Human Performance, the Event Free Clock & Breaking the Safety Cycle Introducing Leading Indicators to Break The “Safety Cycle”

How To Measure Safety Performance? Where to Focus Safety Efforts?

The Safety Cycle Injuries Time Upper Limit Lower Limit

Fewer Accidents? Safety Meetings Safety Initiatives Rules Discipline Training Fewer Accidents? Regulations Awards Safety Meetings Pre-Job Brief

Five Basic Facts People are fallible and even the best will make mistakes. All consequential errors that could lead to injuries are preventable. No worker would intentionally injure themselves. If there is a method that could free a worker from being injured without undue burden, they would adopt it. Fast improvement can only be achieved in an open, non-punitive, and constant learning workplace.

Human Performance Basic Human Performance concepts focus on identifying and improving: Human Errors Reduce the chances of errors occurring, and Reduce the effects of errors resulting in injury and/or system disturbances Failed or Insufficient Layers of Protection Latent Organizational Weaknesses

Layers of Protection

Unwanted Outcomes (Events) Equipment Failure – 20% Individual Errors – 30% Latent errors result in hidden organization-related weaknesses or equipment flaws that lie dormant. Such errors go unnoticed at the time they occur and have no immediate apparent outcome to the facility or to personnel. Latent conditions include actions, directives, and decisions that either create the preconditions for error or fail to prevent, catch, or mitigate the effects of error on the physical facility. Latent errors typically manifest themselves as degradations in defense mechanisms, such as weaknesses in processes, inefficiencies, and undesirable changes in values and practices. Latent conditions include design defects, manufacturing defects, maintenance failures, clumsy automation, defective tools, training shortcomings, and so on. Managers, supervisors, and technical staff, as well as front-line workers, are capable of creating latent conditions. Inaccuracies become embedded in paper-based directives, such as procedures, policies, drawings, and design bases documentation. Workers unknowingly alter the integrity of equipment, such as the installation of an incorrect gasket, mispositioning a valve, misidentification of a circuit, hanging a danger tag on the wrong component, or attaching an incorrect label. Human Errors - 80% Latent Organizational Weaknesses – 70%

Human Performance What is Human Performance? A series of behaviors executed to accomplish specific tasks. The focus on and reinforcement of desired behaviors during all processes and phases of every operation.  These behaviors become the basis for our principles that drive safe, reliable and event free operations within APS. Excellent Human Performance is possible when everyone embraces the principles about Human Performance.

Human Performance Improve Human Performance & YOU WILL Improve Operational Performance The focus on and reinforcement of desired behaviors during all processes and phases of every operation.  These behaviors become the basis for our principles that drive safe, reliable and event free operations (“operations” in the broadest sense) within APS. Excellent Human Performance is possible when everyone embraces the principles about Human Performance.

THE THREE TYPES OF HUMAN ERRORS ARE: Knowledge-based Errors These tasks are new, unfamiliar or unique to the performer They depend heavily upon the performer’s fundamental knowledge, diagnosis, and analysis skills Best described as trial and error or literally “I don’t know” This an error category is typically associated with a lack of training and/or knowledge that would have prevented the error.

THE THREE TYPES OF BEHAVIOR BASED ERRORS ARE: Rule-based Errors These tasks are familiar to the performer Upon correct recognition of a situation or condition, the performer can apply a stored rule to steer towards a known end goal Tasks in this domain tend to follow if-then logic Rule Based Errors are unexpected results that are a different outcome than what was expected when the action was taken. “I thought it was going do this when I did it but instead it did that.” This is the error type that occurs with being to comfortable or being complacent with a situation or task. For example, bicycle riding is considered a skill-based behavior in which very little attention is required for control once the skill is acquired.

