Human Performance
Improvement
Work Group
WECC Strawman Class
Based on INPO and DOE
manuals
1
Objectives
Objectives:
Explain why human performance improvement is
important to you and your Company.
 Describe what can influence human
performance.
 Identify and apply Eight fundamental Human
Performance Error Prevention Tools to
improve safety and reduce errors.
 Reinforce the knowledge and usage of the HP
tools so that they become commonplace in the
daily work environment
2
3
Lessons
Lessons:

Performance Improvement Overview

Human Performance Error Prevention Tools
4
What causes humans to fail
At Risk Behaviors
Normally, humans make about
???? errors per hour.
5 errors per hour
XXX COMPANY 20,000 employees
x 5/hr
100,000 errors per hour
5
What causes humans to fail
At Risk Behaviors
This is made worse when the
person:




Is in a hurry
Under a high workload
Doing more than one thing at a time
Doing the same thing over & over
6
Traps in the Work Environment

Distractions

Interruptions

Unplanned changes
Error Precursors

Those things that “set-up” a mistake to happen






Task demands are greater than the worker’s abilities
Confusing conditions make the job harder
New techniques not used before
Mental shortcuts
Lack-of or unclear standards
Illness / Fatigue
7
Performance Improvement Overview: Common Error Precursors
Task Demands
Individual Capabilities
o High workload (memory requirements)
o Unfamiliarity with task / First time
o Time pressure (in a hurry)
o Lack of knowledge (faulty mental model)
o Simultaneous, multiple tasks
o New technique not used before
o Repetitive actions / Monotony
o Imprecise communication habits
o Irrecoverable actions
o Lack of proficiency; Inexperience
o Interpretation requirements
o Unsystematic problem-solving skills
o Unclear goals, roles, or responsibilities
o “Can do” attitude for safety-critical task
o Lack of or unclear standards
o Illness or fatigue; general health
Work Environment
Human Nature
o Distractions / Interruptions
o Stress
o Changes / Departure from routine
o Habit patterns
o Confusing procedure / Vague guidance
o Assumptions
o Confusing displays / controls
o Complacency / Overconfidence
o Work-arounds / OOS instrumentation
o Mind set (intentions)
o Hidden system responses
o Inaccurate risk perception
o Unexpected equipment conditions
o Mental shortcuts or biases
o Lack of alternative indication
o Limited short-term memory
8
Two Kinds of Errors
Active Errors
Latent
Conditions
Performance Improvement Overview: When Safety Barriers Fail
Events occur if all barriers and the frontline fail...
Process
Training
Employees
Oversight
10
Performance Improvement Overview: Common Error
Precursors
11
Human Performance Error
Prevention Tools
12
Human Performance Error Prevention Tools: Event
Prevention
•
How do We Prevent Events?

Anticipate, prevent, and catch errors at the job
site:





Work Preparation
Work Performance
Work Feedback
Error Prevention Tools
Develop and Implement Defense in Depth:




Process Improvement
Adequate Training
Oversight
Teamwork
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•
1.
2.
The Eight Human Performance Tools:
Tailboards (Job Briefs)
S.T.A.R. – Stop, Think, Act, Review

3.
4.
5.
6.
7.
8.
Also known as “Self-Verification”
Three-way communication
Two-Minute Rule
Stop When Unsure
Questioning Attitude
Phonetic Alphabet
Procedure Use and Adherence
14
Tool #1 – Tailboards:
A pre-job meeting of workers
and/or supervision conducted
before the performance of a job
to discuss the tasks involved,
hazards and related safety
precautions.
15
Human Performance Error Prevention
Tools: TAILBOARDS

WHY:


Helps personnel to better understand
what is to be accomplished and what
should be avoided. They help personnel
avoid surprises in the field and reinforce
the idea that there are no routine tasks.
Allows an interaction between members
of the crew so that there is an
understanding of each members role

Designated Challenger
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
TAILBOARDS
WHAT should be covered:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Task Purpose
Documentation Review
Task Assignments
Safety Hazards and Mitigation
Human Performance
Special Requirements or Unusual
Conditions
Operating Experience
Stop-Work Criteria
Oversight
Questions
17
Human Performance Error Prevention
Tools: TAILBOARDS
•
S.A.F.E.R
18
Contractor in work area – situational awareness
19
Contractor – Situational Awareness
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A tailboard in action
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How would you tailboard this situation?
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Tool #2 - STAR: (Self Checking)

WHAT:


A “Self-Checking” tool where the
performer pauses to focus his/her
attention, reflects on the intended action
and the associated outcome.
Performer must have a sound knowledge
of the task to know what to expect.
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Human Performance Error Prevention Tools: STAR

WHY:


Helps the performer focus attention
on the appropriate component, think
about the intended action,
understand the expected outcome
before acting, and verifying the
results.
Boosts attention and thinking just
before an action is performed.
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Human Performance Error Prevention
Tools: STAR

