IM Human Performance Excellence Introduction - How to Prevent Events August 2012

2 Proprietary & Confidential Information Agenda  Why a Human Performance Excellence Program  Human Performance Tools/Techniques  How do Events Happen?  Anatomy of an Event -  Understanding that multiple issues cause an “event”  Mindset – these techniques help us “back each other up”  Next steps for departments and teams

3 Human Performance Excellence is part of the Way We Work: Our Quality Culture in providing “Secure, Rock Solid IT” Proprietary & Confidential Information

4 Since starting program in 2008, Human Performance continues to be a positive factor in PGD’s overall EFOR* improvement HP is a Nuclear industry program. PGD adopted the program to reduce their EFOR events PGD HP forced outage events continue to improve * Equivalent Forced Outage Rate (EFOR)

5 Proprietary & Confidential Information IM Human Performance Program Structure  Senior leadership selected across IM to establish the program  Sponsors – Anita Sharma, Phil Prugnarola  IMB - Danny Lizano/Eddie Cardelles, Kristi Baldwin  Nuclear - Tom Beneduci, Alex Guerrero, Amolien Chery  IME - Art Ruiz, Bryan O’Sullivan, Sue Gampfer (Program coordinator)  IMO - Mauricio Gonzalez, Nancy Mulshine, Rick Vinton  IMT - Grace Kurian, Paul Carpenter, Dean Hertzog, Linda Cassulo  Info Sec - Roland Miller  IMP - Cecilia Lim (Quality rep), Denise Cormier, Ken Grafe  Formed 3 sub teams to integrate with IM’s quality / process improvement efforts  Team 1 – Critical Tools Identification / CBT materials  Team 2 – How do we measure success  Team 3 - Rollout approach / Workshop and Leaders Guides We established a steering committee to frame out this program for IM using PGD and Nuclear programs as guides

6 Proprietary & Confidential Information Our 2012 midyear performance review shows 35% of our events are attributed to Human Performance Root Cause Revised coding structure as part of the Human Performance initiative High Bars (as of mid May) – Software and Human Performance Root Cause Sub Codes High Bar (as of mid May) – SW Bug, Process not Followed, Accident, HW Failure, Training Inadequate, Communication Gap 2012 Root Cause / Human Performance April YTD

7 Proprietary & Confidential Information The events caused by human performance were not done on purpose - People are fallible and even the best make mistakes 1.People are fallible and even the best people make mistakes 2.Error likely situations are predictable, manageable and preventable 3.Individual behaviors are influenced by organizational processes and values 4.People achieve high levels of performance because of the encouragement and reinforcement received from leaders, peers and subordinates 5.Events can be avoided through an understanding of the reasons mistakes occur and application of the lessons learned from past errors or events Five Principles of Human Performance Human Performance Excellence is a team effort at all levels of our organization.

8 Proprietary & Confidential Information Reducing Errors and Preventing Events Human Performance Tools can help us reduce the occurrence of errors as well as manage the integrity of the defenses we put in place R e + M d = ØE Reducing active errors (Re) and managing defenses (Md) leads to zero significant events (ØE). Because there are both human and organization aspects to human performance, event free performance requires a strategic approach. The strategy is expressed in the formula We want to build a culture around “preventing errors”

9 Proprietary & Confidential Information Why are we doing this program? Program Goal – Prevent Events To reduce the opportunity for and the frequency of human error To target improvements to our “defenses” to help preclude significant events When do we use these tools / techniques? Addressing critical activities when a mistake has significant impact Planned changes to production applications under SLA Where we have had near misses that caused the team to work heroically Making sure you are working on the right equipment/right environment We use many of these techniques today –so what is the difference? Being pro active - think about what could go wrong and plan for it Recognize when results are not what was expected to stop and get help Recognizing when you/team may be at risk for making an error Our focus is on addressing critical activities in our work when mistakes are made, the impact is significant IM Human Performance Excellence Program Concepts

10 Proprietary & Confidential Information Human Performance Tools/ Techniques All Tools/Techniques 1.Self Checking (STAR) 2.Questioning attitude 3.Peer checking 4.Pre Job / Activity Briefing 5.Three Way Communication 6.Procedure use and Adherence 7.Place Keeping 8.Task Preview 9.Job-site review 10.Stop when Unsure 11.Post Job review 12.First check 13.Phonetic Alphabet 14.Concurrent Verification 15.Independent Verification 16.Turnover 17.Flagging We focused on identifying the starter list of techniques which can have immediate benefits IM Starter List 1.Self Checking (STAR) 2.Questioning attitude 3.Peer checking 4.Pre Activity Briefing We will introduce additional techniques over the next year.

