managers plan/think, workers do.

– Moved from skilled individuals doing many things to less skilled individuals, each doing one thing over and over

– Motivating them simple: financial awards can make them work fasterSource: McChrystal, S. (2015). Team of Teams.

Fredrick Winslow Taylor• Taylor efficiencies not working in today’s world

– Much of what we do is now on thought not repetitive, automatic actions.

– Financial bonuses now decrease performance and increase error rates.

– Many employees now searching for more meaning in their work; cultural and short term KPI misalignments abound.

Source: McChrystal, S. (2015). Team of Teams.

Managing Human Beings and Organizations

W. Edwards Deming(1900-1993)

Source: deming.org

• “What you can measure, you can manage”

• “If you can’t measure it, you can’t manage it.”

Managing Human Beings and Organizations

W. Edwards Deming(1900-1993)

Source: deming.org

“It is wrong to suppose that if you can’t measure it, you can’t manage it – a costly myth…

It is the relationship with people, the development of mutual confidence, the identification of people, the creation of a community.

This is something only you can do. It cannot be measured or easily defined.

But it is not only a key function. It is one only you can perform.”

Situational Awareness

• “The perception of elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status into the near future” (Endsley, 1988).

• “Continuous extraction of environmental information, integration of this information with previous knowledge to form a coherent mental picture, and the use of that picture in directing further perception and anticipating future events” (Dominguez, 1994).

Situation Awareness

Three levels of situational awareness:

– Level 1: Perception

• What is going on?

– Level 2: Comprehension

• What does it mean?

– Level 3: Projection

• Where is it going? What am I going to do about it?

Situational awareness is necessary both in individuals and within teams.

Three components of situation awareness:

– Spatial awareness - where you and other objects are in space, orientation to location.

– System awareness – understanding about the state of the system(s)

– Task awareness – understanding about the tasks being engaged in

Situation Awareness

Performance

Based On: Steve Kass, Military Psychology

Situational

Awareness

WorkloadAttention

Pattern

Recognition Working

Memory

Mental

Models

Stress/

Perceived

Safety

“Loss Of Situational Awareness” is NOT one of many phrases to represent individual human error, leading to punishment of that individual.

Instead, it is one of several lenses into human performance that helps to understand why a mismatch between environment and human capabilities occurred.

Mental Models

How people internally represent the task they are performing / situation they’re in.

• Schema – Representing and organizing information into interconnected chunks

– Experts organize into larger, more effective, more accessible chunks

– Novices struggle to organize schemata

Working MemoryShort-term / processing memory (7 ± 2; Miller, 1956)These 7±2 points can be “chunks”, allowing for better storage and processing.Working memory decreases under stress (7±2 => 3-5, or even lower with long term damage)

747 cockpit

Attention and Human Performance

Situation Awareness Errors

Source: SATechnologies

Situation Awareness: Is this a good example?

Situation Awareness: Are these good examples?

Situation Awareness – Common Pitfalls• Attentional narrowing

– Attention grabbed, drawing focus away from critical information• Data overload

– More/faster information presented than a human can process• Misplaced salience

– The wrong things standing and catching your attention• “Out of the loop”

– Uncertainty in data and system status not represented to users• Short-term memory over-reliance

– Holding too many chunks, or for too long (> 30 sec)

Situation Awareness – Common Pitfalls• Complexity Creep

– Additions to a UI or procedure may affect far more than one screen• Low operator confidence in systems• Workload, anxiety, fatigue, loss of perceived safety• Incorrect mental models• Inattention

Situation Awareness – Common Pitfalls• Alarm screens

– “Alarm storms” – critical information scrolling off the screen due to other important alarms

– “Dust storms” – critical information scrolling off the screen due to unimportant alarms

– Alarm accuracy – False Alarms, percent correct

Target Noise

Response Hit False Alarm

No Response Miss Correct Rejection

What are Humans, and What Is Human Error?

Human Error

“Human error is a consequence, not a cause. Errors are shaped by upstream workplace and organizational factors… Only by understanding the context of the error can we hope to limit its reoccurrence”

James Reason

Human Performance Under Stress

A Dynamic Model of Stress and Attention, from Hancock & Warm (1989)

How we make mistakes

From: NERC Cause Analysis Methods

Cognitive Biases

A baseball and bat together cost $11. The bat costs $10 more than the ball. How much does the ball cost?

Did you say $1 for the ball?