WHEN should it be performed:
1.
2.
3.
4.
5.
When operating equipment.
When performing test programs.
When manipulating any controls.
When entering data into a computer.
When revising drawings.
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Human Performance Error Prevention Tools: STAR
•
HOW should it be performed:
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Human Performance Error Prevention Tools: STAR

How:






Halt conversation prior to performing
action.
Perform one action at a time.
Pause and self check between actions
when performing multiple actions.
Recognize when uncertainties or
discrepancies exist and STOP.
Personnel are alert and un-fatigued.
Re-perform self check after loosing
visual of physical contact.
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Human Performance Error Prevention Tools: Tool #3
Tool #3 – Three Way Communication:

Fundamental Human Performance Error
Prevention Tool where the
communication originator (SENDER)
verifies that the RECEIVER understands
the message as intended. The
RECEIVER ensures he/she
understands what the sender is saying.
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Human Performance Error Prevention Tools: 3-Way Communication

WHAT:

Fundamental Human
Performance Error Prevention
Tool where the communication
originator (SENDER) verifies that
the RECEIVER understands the
message as intended. The
RECEIVER ensures he/she
understands what the sender is
saying.
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Human Performance Error Prevention Tools: 3-Way Communication

WHY:


Promotes reliable transfer of
information and understanding, which
ensures correct subsequent action.
WHEN should it be applied:
1.
2.
3.
4.
When providing critical information.
When providing equipment status.
When directing operation of
equipment.
When directing others to perform a
task.
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3 Way Communication
1.
The initiator makes a statement.
2.
The participator repeats the statement
in confirmation.
The
Message
3.
The initiator confirms back that the
statement is correct.
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Human Performance Error Prevention Tools: 2-Minute Rule
Tool #4 – Two Minute Rule:

WHAT:


A fundamental HP EPT that helps the worker
develop an accurate understanding of the work
environment, associated hazards, equipment
condition/status, and other critical work site
attributes.
WHY is it important?:

Improves situational awareness of the job site.
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Human Performance Error Prevention Tools: 2-Minute Rule

WHEN should it be performed?
1.
2.
3.
4.
5.
All work activities
Upon arriving at the work location.
During job walk down.
After breaks, lunch, or other
interruptions.
Anytime conditions change.
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Human Performance Error Prevention Tools: 2-Minute Rule

HOW:
1.
Explore the job site and adjacent areas.
2.
Talk with co-workers
3.
Mitigate hazards
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Four Mental States of Situational Awareness
Red Alert – You’re aware of an imminent hazard. You’ve already
prepped safe, decisive actions and back up plans. You control the
hazard safely. No surprises.
Focused – You notice something, but may not know if it’s a hazard
or not. You assess it, then either avoid it, or control it safely. Beware
tunnel vision here.
Scanning – Mental Radar is actively scanning 360° for hazards and
anomalies and visualizing likely outcomes. Aim to spend most of
your time in this state.
Tuned out - Unaware of surroundings. Mental Radar is off. OK at
home, or on brief breaks at work when resting safely outside
workzone away from all hazards.
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Photo by isafmedia. Used with permission.
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The sniper’s mental state is Focused. The spotter’s mental state
is Scanning. Both communicate effectively with each other. The
result? Situational Awareness that you can bet your life on.
Primarily
Scanning
Primarily
Focusing
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37
Photo by isafmedia. Used with permission.
We spend perhaps 95%+ of each typical day in only
two of these mental states – Scanning and
Focusing.
One “secret” to Situational Awareness is to
alternate between these two mental states when you
work alone, and to ensure that team members
coordinate the two states effectively when working
on a team.
Focused – You notice something, but may not know if it’s a hazard or not. You
assess it, then either avoid it, or control it safely. Beware tunnel vision here.
Scanning – Mental Radar is actively scanning 360° for hazards and anomalies and
visualizing likely outcomes. Aim to spend most of your time in this state.
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Primarily
Focusing
Primarily
Scanning
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Neither Scanning nor Focusing
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Human Performance Error Prevention Tools: Stop When Unsure
Tool #5 – Stop When Unsure

WHAT:


When confronted with confusion or uncertainty, a
person is in unfamiliar territory. Given that the
chance for error is particularly high in such
situations, the best course of action, when unsure,
is to stop and get help from other people.
WHY is it important?

When confronted with confusion or uncertainty, a
person is in unfamiliar territory. Given that the
chance for error is particularly high in such
situations, the best course of action, when unsure,
is to stop and get help from other people.
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Human Performance Error Prevention Tools: Stop When Unsure

WHEN should it be performed?