11 Proprietary & Confidential Information HPE Program – Computer Based Training We updated corporate CBT about Human Performance with IM examples of HP events Provides overview of HPE (theory around HPE) and IM Examples Overview / Job aid of starter tool set CBT will be available in SAP – use it as a reference

12 Proprietary & Confidential Information HPE Program – Job Aids We have a job aid for our “starter” toolset showing purpose, when to use it and at risk practices to avoid.

13 SELF CHECKING / STAR reduces the frequency of errors during skill-based activities STAR (Stop, Think, Act, and Review) Let’s review a few techniques

14 QUESTIONING ATTITUDE reduces the frequency of errors made by the individual in the performance of a rule-based activities Let’s review a few techniques

15 “Work Site Huddle/ Communications” Clarifies expectations between work groups during cross- functional tasks Let’s review a few techniques

16 How do Events Happen? Flawed Defenses Initiating Actions ONE WAY Error Precursors Latent Weaknesses (Land mines) Event An Event is an occurrence for which the undesired effect is of high significance

17 How do Events Happen? Flawed Defenses Initiating Actions ONE WAY Error Precursors Event The last action (correct or incorrect) by an individual. Latent Weaknesses (Land mines)

18 How do Events Happen? Flawed Defenses Initiating Actions ONE WAY Error Precursors Event Error-likely situations are predictable, manageable and preventable - Undetected deficiencies in processes or values creating workplace conditions that degrade integrity of the defense Possible Landmines Training Communications Planning and Scheduling Maintenance processes Procedure development Goals and Priorities Latent Weaknesses (Land mines)

19 How do Events Happen? Flawed Defenses Initiating Actions ONE WAY Error Precursors Latent Weaknesses (management) Event Error-likely situations are predictable, manageable and preventable - Unfavorable prior conditions that increase the probability for error when performing a specific task – Potential precursors Time pressure Distracted Environment Multi Tasking First time or performing infrequent task Overconfidence Vague or incorrect guidance Work stress Fatigue

20 Latent Weaknesses (Land mines) How do Events Happen? Flawed Defenses Initiating Actions ONE WAY Error Precursors Event Error-likely situations are predictable, manageable and preventable - Defenses are means or measures taken to catch human error or to mitigate the effect of human error. Flawed defenses, under the right circumstance, may inhibit the capability of defensive measures to protect. Potential Flaws Inconsistent testing Missing alarms Incomplete check sheets Lack of understanding full risks of activity

21 The Swiss Cheese Model of Accident Causation Hazards Losses Successive Layers of Defenses Events don’t typically occur because of one single error... Awareness of risk Testing & Environments Quality Assurance Procedures/ Check lists Change Management (errors, software defects, equipment failures, etc.) (events)

22 Preventing Events Latent Weaknesses (Land mines) Flawed Defenses Initiating Actions ONE WAY Error Precursors Event Let’s do a case study so you can see how an event is usually caused by several errors or flaws The approach to achieve event free performance requires us to reduce human error and manage the integrity of our defenses

23 CASE STUDY Eastern Airlines Flight 401 The Anatomy of an Event As you watch the video – identify the anatomy of this event.

24 Proprietary & Confidential Information

25 CASE STUDY Eastern Airlines Flight 401 The Anatomy of an Event Let’s discuss – there were several times this event could have been averted…

26 Land MinesError PrecursorsFlawed DefensesInitiating Actions No training on auto pilot disengagement Time pressureNo acknowledgement for altitude alarm Bumped auto pilot off Crew roles not clearly defined DistractionsUnable to verify position of landing gear Controller’s role was limited Unexpected equipment conditions Captain stepped out of oversight role No procedure for burned out bulb Unclear goals, roles and responsibilities Overconfidence (in autopilot) Tunnel vision Answer Key

27 Discuss a recent event and identify –Initiating Action –Error precursors –Landmines –Flawed defenses What was the event’s impact on the business? What was the impact on the team? Review tools - when/how could the team use one of the tools? Team Discussion Points

28 Proprietary & Confidential Information Aug/Sept Goals – Launch program, understand how events happen Program Kick off with IM Leaders – IM Leaders Meeting July 31 Core team members start Workshop Deployment – due by September 30, 2012 IM Leaders meeting Aug 28 – new event cause category reporting IM Communication Meeting September 11 - All employee launch Sept / Dec Goals – Review skill a month, communicate team successes and learning’s Sept – STAR Oct – Questioning attitude Nov – Peer checking Dec – Pre activity brief IM Communication Meeting - program progress – 2013 Stand up for quality sessions HPE Program – Rollout / Communication Plan Share examples of how you/your team used the techniques Our long term goal is make these behaviors second nature –

29 Q & A