– Most people do, but:

– The correct answer is $0.50:

– $10.50 - $0.50 = $10.00

Why do many of us make these kinds of mistakes?

– Mental shortcuts tend to shorten the amount of time it takes us to come up with an answer, but doesn’t necessarily work in all situations.

A quick thought exercise…

Humans

Individuals

– Cognitive biases

IDENTITY THEFT“Apparently, when you publish your social security number prominently on your

website and billboards, people take it as an invitation to steal your identity.”

LifeLock CEO’s Identity Stolen 13 Times–K. Zetter, Wired.com, April 2010

• Recognizing some of the factors that contribute to human error doesn’t necessarily protect you from consequences of it

• Overconfidence can creep in, especially from feeling more competent than you actually are

• Danger exits from illusion of explanatory depth(IOED)

Protecting the Self From Consequence of Error

• People often overestimate their ability to explain mechanical, natural, and social processes (Alter, Oppenheimer, & Zelma, 2010; Keil, 2003)

– You likely know that a zipper closes because teeth somehow interlock. But do you know how the teeth actually interlock to enable the bridging mechanism?

– You probably have a vague notion that an earthquake occurs because two geological plates collide and move relative to one another. But do you know more about the mechanism that initially produces these collisions?

– You may think you know your preferred political candidate’s stance on a policy, but do you really know the intricacies of what they believe on an issue?

Illusion of Explanatory Depth

• You look at a checklist or procedure, and think you understand the intent of the writers and that they anticipated all possible risks.

• You understand how a piece of equipment works in normal operations (> 95% of the time). Can you accurately anticipate how it will work in an abnormal condition?

• You think may think you know your coworkers’ or employees’ knowledge level and skill set, but do you actually know how they would respond to an emergency or crisis?

• Setting up a projector or conference call is simple… or not.

IOEDs At Work

• People are better calibrated when assessing their knowledge for declarative facts and trivia (Rozenblit & Keil, 2002)

– E.g., country capitals• Hints at why IOED occurs – awareness of our lack of specific knowledge

in these domains• People know generally why manmade objects, natural events, and

social events occur, but lack insight on specifically how they work or happen

But, the Domain Matters

• Confusion occurs between why and how, and people end up believing they understand complicated manmade, natural, or social concepts quite deeply

• Further, people are often surprised by the shallowness of their own explanations when prompted to describe the concepts thoroughly

• People understand certain concepts at an abstract level quite well

• But, they only superficially understand their more concrete characteristics

• So, when people mistake their mastery of abstract for concrete characteristics, IOED will emerge.

Why Does IOED Happen?

• Find a way to focus on the information that illuminates the depth of your understanding

• Steer away from focusing on uninformative cues• Focus on concrete rather than abstract knowledge,

and you should realize your ignorance and hopefully take steps to remedy it

How Can You Avoid IOED?

Focus on differences rather than similarities (Namkoong& Henderson, 2014; 2016)Games played from a very young age encourage us to develop this skill

How Can You Shift Your Focus?

Spot the difference

• Focus on instances rather than categories (Fujita, Trope, Liberman, & Levin-Sagi, 2006)

–Particularly necessary for people in a position of power (Smith & Trope, 2006)

Minimize psychological distance (time, space) during decision-making (Trope & Liberman, 2010)

Revisiting issues that were

settled in the distant past

Revisiting decisions that were

made in distant locations

(e.g., retreats, conferences,

working from home)

Cognitive Biases (a sampling)

• Anchoring – something you’ve seen before seems like the benchmark (e.g., first time you paid for gas)

• Attentional bias – You’re more likely to see something if you’re thinking about it

• Cognitive dissonance – uncomfortable to have two conflicting thoughts

• Confirmation bias – pay attention to things that support your belief

• Diffusion of responsibility – “someone else will take care of it”

• Fundamental attribution error – you do things because of the situation, others because of their personality

• Google effect – easy to forget things that are easily available electronically

• Groupthink – people less likely to contradict ideas in a large group

• Hindsight bias – the past seems perfectly obvious• IKEA effect – things you’ve built seem more valuable to

you than things others have built• Illusion of transparency-expect others to understand

your thoughts/feelings more than they can• Loss aversion – you’re more likely to try avoid losing

than gaining

• Organizational bias – you’re likely to think ideas within your organization are better

• Outgroup homogeneity – you’re likely to think that people in another group all think the same

• Semmelweis reflex – rejecting new ideas that conflict with older, established ones

