Presented by: Kate Chepeleff April 17 Human Performance Presented by: Kate Chepeleff www.CITEC.org www.CITEC.org

How do we prevent these events? Human Performance April 17 Traditional Industrial Safety Programs protect you from your Plant.  Human Performance protects the Plant from you.  Human error is often identified as the cause of many safety events and accidents. How do we prevent these events? www.CITEC.org www.CITEC.org

Define the Problem April 17 www.CITEC.org www.CITEC.org

Human Errors in the Medical Field April 17 Human Error www.CITEC.org www.CITEC.org

What is an Event? April 17 Any undesired occurrence that has an adverse effect on safety, quality, or production. *Perrow, Normal Accidents. Living with High-Risk Technologies, 1984, p. 183; Reason. Human Error. 1999, p.187. www.CITEC.org www.CITEC.org

Hierarchy of Health and Safety Controls April 17 Elimination/Substitution/Isolation substitute for hazardous material reduce energy; speed, pressure, voltage, sound level, force change process to eliminate noise automated material handling, separate the hazard from the people Engineering Controls machine guarding, sound enclosures, circuit breakers platforms and guard railing, interlocks, ventilation systems Lift tables, conveyors, balancers Safe Work Practices work place rules, respiratory protection, lockout/tagout confined space entry, hazard communication training blood borne pathogens, hearing conservation Administrative Controls Training /Procedures & Warnings safe job procedures, rotation of workers safety equipment inspections, relief workers computer warnings, odor in natural gas, signs, backup alarms beepers, horns, labels Personal Protective Equipment safety glasses, ear plugs, face shields, safety harnesses and lanyards, steel toe shoes, fire retardant clothing Human Performance pre-Job briefing, procedure use & adherence flagging/operational barriers, self-checking peer checking, post-Job review STOP when unsure www.CITEC.org www.CITEC.org

Human Performance April 17 Is an operating philosophy which acknowledges that people make mistakes It identifies causes of human errors and provides specific tools to help eliminate them Empowers employees, regardless of title or tenure, to contribute equally to the safety and operation excellence of an organization Creates an open questioning environment www.CITEC.org www.CITEC.org

Principles of Human Performance April 17 Humans are fallible. Error is predictable. Organization influences behavior. Behaviors are reinforced. Events are avoidable. www.CITEC.org www.CITEC.org

Human Performance is NOT April 17 NOT a Performance Management Tool NOT an excuse for not holding workers accountable NOT a substitute for existing Operational Excellence efforts NOT A SUBSTITUE FOR EXISTING SAFETY EFFORTS!!! www.CITEC.org www.CITEC.org

What is Human Performance? April 17 Human Performance is Understanding Why we do What we do the Way we do it. Tim Autrey Paradigm Shift Reduce our Errors by Managing our Defenses to leads us to Zero Events Minimize the frequency and severity of plant events www.CITEC.org www.CITEC.org

Severity Pyramid April 17 www.CITEC.org www.CITEC.org

Why use Human Performance? April 17 In 2014, OSHA states there were 4,679 workers killed on the job! Almost 90 deaths a week 13 deaths every day www.CITEC.org www.CITEC.org

Anatomy of Events April 17 www.CITEC.org www.CITEC.org

What is an Error? April 17 www.CITEC.org www.CITEC.org

Accident Investigation April 17 Traditional View Human error is a cause of accidents To explain failure, the investigations must find failures of systems or parts of the systems New View Human error is a symptom of trouble deeper inside a system To explain failure, do not stop at where people went wrong... Instead, find out how peoples’ actions and assessments made sense at the time given the circumstances that surrounded them. www.CITEC.org www.CITEC.org

Performance Modes April 17 “Mistakes arise directly from the way the mind handles information, not through stupidity or carelessness.” Edward de Bono PhD www.CITEC.org www.CITEC.org

Performance Modes April 17 Information processing operates in one or more of three modes– Skill-Based (SB) Rule-Based (RB) Knowledge-Based (KB) They are based on the level of familiarity an individual has with a specific task And the level of attention (degree of information processing) a person applies to the activity. www.CITEC.org www.CITEC.org

Performance Modes April 17 www.CITEC.org www.CITEC.org

Skill Based Performance Mode April 17 Highly practiced actions (routine activity) Usually executed from memory without significant conscious thought in a familiar situation. Behavior governed by preprogrammed instructions developed by either training or experience. Actions guided by subconscious mind possess 10 times the capacity of conscious thought. Error Mode Inappropriate act due to lack of attention Error Rate 1 in 10,000 www.CITEC.org www.CITEC.org

Use your skills… April 17 Count the F’s in the statement below… FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF MANY YEARS Count the F’s in the statement below… FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF MANY YEARS www.CITEC.org www.CITEC.org

What are some tasks that you do that are SKILL BASED? Skill Based Events April 17 What are some tasks that you do that are SKILL BASED? Daily - Driving to and from Work Do you always remember your trip? Weekly – Pumping gas Have you ever not put the cap on and closed the cover? Or… www.CITEC.org www.CITEC.org

Inappropriate act due to lack of attention Error Rate: 1 in 10,000 Skill Based Event April 17 Inappropriate act due to lack of attention Error Rate: 1 in 10,000 www.CITEC.org www.CITEC.org

