HUMAN PERFORMANCE PROVING THE PRINCIPLE
T. Shane Bush Peggy S. Bush (208) 521-5180 2020 Stosich Lane Idaho Falls, ID 83402 [email protected]
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
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
Some small companies claim to go out of business!!!!!!!! Phone Book Listed the Wrong Phone Numbers…..
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.
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
ageri
al Meth
ods
Other/U
nkno
wn
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)
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
WHY A HUMAN PERFORMANCE IMPROVEMENT APPROACH?
80% Human Error
20% Equipment Failures
Human Errors
Unwanted Outcomes
30% Individual
70% Latent Organization Weaknesses
Error Precursors
Perform Mode(s)
Latent Conditions
Suggested Corrective Actions
Three Sources of Input
Suggest The Corrective Actions That Apply
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
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.
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
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”
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
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