Human Performance Improvement

Principles for Managers

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 Course Objective
• Management will be able to create an
environment where workers can make good
decisions by:
– Recognizing the role of the individual and
human fallibility in human performance
– Identifying how organizational systems
influence human behavior
– Embracing the role of the leader to manage
organizational systems and positively
influence human behavior
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When Good Pets Go Bad

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 Human Performance

“People do not operate in a vacuum,

where they can decide and act all-
powerfully. To err or not to err is
not a choice. Instead, people’s
work is subject to and constrained
by multiple factors”.
— Sidney Dekker

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 What is Human Performance?

An individual…

working within
organizational systems…

to meet expectations
set by leaders.

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 How to Improve Human
Performance
Address
Removeerror-
Create
Reinforce error
limitations
traps
tolerant
desired of
TTHH human
systemsnature
behaviors
Individual IISS
W
W
AA
YY
OO
UU
TT
TT
UU
OO
YY
AA
Incentives to meet
W
W
IISS
TTH
H leader’s expectations

Organization

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 Definitions
• Operational Upset: A condition that adversely
affects, or may adversely affect, DOE or
contractor personnel, the public, property,
environment or the DOE mission.
• Error: An unintentional deviation from an
expected behavior.
• Violation: Deliberate, intentional acts to evade a
known policy or procedure requirement for
personal advantage usually adopted for fun,
comfort, expedience, or convenience
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 HPI Principles

1. People are fallible

2. Error-likely situations are predictable
3. Individual behaviors are influenced
4. Operational upsets can be avoided
5. People achieve high levels of
performance based encouragement
and reinforcement.

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 The Individual

HPI Principle #1:

People are fallible, and even

the best make mistakes.

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 Origins of Human Error
Human Errors

70%
System Induced Error

Operational Upsets

30%
90% Slip, trip or
Human 10% lapse
Error Equipment
Failures

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 Basketball

• Count the number of passes between

white-shirted players
• You MUST be accurate
• PAY ATTENTION!

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 Limitations of Human Nature

Mistakes arise directly from the way the

mind handles information, not through
stupidity or carelessness.
— Dr. Edward de Bono

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 Limitations of Human Nature
See page 4 in your Concepts Guide

• Stress • Mind set

• Avoidance of mental • Difficulty seeing own
strain errors
• Inaccurate mental • Limited perspective
models • Susceptible to
• Limited working emotion
memory • Focus on the goal
• Limited attention • Fatigue
resources

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 Hazardous Attitudes
See page 6 in your Concepts Guide

• Pride: “Don’t insult my intelligence.”

• Heroic: “I’ll get it done, by hook or by crook.”
• Invulnerable: “That can’t happen to me.”
• Fatalistic: “What’s the use?”
• Bald Tire: “Gone 60K miles without a flat yet.”
• Summit Fever: “We’re almost done.”
• Pollyanna: “Nothing bad will happen.”

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 Risk

“Risks that you can control are

much less a source of outrage than
risks you can NOT control.”
— Peter Sandman

… in other words, the risks that scare people

and the risks that actually kill people are
very different
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 Performance Modes
See page 7 in your Concepts Guide
Inaccurate Mental
High

Picture
K

When switching from

no

50/50
w
le
dg

Pa
t one performance
e-

te
rn
B
as

s
mode to another a
ed
Attention to Task

Misinterpretation worker is presented

1/1,000
R

with a new situation

ul
e-

If-
B

Th
as

en
but has only old
ed

Inattention information on which

1/10,000
to base decisions.
Sk
ill
-B

A
as

ut
o
ed
Low

Low Familiarity with Task High

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 Error Traps

HPI Principle #2:

Error-likely situations are

predictable, manageable, and
preventable.

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Saw StopTM

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 Error Precursors
Task Demands
• Time pressure (in a hurry)
• High Workload (memory requirements)
• Simultaneous, multiple tasks
• Repetitive actions, monotonous
• Irrecoverable acts
• Interpretation requirements
• Unclear goals, roles, & responsibilities
• Lack of or unclear standards
Work Environment
• Distractions / Interruptions
• Changes / Departures from routine
• Confusing displays or controls
• Workarounds / OOS instruments
• Hidden system response
• Unexpected equipment conditions
• Lack of alternative indication
• Personality conflicts
Unclassified
See page 18 in your Concepts Guide
Individual Capabilities
• Unfamiliarity w/ task / First time
• Lack of knowledge (mental model)
• New technique not used before
• Imprecise communication habits
• Lack of proficiency / Inexperience
• Indistinct problem-solving skills
• “Hazardous” attitude for critical task
• Illness / Fatigue
Human Nature
• Stress (limits attention)
• Habit patterns
• Assumptions (inaccurate mental picture)
• Complacency / Overconfidence
• Mindset (“tuned” to see)
• Inaccurate risk perception (Pollyanna)
• Mental shortcuts (biases)
• Limited short-term memory
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 Error Prevention Tools
• Self-checking • Pre-job briefing
• Peer-checking • Post-job briefing
• Concurrent • Procedure use &
verification adherence
• Independent • Problem-solving
verification • Questioning attitude
• Three-way • Conservative decision
communication making
• STAR • Stop & collaborate
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 The Organization

HPI Principle #3:

Individual behavior is influenced by

organizational processes and
values.

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 New vs. Old View of Human Error

• Human error is a cause of • Human error is a symptom of

accidents trouble deeper inside a
system…
• To explain failure, • To explain failure, do not try
investigations must seek to find where people went
failure wrong.