Rule Based Performance Mode April 17 Task performed by using existing rules from procedures, training, or experience. Prepackaged action determined by recognition of familiar problem. Behavior based upon selection of stored rules derived from one’s recognition of the situation; follows IF (symptom X), THEN (situation Y) logic. The problem, although possibly familiar, is usually unanticipated. Error Mode Not recognizing changes in task requirements, system response, or equipment conditions associated with task due to some preoccupation. Or, so intent on task that pertinent information is not detected, i.e., over attentive. Error Rate 1 in 1,000 www.CITEC.org www.CITEC.org

During Dry Conditions STATIC ELECTRICITY can IGNITE FUMES Rule Based Event April 17 Not recognizing changes in task requirements, system response, or equipment conditions associated with task due to some preoccupation During Dry Conditions STATIC ELECTRICITY can IGNITE FUMES Error Rate: 1 in 1,000 www.CITEC.org www.CITEC.org

Knowledge Based Performance Mode April 17 Unfamiliar situation exists requiring worker to apply analytical skills and judgment Behavior in response to a totally unfamiliar situation (no skill or rule recognizable to the individual) relying on one’s understanding and recollection of knowledge of the system, system’s present state, and scientific principles and fundamental theory related to the system… Error Mode Diagnosis errors - flaws in problem-solving & decision-making typically based upon insufficient information of the true system or equipment status. Error Rate 1 in 10 www.CITEC.org www.CITEC.org

Knowledge Based Event Error Rate: 1 in 10 April 17 Diagnosis errors - flaws in problem-solving and decision-making What would you do if static started a fire? Pull the hose out of the tank? Error Rate: 1 in 10 www.CITEC.org www.CITEC.org

Human Perfomance What is your STOP Criteria? April 17 Error Rate: 1 in 10,000 Changing the Mode you are in The Hardest part is identifying the change in Mode What is your STOP Criteria? Error Rate: 1 in 1,000 Changing the Mode you are in Error Rate: 1 in 10 www.CITEC.org www.CITEC.org

Human Performance Error Rate Pyramid April 17 1 10 1,000 10,000 Event Knowledge Based Rule Based Skill Based www.CITEC.org www.CITEC.org

Performance Modes April 17 Information processing operates in one or more of three modes– Skill-Based (SB) Rule-Based (RB) Knowledge-Based (KB) They are based on the level of familiarity an individual has with a specific task And the level of attention (degree of information processing) a person applies to the activity. www.CITEC.org www.CITEC.org

Error Precursors (Short list) to Events April 17 Error Traps www.CITEC.org www.CITEC.org

What Error Trap will you fall in? April 17 First working Day after time off > 4 Days Poor Communications Overconfidence Distractions End of a Shift or Week High work load Stress Vague or Poor Work Guidance Infrequent or First Time Task Time Pressure www.CITEC.org www.CITEC.org

Are you Stressed? April 17 www.CITEC.org www.CITEC.org

High Work Load? April 17 www.CITEC.org www.CITEC.org

Time Pressure to get the job done? April 17 www.CITEC.org www.CITEC.org

Are you Distracted? April 17 www.CITEC.org www.CITEC.org

Vague or Poor Work Guidance? April 17 www.CITEC.org www.CITEC.org

Poor Communications? April 17 www.CITEC.org www.CITEC.org

Overconfidence? April 17 www.CITEC.org www.CITEC.org

Infrequent or First Time Task? April 17 www.CITEC.org www.CITEC.org

First Work Day after Time Off > 4 Days? April 17 www.CITEC.org www.CITEC.org

End of a Shift or Work Week? April 17 www.CITEC.org www.CITEC.org

How Human Performance Can Help? April 17 The tools are not designed to teach people how to do their job, just how to THINK about it! Methodically focuses us on the task at hand. Teaches us how to ask the right questions. Provides guidance on planning work. Demonstrates “thinking compliance” instead of blindly proceeding. Makes it okay to STOP if unsure. www.CITEC.org www.CITEC.org

Tools Pre-Job Brief What are you going to do? April 17 Pre-Job Brief What are you going to do? Are there documents to follow or reference? What Mode are you in? Has there been an accident doing this task? What Error traps apply? What can go wrong? Can you prevent if from going wrong? Every one participates www.CITEC.org www.CITEC.org

Tools April 17 STOP the job Card The job has become non routine - DOCUMENT the ISSUE Now outside the procedures, parameters, process or situation. No SOP or procedure In Knowledge Based Mode – Trouble shooting Upset condition New Crew members Lack of consensus of the crew on how to proceed Feel “Rushed” Personal Safety/Health Concern The Card then has steps to help resolve the issue Agree on a solution www.CITEC.org www.CITEC.org

Anatomy of an Event April 17 www.CITEC.org www.CITEC.org

What would you do different if you were doing this job? April 17 www.CITEC.org www.CITEC.org

Principles of Human Performance April 17 Humans are fallible . Error is predictable. Organization influences behavior. Behaviors are reinforced. Events are avoidable. www.CITEC.org www.CITEC.org

Are you ready? April 17 www.CITEC.org www.CITEC.org

Questions? Thank you. Kate Chepeleff April 17 Questions? Thank you. Kate Chepeleff Email: chepeleff@citec.org Phone: (315) 268-3778 x 28 www.CITEC.org www.CITEC.org www.CITEC.org