Behavior Based Safety and Human Performance Ideas for Improving Safety Performance Presented by: Dan Klimek Sisk & Company

Behavior Based Safety -- Per PEC Focuses on a Behavior Based HSE Observation Program Note: the Safety Plus card used as an example includes a Behavior Observation Checklist, Hazard ID, Near Miss, and First Aid observations as well as positive recognition. A Behavior Based Safety program is intended to enable company employees to record safety observations, most importantly, stopping of work that is unsafe.

This card is also used for Example: Behavior-Based Observation Card This card is also used for Near Miss, Hazard ID, First Aid and Health, Safety or Environmental events. Data can easily be gathered and trended.

Too often behavior observation cards are filled out without proper discussion. They are filled out just to meet a quota and there is not real thought given to how can gain a long term benefit.

recognized and controlled they will continue until If unsafe acts are not recognized and controlled they will continue until an incident results. --------------------------- Why do people do unsafe things?

This is the result of an unsafe act This is the result of an unsafe act. Several crew members stood by and watched as he tried to move pipe by hand. After the incident all of them said, “I wished I had stopped the activity and talked about a better way to do the job.”

Fighting Complacency Complacency is a natural brain function   Inattention is partly the result of the brains need for efficiency Our brains use 20% of our energy and oxygen Compare your recollection of the 1st time you drove a car -vs- the 1000th time you drove a car. Experience leads to automatic actions, but the trade off is we tend not to pay attention to detail. Again, think about driving home – we make the trip and do not recall making a turn or passing a landmark. The brain is hard wired to sort info and to rank items so we do not pay attention to routine activities What do we pay attention to -vs- what do we ignore

There are clearly limits as to what we can focus on. passing the ball.flv

What did you see in the video? Anything unusual? Number of times the white shirt team passed the ball?

What did you see in the video? Anything unusual? Gorilla Curtain changed color 1 black shirt walked off the screen Number of times the white shirt team passed the ball? 16

ID tasks where people are likely to be complacent Experienced workers – have done this 1000’s of times Optimism bias if no bad past experience New employee – Inexperience and Optimism bias excited about job, no negative experience to compare it to and not familiar with equipment or procedures, or equipment locations Supervisors / management Pressure on employees to do more, keep busy, work faster No past incidents, so do not stop to consider new risks or re-evaluate ongoing risks Distractions caused by changing work scope, job demands, etc.

Let’s Look at some Human Performance Concepts

The People Side of Safety and Performance People are fallible and even the best people make mistakes. People achieve high levels of performance due to encouragement and reinforcement from leaders, peers and subordinates. Individual behavior is influenced by organizational processes and values. Events can be avoided by understanding the reasons mistakes occur and applying the lessons learned from past events or errors.

Two Kinds of Errors Active Error Latent Error do something or make a change that triggers immediate undesirable consequences. Latent Error an error results in some situation or unnoticed condition and lies dormant.

Chances of Not Getting Injured By reducing the number of near misses, where no injury was sustained, we can hope to reduce the numbers of damage, minor and more serious incidents. This confirms the importance of investigating ALL accidents/incidents. All represent failures in safety management and have valuable learning opportunities 1 10 30 600 Sub Standard Acts Sub Standard Conditions Serious/Major Injury Minor Injury Property Damage Near Miss

Inaccurate Mental Picture Control Mechanisms Performance Modes Type of errors that usually occur at upper echelons of organization; not observable High Low Attention (to task) Inaccurate Mental Picture Knowledge-Based Type of errors that usually occur at human-machine interface; observable Patterns RB/KB involve conscious decision making Error Modes: SB – Inattention; RB – Misinterpretation; KB – Inaccurate mental model/picture KB: unfamiliarity ­, anxiety ­, stress ­, search for patterns, ­, assumptions ­, trial & error, panic, event or value-added progress. Conscious, directed thinking can exclude outside sensory information - could miss important information. Time Effects: As time to respond increases, the chance for error diminishes. Chance for error is highest when the unfamiliar situation (especially involving danger) strikes suddenly without warning and requires quick reaction. WANT TO AVOID THIS!!! Workers - SB and RB most often (prescriptive in nature); Managers - RB and KB (discretionary) SB - Unconscious competence; RB - Conscious competence; KB - Conscious incompetence PB - Unconscious incompetence (panic-based) To improve importance - stimulate interest in the task; why job is critical to plant success Biases take over in KB, e.g., pattern matching, frequency and confirmation biases Review error precursors that are particularly potent for each error mode (SB - distractions, illness & fatigue, simultaneous tasks; RB - mind set, confusing procedure; KB - hidden system response, assumptions, lack of fundamental knowledge) Error-Prevention Techniques: SB – self-checking, peer checking, slow down; RB – critical parameter, peer-checking, If2Then2; KB – team problem-solving, devil’s advocate, “buy time,” Purpose of Task Preview - to identify method of best control; not to question competence Reliability or Chances for error: SB - 1:10K (ideal conditions); RB - 1:1K (nominal); KB - 1:2 (urgent) (chances for success improve in KB performance mode as time to make a decision increases) Rule Based If - Then Misinterpretation Skill-Based Auto Source: James Reason. Managing the Risks of Organizational Accidents, 1998. Inattention Familiarity (w/ task) Low High