• Zero-risk bias – likely to choose worse overall solutions that seem less risky

High Reliability Organizational Culture

• Rhode Island Hospital

– A top medical institution

– Deep tensions between doctors and nurses

• “This place can be awful. The doctors can make you feel like you’re worthless, like you’re disposable. Like you should be thankful to pick up after them.” (A nurse interviewed by a reported in 2000)

– “Time-out” procedure called by a nurse

• Surgeon stormed out, saying “If I want your damn opinion, I’ll ask for it. Don’t ever question my authority again. If you can’t do your job, get the hell out of my OR”. (Duhigg, 156)

An example…

• Compensatory techniques informally developed

– Doctors names written on whiteboards – different colors depending on their abrasiveness

– Nurses would communicate ad-hoc when a doctor made a mistake; nurses tended to check up on more error prone doctors

An example…

• July 30, 2007• Neurosurgeon J. Frederick Harrington Jr., asked to perform an

emergency surgery on an 86 year-old patient with a subdural hematoma on the left side

• At the time, Dr. Harrington was in the midst of a lumbar laminectomy –quickly reviewed the slides but didn’t write down the side of the hematoma; his nurse failed to note it as well

Setting the stage…

• In the surgical suite..• A nurse noted that the consent form lacked a side, and asked for a time

out• Harrington snapped “we have no time for this!” and encouraged the

nurse she could log into a computer and check the CT scans, but he would have her terminated if she did.

• He misremembered the side of the hematoma, and operated on the wrong side of the patient’s skull.

• When Harrington realized the mistake, sealed up the skull and skin, turned the patient over and operated on the correct side, a great deal of time was lost. The patient died two weeks later.

• State board fined the hospital $50k

• A few months earlier, a doctor and nurse both admitted they weren’t trained to use a checklist, having failed to mark the spot of another neurosurgery.

• A few months later, a doctor and nursing staff discussed a surgery (identifying the correct side), then proceeded to operate on the wrong side of an elderly woman.

– “I don’t know if [the nurse] even knows why she didn’t speak up” • A year and a half later, a surgeon operated on the wrong part of a child’s

mouth during cleft palate surgery• Ten months after that, a drill bit was left inside a patient ($450k fine)

High Reliability Organizations• “Fishbowl” industries – exceptionally strong social and/or political

pressure crashing down in a failure event.• Complicated systems/fields with a high probability of error.• Major mistakes are so severe, you can’t afford to learn by trial and error.

– Human Error rates typically (3-7 errors per hour, 11-15 under high stress, fatigue, etc.)

• An organization with relatively error free operations over a long period of time.

• An organization that again and again accomplishes a high hazard mission while avoiding catastrophic events.

• An organization in a field in which failures are so severe, they should be avoided at almost any cost.

High Reliability Organizations• Five Principles:

1. Preoccupation with failure

2. Reluctance to simplify

3. Sensitivity to operations

4. Commitment to resilience

5. Deference to Expertise• Not “error free”, but “not disabled by an error”• Physical, social and external facets combine in complex operations• Formal and informal expectations for peak performance• Ability to decentralize in an agile fashion in emergencies. TRUST.• Redundancy in people, roles, training

High Reliability Organizations• “As they strive for high reliability, organizations shift away from having

outside bodies solely determine their quality agenda to developing an agenda that incorporates the organization’s most important goals.”

Mark R. Chassin, M.D., F.A.C.P.The Joint Commission Center for Transforming Healthcare

• Higher job satisfaction, lower turnover, greater willingness to share learning (Egan & Bartlett, 2004)

• Better at interviewing and selecting candidates who fit in well with HRO mission (Ericksen & Dyer, 2007)

• Less losses due to lost wages, training, severance, sick days, etc.

Just Culture

Responding To Human Error

Outcome Bias

“The single greatest impediment to error prevention…

is that we punish people for making mistakes.”– Dr. Lucian Leape, Professor, Harvard School of Public Health,

1999 Testimony before Congress on Health Care Quality Improvement

Over-Reaction Under-Reaction

• Discipline of discrete error

• Discipline person who didn’t see risk

• Over-reaction to singular events

• Turn a blind eye to risky choices

• Allow reckless people to go unchecked

• Pass over severe system design flaws

The case for just culture

Traditional management styles lagging research & employee expectations

Vast amount of work frustration due to inequity and ambiguous signals

RecoveryBarriers Redundancy

Ways of addressing events

First, we must first identify At-Risk Behavior Types

Human Error (3-7 to 11-15 errors per hour)