THE THREE TYPES OF BEHAVIOR BASED ERRORS ARE: Skill-based Errors These tasks are comprised of very familiar actions Performed in comfortable surroundings The human being is, or is close to, being on autopilot

Low - Familiarity - High Task Error Model Error Mode: Inaccurate Mental Model Error Rate 1:10 Rules, Standards, Checklist, Written Procedures Error Mode: Misinterpretation Error Rate 1:100 Memorization, Practice High – Attention - Low Knowledge based – Rule based – Skill based Error Mode: Inattention Error Rate 1:1,000 Low - Familiarity - High

Error Trap Recognition (TAPE Method) Error Traps Error Trap Recognition (TAPE Method) Time Specific Error Traps Activity Specific Error Traps Daily Cycle (time of day) Inadequate Layers of Protection Weekly Cycle (day of week) Time Pressure Task Monthly Cycle (summer effects, etc.) Distractive Task Holiday Effects First Time or Infrequent Task Person Specific Error Traps Environment Specific Error Traps Compromised Physical & Mental Conditions Weather Conditions Negative Personal & Age Effects Unproven, Unseen, & Unauthorized Walk Paths Inexperience Sloping Footing/Terrain Not Understanding or Complying with the Rules Low Visibility Error Precursors Unfavorable conditions embedded in the job site that create mismatches between a task and the individual Interfere with successful performance and increase the probability for error. Exist before an error occurs. Most are outcomes of latent organizational weaknesses Can usually be corrected by addressing processes, programs, values, etc. Multiple error precursors - increase chances of error; change the situation We need to have an intolerance for error traps and change the job-site conditions to minimize the chance for error.

Some Human Performance Tools for Individuals Questioning attitude Stop when unsure Self-checking Procedure use and adherence Three-way communication Phonetic alphabet Place-keeping Two Minute Drill Conservative Decision Making

Some Human Performance Tools for Teams Pre-job briefing (Tailboard) Peer check Flagging Turnover Post-job review Concurrent Verification

Some Human Performance Tools for Leaders and Management Observations & Feedback Self-Assessments Operating experience

What is an Event Clock? A real time Human Performance tool to effectively communicate current human performance status relating to safety and reliability. Qualifying Events reset the clock to zero Helps improve safety and reliability by being a vehicle to share lessons learned following Qualifying Events so that we engrain the HP tools into how we do business.

2012 Event Clock Criteria Fatalities Amputations Loss of Consciousness Electrical Contacts with Injury Arc Flashes with Injury Fractures (non-dental) Lost-time Injuries Switching Order & Clearance Errors (resulting in an event) Motor Vehicle Accidents greater than $5K damage Unplanned Significant Outages (with feeder breaker trip) OSHA Violations with an event

Event Clock Resetting Types Avoidable: Total # Events Fatalities Lost Times 5 Fractures 2 Amputations Loss of Consciousness Electrical Contacts w/ Injury Arc Flashes w/ Injury Switching & Clearance Events 3 Motor Vehicle Accidents >$5,000 Unplanned Feeder Outages (@ Sub Breaker) 6 Events with OSHA Violations  1 Total Event Clock Resets 20

ED/CS/RR Event Clock Organization 2012 Resets 2012 Incentive Threshold Energy Delivery 19   Customer Service 1 Rates & Regulatory Total 20 32 Days Since Last Reset 44 Average Days Between Resets 18

Organization Days Since Last Reset # 2012 EFC Resets Last Resetting Event Last Reset Date Atwell - Tot Transmission Construction 70  3 32603  7/13/2012 Lucas/Tetlow - Total ED Power Ops & Maint 68  11 32596  7/15/2012 Easterly - Total Rural AZ Delivery 37 32701  8/15/2012 Smith - Total ED Asset Mgmt & Plng 1856  0 26223  8/23/2007 McElmury - Total Safety&Perf Excellence 331 31796  10/26/2011   Daniel - Total Distribution Constr 60  2 32628  7/23/2012 Froetscher - Total Energy Delivery  19 Orlick - Marketing None None  Goguen - Total Cust Svc Ops 795 30350  7/19/2010 Loveridge - Total Meter Operations 146  1 32381  4/28/2012 Casuga - Total Cmty Dev/Cust Offices 780 30393  8/3/2010 McLeod - Total Customer Service Guldner - Total Rates & Regulation 1134 29162 8/14/2009 Total ED/CS/RR  20 32701

Breaking the “Safety Cycle” Injuries Time Trend

Close Calls are a gift from God

(602) 371-7873 Charles.Thomack@aps.com Section Leader, Safety Presented by: Chuck Thomack, CSP Section Leader, Safety (602) 371-7873 Charles.Thomack@aps.com Date: September 28, 2012