When uncertainty, doubt, confusion, or questions
persist
When encountering conditions inconsistent with
the procedure
If beyond the scope of the plan or process
When feeling distrustful of another individual
When unexpected results or unfamiliar situations
are encountered
When something expected does not happen
When uncertain regarding compliance with
expectations or procedures
When unfamiliar with an important work situation
When inexperienced or lacking knowledge with a
task
When someone else expresses doubt or concern
42
Human Performance Error Prevention Tools: Stop When Unsure

HOW:



Stop the activity.
Place the equipment and the job site in a safe
condition.
Notify your immediate supervisor.
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Human Performance Error Prevention Tools: Questioning Attitude
Tool #6 – Questioning Attitude

WHAT:
Attitude is a state of mind or a feeling toward a
subject or object of interest.
A questioning attitude promotes a preference for
facts over assumptions and opinion. Questions such
as “What if…,” or “Why is this acceptable?”
45
Human Performance Error Prevention Tools: Tool #6
Tool #6 – Questioning Attitude

WHY is it important?:

A questioning attitude fosters situational
awareness, promotes a preference for facts
over submission and opinion, and
encourages thought about safety BEFORE
action is taken. Without sufficient facts or
verification, the performer stops the activity
to address unexpected work situations that
could lead to either a serious mistake or a
significant event.
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Human Performance Error Prevention Tools: Questioning Attitude

WHEN should it be performed?










During self-checking (Think step of STAR)
Before performing an important step or phase of an
activity
When making a decision about an important activity
When experiencing uncertainty, confusion, or doubt
When experiencing a “gut feeling” that “something is
not right”
When encountering unanticipated changes in
conditions
When conflicts or inconsistencies exist between plans,
procedures and actual conditions
After encountering unexpected results
After discovering missing information or resources
Upon hearing danger words: “I assume,” “probably,” “I
think,” “maybe,” “should be,”
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Human Performance Error Prevention Tools: Questioning Attitude

HOW:



Stop, Look, and Listen –
Ask questions – Gather relevant
information.
Proceed if sure – Continue the activity if
the uncertainty has been resolved with
facts. Otherwise, do not proceed in the
face of uncertainty!
48
Human Performance Error Prevention Tools: Questioning Attitude
Perception, Comprehension, and
Projection.
SCAN
FOCUS
ACT.
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Situational awareness
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Human Performance Error Prevention Tools: Phonetic Alphabet
Tool #7 – Phonetic Alphabet

WHAT:

Several letters in the English language sound
alike and can be confused in stressful or noisy
situations. The Phonetic alphabet specifies a
word for each letter of the alphabet reducing the
likelihood that the letters will be confused.
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Human Performance Error Prevention Tools: Phonetic Alphabet
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Human Performance Error Prevention Tools: Phonetic Alphabet

WHY is it important?:
 The phonetic alphabet can reduce the
effects of noise, weak telephone or
radio signals, or even a person’s
accent

WHEN should it be performed?
 When communicating alpha numeric
information
 When specifying phase or channel
designations
 When a sender or receiver may
misunderstand the designations of an
order
55
Human Performance Error Prevention Tools: Phonetic Alphabet

HOW to use the Phonetic Alphabet?:



Speak distinctly and slowly
Use terms like “Stop” , “Correct”, “Wrong”
Do Not use Slang Terms
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Human Performance Error Prevention Tools: Tool #8
Tool #8 – Procedure Use and Adherence

WHAT:

Understanding the overall purpose and strategy of
approved procedures, promotes a safe reliable
outcome. Adhering to approved procedures helps
to dispel doubt and provides clarification
regarding questions in the execution of various
tasks and duties
57
Human Performance Error Prevention Tools: Procedure Use and Adherence

WHY is it important?:

Procedure quality is paramount to safety
and reliability. The completeness,
accuracy, and internal consistency of the
instructions, and its usability (easy to
understand and follow) all impact the
user. Procedures have been written over
the years based on experience and
proven uses of equipment. Procedures
MUST be followed. Short cuts are often
precursors of error
58
Human Performance Error Prevention Tools: Procedure Use and Adherence

WHEN should it be performed?



When manipulating, altering, monitoring, or
analyzing equipment
When a procedure exists for a work activity
When required
59
Human Performance Error Prevention Tools: Procedure Use and Adherence
HOW:



Make sure you have the correct
procedure or SW log and it has been
checked
Review the procedure or SW log before
starting work, confirming understanding of
the procedure’s overall purpose and
expected outcome. Make any
changes/revisions before you start
switching.
Follow the procedure as written without
deviation being aware of the potential
impact the action can have on equipment.
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Human Performance Error Prevention Tools: The Four Tools
•
1.
2.
The Eight Human Performance Tools:
Tailboards (Job Briefs)
S.T.A.R. – Stop, Think, Act, Review

3.
4.
5.
6.
7.
8.
Also known as “Self-Verification”
Three-way communication
Two-Minute Rule
Stop When Unsure
Questioning Attitude
Phonetic Alphabet
Procedure Use and Adherence
61
Human Performance Error Prevention Tools: The Working Connection
Each employee has a role and a responsibility in
error prevention, at all levels in an organization.
Individuals
Leaders
Organization
62
Human Performance Error Prevention Tools: Individuals
Role of the Individual:
 Apply
and use Error Prevention
Tools.
 Coach and reinforce use of EPTs
with others.
63
Human Performance Error Prevention Tools: Visibility
Role of Visibility between Peers and
Leaders:






Observations
Role modeling
Reinforcing expectations
Coaching
Recognition
Brother’s Keeper
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65
Human Performance
Make it a Habit
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