HUMAN PERFORMANCE PROVING THE PRINCIPLE

T. Shane Bush Peggy S. Bush (208) 521-5180 2020 Stosich Lane Idaho Falls, ID 83402 Shane@bushcohpi.com

First, A Quick Review of The Fundamentals…………

To proactively prevent “Unwanted Outcomes” triggered by human error.

Purpose of Human Performance Improvement

Unwanted Outcomes

So what is an error?

Most people associate an error with a bad outcome! Accident, incident, incorrect answer, etc.

Good - rare (serendipity) sticky notes? Bad - an outcome that causes you grief Benign - little to no consequences (most)

Error: Can have one of three outcomes….

To proactively prevent “Unwanted Outcomes” triggered by human error.

Purpose of Human Performance Improvement

Unwanted Outcomes

Unwanted Outcomes: Injury Mission Interruption Damage

Most Errors have one Common Denominator…………..

The Human Performance Tool Box: 1. Pre-Job Briefing 2. Two-Minute Rule 3. Three-Way Communication 4. Phonetic Alphabet 5. Procedure Use & Adherence 6. Place Keeping 7. Flagging/Operational Barriers 8. Self-Checking 9. Independent Verification 10. Concurrent Verification 11. First Check 12. STOP When Unsure 13. Peer Checking 14. Post-Job Review

“I know you think you know what I said, I just don’t think you know what I meant.”

August 24, 2017 Lottery Ticket $758 Million

Wrong store told they sold the winning ticket and soon will receive

$50,000.000

April 17, 2017 Idaho Falls, Idaho

Doctor mistakenly removed wrong kidney!

Doctor was Given the Wrong MRI Results….

What happened on February 13, 2017 in Orange County?

Harrison Ford Lands on Taxiway instead Runway………. Confused on Airport Layout.

What happened on February 26, 2017

Announced La La Land instead of Moonlight As Best Picture. Given the Wrong Card!

Does anybody remember an error on December 20, 2015?

Some small companies claim to go out of business!!!!!!!! Phone Book Listed the Wrong Phone Numbers…..

Two 10-year sentences accidently entered to serve simultaneously instead of back to back

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

Carnegie Mellon in admission bungle Hemali Chhapia, TNN | Feb 19, 2015, 04.26AM IST inShare5

Admit letters for the 2015 fall entry were sent out by this top university in the US to prospective masters’ students around the world on Monday. In a matter of a few hours, the university sent out rejections and stated that the gaffe was a result of serious mistakes in their process for generating acceptance letters.

MUMBAI: Carnegie Mellon, a top destination for engineering graduates around the world, accidentally admitted 800 candidates to its blue-chip computer science programme, only to retract the offer about seven hours later. Admit letters for the 2015 fall entry were sent out by this top university in the US to prospective masters' students around the world on Monday. In a matter of a few hours, the university sent out rejections and stated that the gaffe was a result of serious mistakes in their process for generating acceptance letters. While this caused disappointment among all those who were rejoicing after a stressful and anxious wait, some others already employed rushed to their bosses with happy resignation letters.

Cool Hand Luke

Error: Something you didn’t intend to do.

Error: Something you didn’t intend to do.

WHY A HUMAN PERFORMANCE IMPROVEMENT APPROACH?

80% Human Error 30% Individual

20% Equipment Failures

Human Errors

Unwanted Outcomes 70% Latent Organization Weaknesses

INDUSTRY EVENT CAUSES DUE 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 M

anag

emen

t

Enviro

nmen

tal C

ondit

ions

Human

-mac

hine I

nterfa

ce

Superv

isory

Methods

Work

Orga

nizati

on/Plan

ning

Writt

en Proc

edure

Res

ource

Man

agem

ent

Work

Sched

ule

Trainin

g/Qua

lificati

on

Verbal

Commun

icatio

ns

Work

Practic

es

Man

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al Meth

ods

Other/U

nkno

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Num

ber o

f Cau

ses

1,676 = Org behavior (68%)

806 = Individual behavior (32%)

WHY A HUMAN PERFORMANCE IMPROVEMENT APPROACH?

80% Human Error 30% Individual

20% Equipment Failures

Human Errors

Unwanted Outcomes 70% Latent Organization Weaknesses

Smoke

Pre-baby boomers (born before 1945)

Baby boomers (born between 1946-1964)

Post baby boomers (born after 1965)

Text ‘Yes’ to 1947832

Baby Boomers are retiring at 8,000 people per?: A.Week

B.Day

C.Year

Quiz

Baby Boomers are retiring at 8,000 people per?:

B. Day

Quiz

And will continue to retire at 8,000/day for the next?:

A.10 Years

B.15 Years

C.18 Years

Quiz

And will continue to retire at 8,000/day for the next?:

B. 15 Years

Quiz

What does all this have to do with the “Revolution of Safety for the Next Generation?