• They must find people’s • Instead, find how people’s

inaccurate assessments, assessments and actions
wrong decisions and bad made sense at the time,
judgments given the circumstances that
surrounded them.

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The Dryden Event

Air Ontario Flight 363 Fokker F28

Dryden, Canada
March 10, 1989

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 Types of Error
See page 12 in your Concepts Guide

• Active Errors change equipment, system

or processes that trigger immediate
undesired consequences.

• Latent Errors result in undetected

organization-related weaknesses or
equipment flaws that lie dormant.

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 Understanding Events

• Incentives are the cornerstone of human

behavior
• Dramatic events often have distant even
subtle causes
• Conventional wisdom is often wrong
• Knowing what to measure and how to
measure it makes a complex world much
less complicated
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 Organizational Processes

Workplaces and organizations are

easier to manage than the minds of
individual workers. You cannot
change the human condition, but
you can change the conditions
under which people work.
— Dr. James Reason

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The Value of Error Tolerance

Error without consequence is a

good thing — it shows that our
systems are error-tolerant and
that they are working.

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Defenses in Depth
See page 14 in your Concepts Guide

• Redundancy: many
layers of protection.
• Diversity: many
different varieties of
protection.
• Independence:
separate/autonomous
layers of protection.

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 Traditional Heisenberg Model
See page 16 in your Concepts Guide

• Number of errors is
1
Major Accidents relative to the severity
of consequences
• For every major
Significant Events 10

accident there are

Near Misses
30 many errors
Nonconsequential
• Leads us to assume
Errors 600 that driving down errors
will eliminate major
accidents
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 New View of Heisenberg Model

• The consequence of
Reactive
Major Accidents error has no relationship
to the number of errors
Significant Events • It is related to the
number and integrity of
defenses
Near Misses
• Any error can lead to a
Nonconsequential
major accident if
Errors
Proactive defenses fail

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 Zero Operational Upsets
See page 20 in your Concepts Guide

Re + Md → OU
Reducing Error AND Managing Defenses
leads to Zero Operational Upsets

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Medical Mistakes

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 Organizational Values

HPI Principle #4:

Operational upsets can be avoided

by understanding the reasons
mistakes occur and applying the
lessons learned from past events.

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 Blame Cycle
See page 23 in your Concepts Guide

Human
Error

More flawed Individual

defenses and counseled and/
error precursors or disciplined

Reduced trust
Latent
organizational
weaknesses persist

Management Less
less aware of Communication
jobsite
conditions

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 Culpability Decision Tree
Was the behavior
intended? See page 26 in your Concepts Guide
YES NO

Did the
employee have
Were the medical
consequences restrictions?
intended?
NO
NO
YES YES
Did the employee
knowingly violate
Intentional a requirement?
sabotage

YES NO

Were restrictions Were the

communicated requirements
and clearly available, workable,
understood? intelligible, and
correct? Did the employee
YES NO
pass the
YES NO
substitution test?
Possible System-
intentional induced Possible System- YES NO
violation violation intentional induced
violation violation
Did the employee Were there
have a history of deficiencies in
unsafe acts? training, selection
or inexperience?
YES NO
YES NO

Corrective System-induced Negligent error

System-induced
measures error or or intentional
blameless error error
indicated violation

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 Accountability vs. Culpability
See page 40 in your Concepts Guide

Accountability Culpability

The power to accomplish

performance objectives vs. The blame for failure

A starting point for A dead end that

improvements vs. discourages reporting

Arises from empowerment Is disempowering and

and partnership vs. divisive

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 Performance Culture
See page 28 in your Concepts Guide

• Encourage Reporting: Value errors as

leading safety data
• Create a Just Work Environment: Don’t
try and punish errors out of the system
• Flexibility: Prepare workers to adapt
effectively to changing demands
• Learning: Create opportunities for
observation, reflection and feedback
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Barriers to a Learning Organization

• 20 years of experience = 1 year of learning

repeated 20 times
• Experts use their informational advantage
to reinforce their biases

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 Human to Systems Interface

• People will never

perform better than
what the organization
will allow
Organizational
Systems:
Systems in Practice Organizational
Systems: • If a system relies on
Values Processes
people doing the right
thing every time, it will
fail
• No working system
remains in stasis
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 The Leader

HPI Principle #5:

People achieve high levels of

performance based largely on the
encouragement and reinforcement
received from peers, leaders, and
subordinates.

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 Fallacy of
Competing Resources
See page 31 in your Concepts Guide

Optimization

Y
C
PT
U
KR
N
BA
PROTECTION

Better

l
et na
defenses

E
ps o

PH
U rati
converted into

pe

RO
increased O

ST
production

TA
CA
Unrealized Potential

PRODUCTION
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 How Leaders Influence
Protection vs. Production
See page 33 in your Concepts Guide

• What they pay attention to, measure, and control

• Their reactions to critical incidents or crises
• The allocation of resources
• Their criteria for allocation of rewards and
punishment
• Their criteria for selection, advancement, and
termination
• Their deliberate attempts to coach or model
behaviors.
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 Reality Check

• Safety values express how you desire

safety to be in your organization.
• Safety systems are real defenses and
actionable programs that provide
measurable safety data sets.

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 Implementing HPI

• HPI is not just training

• It is a way of doing business that includes:
– Behavioral observation and walk-arounds
– Conduct of operations and work management
– Systems development and re-engineering
– Issues reporting, management and corrective
actions
– Event investigation and lessons learned
– Performance management and assurance
– Simulations and training
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