Turning Defense into Offense
HUMAN PERFORMANCE
FUNDAMENTALS
Introductions
•
•
•
•
•
Name
Position
Location
Time on job
Expectations
2
Housekeeping
•
•
•
•
•
•
Restrooms
Exits (fire assembly area)
Breaks
Cell Phones
Parking Lot
Safety Note
3
Purpose of this Training
To reduce the frequency and severity
of events and improve operational
performance.
Senior Management Quote Here
4
At (your company name here), we
value safety
• HP Tools and Concepts
• Error free = event free
• Event-Free Clocks
• Goal is ZERO accidents
5
Why Learn this at (your company name here)?
• Values: what we care about most; our
beliefs.
• Culture: all the common values of the
company. These influence everyone’s
attitudes, choices, and behavior.
• Performance Improvement: we can
anticipate an error-free workplace
6
Training Objectives
• Describe the types and causes of
human error
• Describe human performance concepts
and principles
• Apply the principles of human
performance in a case study
• Identify the human performance tools
• Apply the appropriate tools in work
situations
7
Module 1
Types and Causes of Human
Error
8
Defining Human Performance
•
•
•
•
Department of Energy (DOE)
Concepts
Principles
System
– Not step-by step process
• Behaviors
9
Little Things Lead to Big Things!
1
10
30
600
10
Layers of Responsibility Contributing to
Human Performance
Leaders
Organization
Individuals
Human
Performance
11
The Elements that Impact Human
Performance
It is a system of interdependencies
12
Counting Exercise
Read the following sentence
and count the number of F’s
you find.
13
Counting Exercise
FINISHED FILES ARE THE RESULT OF
YEARS OF SCIENTIFIC STUDY
COMBINED WITH THE EXPERIENCE OF
YEARS.
14
Counting Exercise
FINISHED FILES ARE THE RESULT OF
YEARS OF SCIENTIFIC STUDY
COMBINED WITH THE EXPERIENCE OF
YEARS.
Did you find six?
15
Reading Exercise
Clearly read the following
paragraphs.
16
Reading Exercise
Aoccdrnig to rscheearch at Cmabrigde Uinervtisy, it deosn't
mttaer in waht oredr the ltteers in a wrod are wirttn, the olny
iprmoetnt tihng is that the frist and lsat ltteer be at the rghit
pclae.
The rset can be a total mses and you can sitll raed it wouthit
porbelms. Tihs is bcuseae the huamn mnid deos not raed ervey
lteter by istlef, but the wrod as a wlohe. Amzanig huh?
17
Types of Errors:
•
Active Error – An
obvious mistake that
has immediate, visible
consequences.
•
Latent Error –
A hidden mistake that
has consequences that
are not immediate. *
(Seat belts are a good idea)
18
How we commit errors
Slip
Attention Failure
Intrusion,
Intrusion,Omission,
Omission,
Misorder,
Mistiming
Mis-order,
Mistiming
Lapse
Memory
Memory Failure
Failure
Forgetting
Forgetting intention
intention
Lost
Lost place
place
Omitting
Omitting planned
planned item
item
Unintended
Unintended
Action
Action
Human
Error
Mistake
Planning Failure
Misapplication of good rule
Application of bad rule
Intended
Action
Violation
Shortcuts
19
Human Information
Processing
Shared
Attention
Resources
Sensing
Thinking
Acting
Source: Wickens, 1992
Information
Flow Path
20
Performance Modes
High
1 in 10
1 in 100
Source: James Reason. Managing the Risks
of Organizational Accidents, 1998.
Attention (to task)
Inaccurate
Mental Picture
Error Rate
Reduction
1 in 1,000
Misinterpretation
Inattention
Low
Low
Familiarity (w/ task)
High
21
Error Traps
produce an
error-likely
situation
22
Sometimes we’re up and
sometimes we’re down!
Recognize and work with it.
23
Event Causation
24
Module 2
Human Performance Concepts
and Principles
25
Five Principles
of Human Performance
1. People are fallible.
2. Error situations are predictable.
3. Organization influences behavior.
4. Reinforcement effects performance.
5. Understanding the past helps avoid events.
26
Layers of Responsibility Contributing to
Human Performance
Leaders
Organization
Individuals
Human
Performance
27
Behavior vs. Result
1
2
3
4
1
1
2
2
3
3
4
4
5
4
3
2
1
1
2
3
4
5
4
4
3
3
2
2
1
1
4
3
2
1
Which shooter had better “results”?
28
Performance Formula
Behavior: the
way you do your
job
Results: getting
your job done
Performance:
everyone succeeding
together
29
Functions of Defenses
•
•
•
•
•
•
Create Awareness
Detect and Warn
Protect
Recover
Contain
Enable Escape
30
Defense in Depth
31
Sources of Latent
Organizational Weakness
Processes
•
•
•
•
•
•
Control of work
Training
Accountability
policy
Equipment design
Process
development
Use of work force
Values
•
•
•
•
•
Priorities
Measures &
controls
Coaching &
teamwork
Rewards &
sanctions
Reinforcement
32
Module 3
Applying the Principles
33
Develop Case
Study/Video for your
Organization
34
Questions on the Case Study
1. What were the consequences of this event, short and long
range, and what was their significance?
