Human Performance Improvement Human Performance Improvement (HPI) Orientation Briefing (1 hour) This is a presentation on Human Performance Improvement. Fluor has undertaken this HPI initiative at its large complex nuclear projects in order to improve communications, worker safety and operational reliability. The goal is to foster develop a highly reliable organization that focused on preventing and mitigating events. HPI was developed in the US Nuclear Power Industry by the Institute of Nuclear Power Operators to address plant and system safety. Fluor has adapted HPI to Health, Safety & Environmental programs as a safety culture improvement tool that engages the workforce in the planning stages of work to identify errors precursors and error likely situations, that if left unmitigated, could result in adverse events. This presentations is a high level overview of the concepts of HPI used to introduce HPI concepts to the audience.

HPI Orientation Briefing– What you should hear in this briefing : Basic HPI Concepts and Principles Active Errors/Latent Errors The “Anatomy of an Event” Model Human Performance Principles Common Error Precursors Common Error- Prevention Tools Defenses – The Swiss Cheese Model Examples of Defenses An analysis of events in the nuclear industry by INPO classified as significant 1995 through 1999 revealed that 3 of every 4 events were caused by human error. The INPO study disclosed that “the risk is in the people- the way they are trained, their level of professionalism and performance, and the way they are managed.” Human Performance is behavior plus results. Good results can be achieved with questionable behavior, however, for long-term sustained value-added results, one must look closely at behavior, what influences it, motivates it and shapes it. HPI is designed to evaluate those organizational and administrative systems, values, job-site conditions that influence behaviors and affect the level of performance achieved by the organization.

Most accidents or injuries due to human error (not hardware failure) HPI – Why? Industry data shows - Most accidents or injuries due to human error (not hardware failure) Three out of four significant events due to human error 70 percent of those human errors are due to organization process weaknesses

HPI – Why? Events Minimize the frequency and severity of events, incidents, injuries Evaluate Consequences, Manage Risks!

What we know about human error: HPI – What we know… What we know about human error: It abounds in every industry It is a major contributor to events, incidents and occurrences It is costly, adverse to quality and safety It impacts productivity It is often due to process weaknesses , not from lack of skill or knowledge

HPI – Five Principles People are fallible, and even the best make mistakes (~ 5/hr.) Error-likely situations are predictable, manageable, and preventable Individual behavior is influenced by organizational processes and values People achieve high levels of performance through the encouragement and reinforcement received from leaders, peers, and subordinates Events can be avoided by understanding the reasons mistakes occur The Five Key Principles of HPI Humans are fallible. We all make mistakes. Most go unnoticed because there are no negative consequences to them. Errors are predictable. It is predictable that error rates will increase given certain stresses and situations. Pilots flying in adverse weather conditions double their error rate. Consider fighter pilot’s error rates…even higher error rates. Yet airplanes are not falling from the skies each time the thunderstorms arise. Because errors and error-likely situations have been considered and Defenses, both physical engineered systems and administrative have been put in place to prevent or minimize the effects of human error. Behavior is driven by the organization, the management, the paper, the job conditions. Everyone is part of the organization- worker, supervisor, manager, procurement, engineer, client. Encouragement and reinforcement drive behaviors to achieve good or poor results. Training and new operator to a procedure and testing him in a classroom he demonstrates knowledge. Paring the same new operator up with an experienced one, he learns “how work really gets done…” Which way do you think the new operator will perform the job over time? Events can be avoided if we know where to look based on past performance.

