Elements of an Effective HPI Program HPWG Elements of an Effective HPI Program Rob Fisher President, Fisher IT, Inc. 802-233-0760 Rob@fisherit.com October 9, 2013 Copyright, Fisher IT, Inc.

Charles F. Kettering – Inventor & Philosopher “A problem thoroughly understood is always fairly simple.” “Found your opinions on facts, not prejudices. We know too many things that are not true.” Charles F. Kettering – Inventor & Philosopher 1876- 1958 “Why is the human skull as dense as it is? Nowadays we can send a message around the world in one-seventh of a second, but it takes years to drive an idea through a quarter-inch of human skull.” Copyright, Fisher IT, Inc.

Understanding Human Performance Systems model Interconnectivity Latent conditions Need for multiple feedback loops Need a systems approach to Human Performance Copyright, Fisher IT, Inc.

Most problems in industry are related to Human Error… True or False? Most problems in industry are related to Human Error… Copyright, Fisher IT, Inc.

The Program MUST be based on… 90% of events are caused by something OTHER THAN JUST the individual 95% of people respond very similarly to the same stimuli People do what they do at the time that they do it for reasons that make sense to them at the time Human Performance is NOT Common Sense Copyright, Fisher IT, Inc.

Copyright, Fisher IT, Inc. Definitions We MUST learn to separate the ERRORS from the EVENT Error: An action or inaction that unintentionally: Results in an undesirable or unwanted condition OR Leads a task or system outside of limits OR Deviates from a set of rules Event (or incident): The undesirable result of an error, a set of errors or a set of conditions Deviation: Not strictly complying with a rule, standard or expectation Violation: Intentionally not complying with a rule, standard or expectation Active Error: An action or inaction that results in immediate consequence Latent Error: An action or inaction that results in consequences that are delayed or create latent conditions Errors and violations are different things We MUST pay attention to all types of errors Copyright, Fisher IT, Inc.

For Every Deviation From A Definition… Your Program Weakens! Copyright, Fisher IT, Inc.

You cannot ‘correct’ your way to excellence The Three Legged Stool Prevention – How much emphasis do we put on keeping bad things from happening? Detection – Are we looking at the right threshold to identify problems? Correction – Do the things we do to fix problems: Match the significance of the problem? Take other, similar but worse problems into account? Not cause problems of a different type? You cannot ‘correct’ your way to excellence Copyright, 2013, Fisher IT, Inc.

Copyright, Fisher IT, Inc. Three Key Indicators… Prevention The number and quality of Pre-Task briefs should increase Detection The number and quality of MANAGEMENT observations should increase Correction The number and quality of non-injury (near miss, close call, etc.) should increase Copyright, Fisher IT, Inc.

Human Performance Improvement is about improving our abilities We are hired to do an OCCUPATION (operator, mechanic, mobile equipment operator, janitor) These Occupations require us to do JOBS These jobs contain TASKS (sections in a procedure or checklist) These tasks contain ACTIONS or Steps (lock-out-tag-out THIS pump Hang tags on each electrical supply Hang locks on each electrical supply Hang locks on each water supply Drive Mobile Equipment, Perform Lock-out-tag-out Operate equipment, Weld Drive fork lift into THIS tight place to handle THIS load THIS way Lift load up to see tight space Load goes into area in truck Human Performance Improvement is about improving our abilities at the TASK and STEP level Copyright 2013, Fisher IT, Inc.

Pre-Task Brief Measures Number Count them all Segregate those with high risk and / or fatality-serious injury potential Quality Capability of supervisors to perform PTBs Effectiveness of PTB in the field Copyright, Fisher IT, Inc.

Organizational values influence individual behaviors… True or False? Organizational values influence individual behaviors… Copyright, Fisher IT, Inc.

Management Observation Measures Number Again – count them all Percentage of HRT / FSIP that get observed Quality Percent that are value based Lessons learned Copyright, Fisher IT, Inc.

Copyright, Fisher IT, Inc. TRUE BUT…. The values of the small organization always trump the values of the big orgainzation related to individual behaviors… Copyright, Fisher IT, Inc.

Near Miss Measures (and root cause measures) Number Do I need to say it again? Ratio of near miss report to events Quality Event investigation tool checklist (or equivalent) Do cause analyses follow the process? Root Cause Corrective Action Reviews Copyright, Fisher IT, Inc.

“We have good processes… If we could just get people to follow them we would be fine!” Copyright, Fisher IT, Inc.

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Deviation Potential © Simplified Difficulty Deviation Potential = Risk + Observation www.fisherit.com Copyright, 2012 Fisher IT, Inc.

Deviation Drift Rule Requirements (Believed Norm) Performance Gap Investigation Rule Requirements (Believed Norm) Performance Gap (discovered by investigation) Deviation Drift (New Norm) Standards Safety Threat Incident T1 T2 Incident Date Time (years)

Deviation Potential – Simplified No Intent to Violate Errors (>90%) Physical Mental Unconscious Errors Taught once - must remember now Stated earlier - Difficult tasks Unnecessary tasks Unreasonable tasks Easy to shortcut Contact with other organization Has to stop and do something else Wrong rule Misapply rule Trying to comply and taking a shortcut Often tribal (a group) Drift Difficulty Rule Based - 3 General Categories Wrong Rule - Rule problem Misapplication - Information problem Just Don’t comply Personal compliance issue Deviation Potential © = Perceived Risk + Observation Personal Peer Injury Personal financial loss if caught Equipment damage Verbal reminders Violations (<10%) Conscious Supervisor Corporate Just don’t comply Accountability issue personal compliance issue Usually a single individual (or underling) Corporate financial loss if caught Equipment damage Root Cause & Corrective actions Intent to Violate www.fisherit.com Copyright, 2012Fisher IT, Inc.

Use this path to determine system failures Deviation Analysis Individual Driven Violations Was a safety rule or operating procedure knowingly violated? Would other similarly qualified people have done the same thing in the situation? Were the rules available, workable, intelligible, correct and consistently reinforced? YES NO Use this path to determine system failures Are there deficiencies in: Knowledge/skill Training Experience Selection ? Does the individual have a history of unsafe acts? Yes Use Deviation Potential Model To determine whether “knowingly violated” Violation – An action or inaction that intentionally deviates from a rule or standard Error – An action or inaction that unintentionally creates a problem or deviates from a rule or standard AND Use Performance Mode Model to assist Use Performance Mode Model to assist Individual & System Driven Violations & Errors System Driven Errors Copyright, Fisher IT, Inc.

Copyright, Fisher IT, Inc. Root Cause Analysis Should NOT be based on failed barriers Should always analyze the WITH model Should look for the REASON for a deviation using the models Should determine the LATENT drivers (or causes) Should not focus on the individual but on why the individual did what they did, and what systemic drivers made it feel right Copyright, Fisher IT, Inc.

Copyright, 2012, Fisher IT, Inc. Closing Summary Organizations that integrate human performance concepts into their day-to-day work improve: Performance in safety, quality, effectiveness & efficiency and Communication which significantly improves overall engagement Use the new language to describe errors, events, deviations and violations Use the new knowledge to analyze problems Recognize the performance mode you are in to minimize the error potential Recognize the triggers that tell you a trap exists that increases the probability and potential for errors Use the tools to avoid or minimize the impact of the traps Copyright, 2012, Fisher IT, Inc.