(The better we are the harder it is to perceive drift)

At-Risk Behavior

(< 2% but extremely dangerous)

Reckless Behavior

Just Culture Approach

Managing Risk – Fairly and Consistently

Repetitive Human Error

Repetitive At-Risk

Reckless Behavior

At-Risk Behavior

Human Error

Console Remediate or Discipline

Remediate or Discipline

DisciplineCoach

▪ One approach that works across all values

▪ One approach that works both pre and post event

▪ One approach that applies to everyone at all levels

Collaboration in Emergencies

February 2, 2011, in ERCOT region

–Unexpectedly cold weather

–Several power plants (weatherized to handle 110°+F weather) were unable to come or stay online

–ERCOT initiated EEA level 3 (rotating outages) due to insufficient physical responsive capability

February 2, 2011, in ERCOT region

– A transmission operator, receiving the order, opened a breaker to a circuit, without realizing that circuit fed a natural gas compressor

– By doing so, the compressor went offline and the pipeline pressure began to drop, offlining another natural gas power plant and an NG feeder to a neighborhood, further worsening conditions

– Coordination and collaboration between parties?

– How long did it take for the parties to collaborate?

Near Miss Reporting

Near-Miss Reporting

Near-misses are times when errors ALMOST occur but don’t –due to luck, an error catch, or barriers just barely working (or successfully working but in the wrong context)In some organizations with after action reviews they may come up but often aren’t documented in a taxonomy

Peer Check

Safety Check

Near-Miss Reporting

– Every time a near miss occurs, it is an OPPORTUNITY.

– But, it needs:• Corporate culture that

supports near miss reporting (e.g., just culture)

• Treatment of the individual as an SME on the error, not a liability

Peer Check

Safety Check

Near-Miss Reporting

– But it needs:

• An organization focused on being proactive, not reactive

• An organization with the ability to not only capture, but also track and trend near misses (organizational situational awareness)

Peer Check

Safety Check

Near-Miss ReportingTake the analogy of user experience (UX) in software development:

A bug fixed during the software development (alpha) stage: 1x

A bug fixed during the testing (beta) stage: 10x

A bug fixed in the production phase: 1000x!

This study was focused on financials (dollars) in terms of development costs.

But, it also can apply to stock price, public reputation, strength of relationships between entities, etc. So – a near miss reporting system can be a significant pathway to cost and reputational risk savings.

Erhlich & Rohn, 1994

Near-Miss ReportingChallenges and solutions to near miss reporting:

Natural disinclination to admit to an error.

Anonymous or at least confidential reporting

Suspicion that a report can be counted against the reporter

An organizational policy of indemnity.

Separation of group functions

Source: DOE Human Performance Improvement Handbook, Volume 2

Near-Miss ReportingChallenges and solutions to near miss reporting:

Skepticism – management won’t take action

Feedback to reporting community

Reporting will take too much time or effort

Reporting infrastructure needs to be easy and available to all

Source: DOE Human Performance Improvement Handbook, Volume 2

Near-Miss ReportingA pathway to implementing a near miss reporting structure:

Inform, organization-wide

Designate an event report coordinator

Develop a report format

Make the report form readily available

Provide examples of reports

Encourage reporting of errors

Track and trend errors

Use data in ongoing training and lessons learned

Near-Miss ReportingSome additional suggestions for near miss reporting:

Positive reinforcement: A positive recognition for a reporting event (aligning with an organization’s well stated mission of continuous improvement). Strongly suggest social-domain, not financial domain.

Tracking reports: Allow reporters to see, at some level, that their report is being taken seriously, and tracking and growth is occurring.

“All organizations are perfectly aligned to get theresults they get.”

Arthur W. Jones

The same is true for critical infrastructures.Having the right cultures and collaborations canlead to our getting the results we want.

Photo: J. Merlo, NERC

Core Philosophy?

Wrap-up

Closing Thoughts

In many ways, human beings are like components on the grid. Theyeach have their tolerances and optimal ranges of function.

If you interconnect them well, you can build a strong, reliable and self-healing system. Conversely, you can create sub-synchronousresonances by incorrectly interconnecting them: in this you createinefficient circuits that waste energy and time, and create heat, riskand cost.

Managing people is no more and no less than being an organizationalreliability coordinator.

Thank youMike Legatt, Ph.D., CPT

legatt@resilientgrid.com

Strengthening Human Performance in the Control …...1 Strengthening Human Performance in the...

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