HPI - Two Kinds of Errors Active Error Typical: Plant-touchers Latent Error Typical: Paper-touchers (leading to latent conditions)

HPI - Anatomy of An Event Error Precursors Vision, Beliefs, & Values Latent Organizational Weaknesses Mission Goals Policies Processes Programs Flawed Defenses Initiating Action

Individual Capabilities Work Environment Human Nature HPI - Error Precursors Task Demands Individual Capabilities Work Environment Human Nature 2

HPI - Error Precursors – Short List TASK DEMANDS INDIVIDUAL CAPABILITIES Time pressure (in a hurry) Unfamiliarity with task / First time High workload (memory requirements) Lack of knowledge (mental model) Simultaneous, multiple tasks New technique not used before Repetitive actions, monotonous Imprecise communication habits Irrecoverable acts Lack of proficiency / Inexperience Interpretation requirements Indistinct problem-solving skills Unclear goals, roles, and responsibilities “Hazardous” attitude for critical task Lack of or unclear standards Illness / Fatigue WORK ENVIRONMENT HUMAN NATURE Distractions / Interruptions Stress (limits attention) Changes / Departures from routine Habit patterns Confusing displays or controls Assumptions (inaccurate mental picture) Workarounds / OOS instruments Complacency / Overconfidence Hidden system response Mindset (“tuned” to see) Unexpected equipment conditions Inaccurate risk perception (Pollyanna) Lack of alternative indication Mental shortcuts (biases) Personality conflicts Limited short-term memory

HPI – Most Common Error Precursors Time Pressure Interpretation of Requirements Unclear Roles and Responsibilities Distractions, Interruptions Work-arounds Inaccurate risk perception First time with task Lack of knowledge Technique not used before Imprecise communication Assumptions Complacency, overconfidence

HPI – Common Error-prevention Tools Pre-job Briefing Self-checking S.T.A.R. Peer-checking Three-way communication Phonetic Alphabet Post-job Briefing Mental Models Questioning Attitude Situational Awareness Procedure use & adherence Stop when unsure

HPI - Error-prevention Tools - Pre-job Briefing A pre-job briefing is a meeting of individual performers and their supervisor (or lead) conducted before performing a job to discuss the tasks, critical steps, hazards, and related safety precautions. [Participants clarify the task's objectives, roles and responsibilities, and resources. Interaction among participants is mandatory]

HPI - Error-prevention Tools - Pre-job Briefing A Dialog (SPEAK): Safety Critical Steps? Prior Performance? Error-likely Situations? Anticipate Worst-case Consequences (What can go wrong?) Key Defenses?

HPI - Error-prevention Tools - Pre-job Briefing (your role) Your Role in a PJB: Be Prompt (on time) Participate (add to the conversation) Listen (pay attention to discussion) Ask Questions Prepare to Conduct Work Using Appropriate Controls

HPI - Error-prevention Tools – Post-job Briefing A Post-job Briefing is a meeting conducted after a task is completed. In the post-job briefing, questions are asked to identify flawed defenses, error precursors, and weak organizational processes for future resolution.

HPI - Error-prevention Tools – Post-job Briefing A Dialog (CLEAR): Changes needed? Lessons learned? Errors left uncorrected? Adequate resources? Results not expected?

HPI - Error-prevention Tools – Self-Checking Use of S-T-A-R: Stop: focus on the correct component Think: consider the intended action Act: take appropriate action Review: review results (as expected?) Use as you prepare to work on components, systems or structures

HPI - Error-prevention Tools – 3-way Communication Sender: state message to receiver Receiver: reply with paraphrased message received Sender: confirm or correct message as received (affirmative/negative)

HPI - Error-prevention Tools – Phonetic Alphabet

HPI - Error-prevention Tools – Mental Models Situational Awareness: Be aware of your surroundings, the jobsite conditions, and the existence of error-likely situations….. Questioning Attitude: Do not proceed in the face of uncertainty; base your actions on facts….

HPI - Defenses, Controls and Barriers- The ‘Swiss cheese’ model The Reason model…“defense in depth” Some holes due to active errors Other holes due to latent (hidden) conditions Hazards Incident or Event

HPI - Examples of Defenses Training, qualification Self-assessment Procedures Planning and scheduling Fieldwork supervision Problem reporting Engineered safety features Hazardous energy control (LO/TO) Personnel protective equipment (PPE) Reviews/approvals Safety briefings