2. What were some of the latent organizational weaknesses?
3. What defenses were removed or flawed?
4. What values or organizational beliefs may have contributed to
the event?
5. What were some of the error traps?
6. What can we learn from this case study?
35
Module 4
Human Performance Tools
36
Error-Prevention Tools
1. Self-checking - S.T.A.R.
2. Peer-checking - Team S.T.A.R.
3. Three-Way Communication
4. Pre-Job Briefing (FKA Tailboard)
5. STOP if Unsure
6. 2-Minute Drill
37
Error-Prevention Tools (continued)
7. Questioning Attitude
8. Turnover
9. Place Keeping
10. Flagging
11. Phonetic Alphabet
12. Conservative Decision Making
38
Error-Prevention Tools (continued)
13. Procedure Use and Adherence
14. Concurrent Verification
15. Post-job Review
Management Tools include:
1. Observations
2. Self-Assessments
3. Operating Experience
39
Self-Checking - S.T.A.R
•
STOP – Is my attention focused on
the task?
•
THINK – What action am I about to
perform?
•
ACT – Am I performing correctly?
•
REVIEW – Did I get the expected
results?
*
40
Peer-Checking
Team S.T.A.R
•
Use a second set of eyes to detect and
correct.
•
Both individuals actively participate in task
performance.
•
Use this tool prior to the performance of
critical tasks.
41
Sometimes we just blow it!
42
3-Way Communication
•
Helps you verify that the correct information is
transferred.
•
Used during the execution of critical steps to
formalize the communication.
•
Repeat-back is required when obtaining a
clearance or a switching order.
•
Regulatory requirement in certain situations

Critical transactions (i.e. communicating to
control personnel)
43
3- Way Communication
What Dennis said (as he was leaving the
room):
“Don, turn off the foam machine”
What Don heard:
“Don’t turn off the foam
machine.”
44
The Result
45
Pre-Job Briefing
•
What is the task to be accomplished?
•
Who’s doing what?
•
How will we communicate?
•
What safety equipment do I need?
•
What is the worst thing that could happen
and how am I going to prevent it?
46
STOP if Unsure
•
If you have a feeling something is not
right – Stop!
•
If you are not positive of the course of
action or the outcome of your actions –
Stop!
47
Two-Minute Drill
•
Initial worksite assessment.
•
Use after a break or distraction.
•
Helps to reset and verify work conditions.
•
Provides a chance to assess changing workplace
hazards at the workplace.
48
Questioning Attitude
•
•
•
•
•
Challenges assumptions
Stimulates a healthy skepticism
Vigilance when things don’t seem right
Being open to challenges by others
Use when uncertain, confused, doubtful
49
Turnover
•
Information/awareness continuity
•
Accurate transfers
•
Transferring responsibilities
•
Over communicate – Don’t assume
•
Record information – Ensure accuracy
•
Ask clarifying questions
50
Place Keeping
•
•
•
•
Prevents step duplication or omission
Records step completed and yet to be performed
Use during Switching and Clearance procedures
Circle & Slash the step number, sign or initial a
blank or, check a box
51
Flagging
•
Correct equipment identification
•
Alerts others that equipment is unavailable
•
Shields components from inadvertent use
•
Used on similar–looking equipment
•
Mandates use of peer and self-checking
•
Remains in place until work is complete
52
Phonetic Alphabet
•
Provides understandable difference between
letters
•
Use when letters might sound alike
•
Use in high noise areas
•
Use at times of poor radio/telephone
reception
53
Standard Phonetic Alphabet
54
Conservative Decision Making
•
•
•
•
•
•
Deliberate and methodical
Clarifies goals and options
Planning
Resources and expertise
Minimize uncertainty
Facts only – challenge assumptions
55
Procedure Use & Adherence
• Understand a procedure’s intent and purpose and
follow its direction.
• Perform all actions as written.
• Stop if procedure cannot be used as written.
• Procedure may be corrected before continuing.
• Expectation: Frequent document use instead of
memory and recall.
56
Concurrent Verification
•
Separate confirmation by two individuals
•
Error prevention on equipment status/condition changes
•
Independent conclusions by all parties
•
Verifier takes no cues from performer
•
Not Peer Checking
57
Post-job Review
•
Identifies what went well
•
Identifies potential improvements
•
Allows feedback from active participants
•
Identifies actual versus planned outcome
•
Determines future changes in similar tasks
•
Reviews lessons learned
58
Module 5
Apply the Tools
59
How valuable is good
communication?
60
61
Objective Review
• Describe the types and causes of
human error
• Describe human performance concepts
and principles
• Apply the principles of human
performance in a case study
• Identify the human performance tools
• Apply the appropriate tools in work
situations
62
The Big Question
• Questioning Attitude
“What’s the worst that could
happen
and how am I going to prevent it?”
63
Your turn
Questions?
64
Thank
You
65
Knowledge Check
• Complete the knowledge check on your own.
• XX% minimum is required.
• You may use your notes.
• Time limit: XX minutes.
66