Mature Generation: Some resistance to change Years of doing it a certain way Are usually the bosses Worked to rules Saturday Worked Harder

Next Generation: Embrace, even love change There is no old way Prefer mentor over boss Eager for change Right Now! Saturday is Day-Off Resistant to heavy handed

How many of you remember

buying your first?:

Computer? VCR? Color TV?

Do different generations communicate differently???

The Opposite of Human Performance is Complexity…..

WHY A HUMAN PERFORMANCE IMPROVEMENT APPROACH?

80% Human Error

20% Equipment Failures

Human Errors

Unwanted Outcomes

30% Individual

70% Latent Organization Weaknesses

30% Individual

70% Latent Organization Weaknesses

What The …………..

Really?!

Start Breaking it Down

Skill Based (30%) Org Factors Known to Influence Skill Based Errors of Inattention (70%)

OK………

Rule Based (30%) Org Influencers (70%)

Knowledge Based (30%) Org Influencers (70%)

Then they added the flippin error pre-cursors!

And did they Stop There?

NO! Let’s Add Latent Organizational Weaknesses

And then they decided if we add color to it and put in on one slide that has to make it simplier……

And that is about as simple as The government could make it.

This is going to be Huge!

The Opposite of Human Performance is Complexity…..

DOE Human Performance Occurrence Guide 231.1-2

And that is about as simple as The government could make it.

Error Precursors

Perform Mode(s)

Latent Conditions

Suggested Corrective Actions

Three Sources of Input

Suggest The Corrective Actions That Apply

Software is what it took to bring it all together

People Need Reminded A Lot More Than They Need Re-Trained

30%

100%

Discretion of Employee

Perc

ent o

f Effo

rt Discretionary Effort

50%

CEREBRAL

RIGHT LEFT

Analytical Math Compliance Regulated Mandatory Text Logical Factual

Creative Synergistic Imaginative Holistic Contextual Futuristic Intuitive Feelings

CEREBRAL

RIGHT LEFT

Analytical Math Compliance Regulated Mandatory Text Logical Factual

Creative Synergistic Imaginative Holistic Contextual Futuristic Intuitive Feelings

Say the color, word, color, word …

Yellow Green Blue

Blue Green Red Yellow Green Blue Red Yellow Blue

Say the color, word, color, word

Are you right eyed or left eyed?

30%

100%

Discretion of Employee

Perc

ent o

f Effo

rt Discretionary Effort

50%

THE KEY TO UNDERSTANDING ERRORS

Context !

LO/TO

X

Facts

X

Principles 1. 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.

Finished Files are the Result of Years of Scientific Study Combined With the Experience of Many Years.

Principles 1. 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.

Buffalo Goring Yellowstone Park

Principles 1. 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.

Work Location

Physical Plant Touchers Paper Plant Touchers

Decisions

Org Processes Values Mind the

Gap

65 74

65 78

9

Principles 1. 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.

Principles 1. 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.

Drill into conduit

Fire Hydrant

Electrical Panel

Back Into Power Pole

Root Cause

Root Cause

Root Cause

Root Cause

Error Precursors Time Pressure Stress

Habit Patterns

Changes Assumptions

Repetitive Actions

Simultaneous

Hidden System Response

Workarounds

Complacency

New Technique

Hazardous Attitude

Interpretation

Unclear Goals

Organizational Weaknesses

“The Dirty Little Secret of Root Causes”

… is how prepared you are for plan B.

Bob’s Veterinarian/Taxidermist

“Either Way You Get Your Dog Back”

Sheryl Sandberg, COO Facebook

Resiliency: “The Strength and Speed

of our Response to Adversity”

Just the Facts Mam.

The Correct Perspective

Inside

Hindsight

Outside

See the world from the point of view of people inside the situation – not from outside or hindsight

CONTEXT Does not justify behavior – it explains it.

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 tools

What 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

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Capacity Factor(% up)

Cost (¢/kwh)

Rx Trips/Scrams

Significant Events/Unit

100%

90%

80%

70%

60%

50%Industrial Safety

NEI (Nuclear Energy Institute)

Does an HPI Approach Make Sense? U.S. Nuclear Industry Performance 1985-2015

HPI Initiated