Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Human Performance P = B + R

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP What is the “Next Level” we hear so much about? Courtesy of OSHA Training Institute, Des Plaines, IL “You keep using those words but I do not think they mean what you think they mean…” Aneigo Montoya, Princess Bride

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Generations of Levels First Level Trailing Indicators OSHA 300 Logs EMRs Courtesy of OSHA Training Institute, Des Plaines, IL

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Generations of Levels Second Level Weighted Audits, Surveys & Observations Systems can be sided by their own terms Courtesy of OSHA Training Institute, Des Plaines, IL

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Generations of Levels Third Level Predictive Audits (Risk Rating) Combination of weighted audits, surveys & observations to provide a set of risks likely to result in events. Courtesy of OSHA Training Institute, Des Plaines, IL

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Generations of Levels Next Level Based on Aristotle “We are what we repeatedly do, Excellence, then, is not an act but a habit.” Courtesy of OSHA Training Institute, Des Plaines, IL

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Generations of Levels Next Level To understand, we have a formula: Given P = B + R, then R e + M d → E Courtesy of OSHA Training Institute, Des Plaines, IL

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Human Error is normal It is provoked by conflicting management & leadership priorities and by weakness in the organization, processes and culture.

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Behavior can be seen and heard Results are measureable

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Human Performance We must look at what is an accident or event. What is it? Injury? Near Miss?

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Human Performance Cutting plastic sheeting with a knife. Standing too close. Girl Scouts Know Better! First time

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Human Performance Cutting plastic sheeting with a knife. Standing too close. Girl Scouts Know Better! Second time

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Human Performance Cutting plastic sheeting with a knife. Standing too close. Girl Scouts Know Better! Third time

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Human Performance The Accident or Event is the action which may or may not result in injury. The Initiating Action was based on a choice, a human choice. Choice was manifested in Behavior. The measurable Result was observable. P = B + R

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Human Performance How many of these choices might be made by a human in your organization? How many are bad choices (errors)? How many do we make in a minute?

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Human Performance How many do we make in hour? How many in a week? How many in a year? By how many employees?

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Human Performance How many do we make in hour? How many in a week? How many in a year? By how many employees?

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Human Performance How many, statistically, will be bad choices? (errors) How many may result in serious injury? What about acts of God?

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Events Causes: Image courtesy of INPO

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Reducing Error ReRe

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Common Traps of Human Nature Stress Mental Strain Avoidance AssumptionsHabit Confirmation BiasSimilarity Bias Frequency BiasAvailability Bias Limited PerspectiveFatigue Motivated Toward Goal Accomplishment Difficulty Seeing One’s Own Error

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Common Traps of Human Nature PrideHero FatalisticSummit Fever InvulnerabilityPollyanna Bald Tire

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Slips, Lapses, Mistakes and Errors People tend not to err intentionally. Line employees tend to make Active Errors – have an immediate effect Managers tend to have Latent Errors- have a delayed effect

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Violations Why? Low detection potentialNo Boss around Peer pressureNot corrected Perceived authorityBoss doesn’t care Conflicting demandsCompetition Lack of trainingPrecedent Emulation of role models!!!!!!!

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Violations People sometimes violate procedures, for evil or for good. Honest intent to deviate from procedure to achieve a greater good Hostile acts (over time, good intentioned deviation may become hostile)

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Fundamental Prevention Tools Situational AwarenessTask Preview Pre-job BriefingPeer-Checking Questioning AttitudeFlagging Procedure UsePlacekeeping 3-way CommunicationPhonetic Alphabet Validate AssumptionsSignature Concurrent Verification(Honey Do’s)

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Positive Control Many errors can be accounted for if an employee has positive control of their tool or work situation.

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Clear Expectations for HU Tools Specific Observable Objective Doable Active

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Critical Steps Used to prepare for a work activity S ummarize the critical steps A nticipate errors for each critical step F oresee probable results of error for each step E valuate controls at each critical step R eview previous experience and lessons learned to each critical step

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Competence vs. Control Respecting Human Fallibility Positive Control means what is intended to happen is what happens, and that is all that happens. Built in checks are not an accusation on competence!

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP At-Risk Practices Basic Safety Risks First and Second Level Generation Items

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Selecting and Adapting HU Tools See: Human Performance Tools, November, 2007; Department of Energy

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Work Execution Work Preparation Work Performance Work Feedback

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Managing Defenses MdMd

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Defense-In-Depth Engineering Controls Administrative Controls Cultural Controls Oversight Controls

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Managing Defenses Plan Do Check Adjust

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Beware of Latent Errors They do not fade away, they collect! “Liberation and mobilization of human energies- rather than symmetry and harmony-constitute the purposes of organization. Human performance is its goal and its test.” Peter Drucker

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Finding & Correcting Latent Weakness Self-assessments KPIs & Trending Benchmarking Independent Oversight Behavior Observations Problem Reporting Causal Analysis Management Oversight Surveys & Questionnaires Corrective Action Program Change Management

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Performance Model w/ Defenses Image courtesy of INPO

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Results in and of a Zero Event Culture → E

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Safety Culture Must cultivate a Questioning Attitude! Events often result from a shared assumption, value and/or belief of the organization. All must be watchful and question the established culture at all times.

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Leadership ANY individual who takes personal responsibility for his or her performance as well as the organization's performance AND attempts to influence the improvement of the organization that supports that performance.

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Key Leadership Practices Facilitate open communication Promote Team Work Reinforce desired behavior, appropriately Eliminate Latent organizational weakness Value prevention of errors

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP HU Fundamentals 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 largely because of the encouragement received from leaders, peers, and subordinates. 5.Events can be avoided through an understanding of the reasons mistakes occur and application of the reasons learned from past events (or error).

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP Resources Human Performance Reference Manual, Oct., 2006: Institute of Nuclear Power Operations (INPO). Human Performance Tools: For Individuals, Work Teams, and Management, Nov., 2007: Department of Energy, Human Performance Center. Instructor Notes

Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP R e + M d → E

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