Performance Modes Three performance modes Knowledge based Rule based Analysis / reasoning Error rate highest (1/10 –1/2) No rule to follow Proceed based on experience (you don’t know what you don’t know) Rule based Procedures / checklists Error rate higher (1/100) Poor or inappropriate rules Misinterpretation of the rules Inadequate training Skill based Habit; little thought Low error rate (1/1000) Forgot something (know how; just forgot) Distraction / interruption

Error-Traps Task Demands Individual Capabilities Work Environment Performance Reliability: increases as number of error precursors decrease decreases as number of error precursors increase Error-Traps Task Demands Individual Capabilities Limited short-term memory Personality conflicts Mental shortcuts (biases) Lack of alternative indication Inaccurate risk perception (Pollyanna) Unexpected equipment conditions Mindset (“tuned” to see) Hidden system response Complacency / Overconfidence Workarounds / OOS instruments Assumptions (inaccurate mental picture) Confusing displays or controls Habit patterns Changes / Departures from routine Stress (limits attention) Distractions / Interruptions Illness / Fatigue Lack of or unclear standards Hazardous “Can-do” attitude for critical tasks Unclear goals, roles, & responsibilities Indistinct problem-solving skills Interpretation requirements Lack of proficiency / Inexperience Irrecoverable acts (Recognize Critical Steps) Imprecise communication habits Repetitive actions, monotonous New technique not used before Simultaneous, multiple tasks Lack of knowledge (mental model) High Workload (memory requirements) Unfamiliarity w/ task / First time Time pressure (in a hurry) Work Environment Human Nature

Top Ten Human Performance Tools Job Brief (JSA) Self-Check Peer-Check Procedure Use Place-Keeping Effective Communication Questioning Attitude Knowledge/Training Coaching Turnover ERROR

Self Checking STAR STOP THINK Pause to enhance attention to details. Eliminate present or future distractions Focus on the task at hand THINK Understand specifically what is to be done Question the situation using SAFER Do not proceed in the face of uncertainty

Self-Checking STAR ACT REVIEW Physically touch or point to correct components Read aloud from procedures, instructions, labels Perform the intended action correctly and safely Take preventative actions as anticipated REVIEW Verify the actual response is what was intended Ensure all actions serve to reduce injury and error Step back and do a “sanity check” of the results

Peer Checking (Mentoring for SSE) Explain intentions and agree on actions and expected results before taking action Confirm action is appropriate and in accordance with written instructions, authorizations, etc. Perform the action Agree that results are what was expected Like self-checking using STAR, Peer Checking is a simple yet effective barrier to human error. Practicing these techniques over time will help them to become ingrained in our safety culture both at work and at home.

Questioning Attitude Think about what we are doing in sufficient detail to identify areas of confusion or concern When areas of confusion or concern are identified, raise the issue and take the time necessary to resolve it Go into each job confident, but not overconfident Develop a healthy uneasiness about what might be hidden or different today

Accidents are failures of fore thought Accidents are failures of fore thought. The personnel involved when asked say “I just didn’t see it coming.”

What are People Rewarded for? The problem all companies have is doing what the safety manual / safety rules state There are always pressures on you and sometimes following safety “procedures” is . . . It is likely that a procedure has been violated many times before an accident occurs

Your Role to Help Employees Perform Safely Take Away Your Role to Help Employees Perform Safely Make sure employees are highly trained and retrained Really do maintenance Implement redundancy in processes, instruction and equipment Encourage self checking and peer checking – especially critical or infrequent tasks Supervisors – stand back and watch – actually oversee the work

Integrate Safety Into Production Take Away Integrate Safety Into Production People are fallible and even the best people make mistakes. Review and following safety rules People achieve high levels of performance due to encouragement and reinforcement from leaders, peers and subordinates. When co-workers look at compliance and talk about safety – 2 people benefit Individual behavior is influenced by organizational processes and values. Putting safety talk into action builds a positive environment

So how does this fit into driving? We all drive There is lot going on and we do not think about our driving. Complacency - Experience leads to automatic actions, but we tend not to pay attention to detail Optimism bias -- we all rate ourselves as better than average drivers Enforce safe driving rules and other procedures Get info about accidents and use at frequent safety meetings

Questions? Discussion?