1. Keys to Improving Work Methods and Instructions Rob Fisher President, Fisher IT, Inc. 802-233-0760Rob@fisherit.com Copyright, Fisher IT, Inc.

2. At a Glance… Establish / reestablish some definitions Error traps in procedures and processes – Top 5 error traps – Deviation potentials and drift Using HPI concepts in instructions – Focus on the system – HP models Copyright, Fisher IT, Inc.

3. True or False? Copyright, Fisher IT, Inc.

4. OSHA Act of 1970 – SEC. 5. Duties (a) Each employer -- (1) shall furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees; (2) shall comply with occupational safety and health standards promulgated under this Act. (b) Each employee shall comply with occupational safety and health standards and all rules, regulations, and orders issued pursuant to this Act which are applicable to his own actions and conduct. Copyright, Fisher IT, Inc.

5. HP Defined Copyright, Fisher IT, Inc.

7. HP RE-Defined? Copyright, Fisher IT, Inc. X XX X

8. Some Things to Remember 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 2010, Fisher IT, Inc.

9. Definitions 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 Error Traps - An unfavorable condition that increases the probability for error during a specific action Error-Likely Situation - A work situation in which there is a greater opportunity for error when performing a specific action or task due to error precursors. Organizational weakness – weaknesses in the processes or values that allow the existence of an error trap or WITH model characteristic to progress to an event Copyright, Fisher IT, Inc.

10. 10 Alarms and Warnings Rules Protective Equipment and Devices Barriers, Guards and Engineered Safeguards Training DANGER Root Causes Drivers INCIDENT Gaps The “Swiss Cheese Model” Supervisor Swiss-Cheese Model Defenses – Measures or barriers intended to protect against errors or hazards, mitigate consequences of a hazard, or promote consistent actions.

11. Copyright 2012, Fisher IT, Inc. We are hired to do an OCCUPATION ( operator, mechanic, mobile equipment operator, janitor) These occupations require us to do JOBS These jobs contain TASKS These tasks contain ACTIONS (Steps) Lock-out-tag-out THIS pump 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

12. True or False? Copyright, Fisher IT, Inc.

13. 5 Criteria –Are your Work Instructions…. Available, Workable, Intelligible, Correct and Consistently reinforced? Copyright, Fisher IT, Inc. Derived from "Managing the Risks of Organizational Accidents", James Reason, 1994, pp 209

14. Top 5 Procedure Traps to Watch For Field Decisions Difficulty Vagueness and Misleading Information Multiple Actions Conflicting Information, Actions & Formats

15. Trap 1 - Field Decisions The procedure user must make a decision with little or no guidance for making that decision. For example if the user has to: – Decide what to do out of multiple options without guidance – Determine if certain conditions exist – Determine if certain sections of procedure are applicable – Determine if the task is completed – Determine if certain requirements are met Decisions made in error prone situations have a field error rate 11 times higher than that of a well written step!

16. Field Decisions (cont.) Conditions affecting the quality of Field Decisions are: – The number of aspects to be considered – Existence of a decision aid – Readiness of the information – Decision maker’s experience and personality

17. Trap 2 - Difficulty Mental Difficulty Told once (in training, memo, OJT, etc.) and now the individual must remember to use it and how to use it Told earlier (in precautions, limitations, procedure step) and now the individual has to figure out when to apply it Physical Difficulty Difficult tasks Unnecessary or unreasonable tasks Easy to shortcut Contact with other organization Has to stop and do something else

18. Trap 3 – Multiple Actions (& embedded actions) 3 or more actions in the same step Actions in a NOTE, CAUTION or WARNING (real or embedded) Actions in Precautions, Limitations, and Pre- requisites

19. Trap 4 – Vague Terms and Misleading Information Vague Terms Abstract verbs like: Impact, Affect, Analyze, Determine, Review, Check, Ensure, Verify Abstract adjectives like: Slow, Fast, Sufficient, Normal, All, Periodically, Routinely Abstract phrases like: When Directed, As Soon As Management …., May be, Should

20. Misleading Information Misleading information is incorrect, but it’s not easy to detect and avoid the error traps it creates and may involve: – Missing critical steps to carry out a task – Missing critical data – Missing critical references – Missing critical scopes The most effective ways of discovery of misleading information are walk-through and full scope verification

21. Trap 5 – Conflicting Instructions Actions that are required by procedural steps but are contrary to the normal actions expected by the workers or formats that are “different” to the user: – Inconsistent actions – Inconsistent words – Inconsistent expressions – Inconsistent format Note: Use of double-negative statements in procedure steps increases the error rate of the step by 280%

22. Copyright, Fisher IT, Inc.

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

24. www.fisherit.com Copyright, 2012Fisher IT, Inc. Deviation Potential – Simplified Deviation Potential © = Difficulty Perceived Risk + Observation Conscious Unconscious Errors Just don’t comply Accountability issue personal compliance issue Usually a single individual Wrong rule Misapply rule Trying to comply and taking a shortcut Often tribal (a group) Drift Rule Based - 3 General Categories Wrong Rule - Rule problem Misapplication - Information problem Just Don’t comply Personal compliance issue PhysicalMental Peer Supervisor Corporate Personal Intent to Violate No Intent to Violate Violations (<10%) Errors (>90%)

25. Rule Requirements (Believed Norm) Standards Time (years) Deviation Drift (New Norm) Safety Threat Incident Performance Gap (discovered by investigation) Investigation T1T2Incident Date Deviation Drift

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

27. WITH Model Work Environment Individual Capabilities Task Demands Human Nature General influences on task performance related to workplace, organizational and cultural conditions Unique mental, physical and emotional capabilities of an individual related to a specific task Specific mental, physical or team requirements of a task Generic characteristics of human beings that makes us more vulnerable to errors under certain conditions Copyright 2010, Fisher IT, Inc.

28. Conclusions The fit, form and content of instructions has a marked impact on fatality prevention We have to take the WITH model into account when writing instructions and briefing tasks Deviation probability can be predicted and avoided if we understand it We can build quality into the processes by: – Not putting the traps in and / or – Teaching people how to identify and deal with them Copyright, Fisher IT, Inc.