1. Presented by: Kate Chepeleff
April 17
Human Performance
Presented by:
Kate Chepeleff

2. How do we prevent these events?
Human Performance
April 17
Traditional Industrial Safety Programs protect you from your Plant. 
Human Performance protects the Plant from you. 
Human error is often identified as the cause of many safety events and accidents.
How do we prevent these events?

3. Define the Problem
April 17

4. Human Errors in the Medical Field
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Human Error

5. What is an Event?
April 17
Any undesired occurrence that has an adverse effect on safety, quality, or production.
*Perrow, Normal Accidents. Living with High-Risk Technologies, 1984, p. 183; Reason. Human Error. 1999, p.187.

6. Hierarchy of Health and Safety Controls
April 17
Elimination/Substitution/Isolation
substitute for hazardous material
reduce energy; speed, pressure, voltage, sound level, force
change process to eliminate noise
automated material handling, separate the hazard from the people
Engineering Controls
machine guarding, sound enclosures, circuit breakers
platforms and guard railing, interlocks, ventilation systems
Lift tables, conveyors, balancers
Safe Work Practices
work place rules, respiratory protection, lockout/tagout
confined space entry, hazard communication training
blood borne pathogens, hearing conservation
Administrative Controls
Training /Procedures & Warnings
safe job procedures, rotation of workers
safety equipment inspections, relief workers
computer warnings, odor in natural gas, signs, backup alarms
beepers, horns, labels
Personal Protective Equipment
safety glasses, ear plugs, face shields,
safety harnesses and lanyards, steel toe shoes, fire retardant clothing
Human Performance
pre-Job briefing, procedure use & adherence
flagging/operational barriers, self-checking
peer checking, post-Job review
STOP when unsure

7. Human Performance
April 17
Is an operating philosophy which acknowledges that people make mistakes
It identifies causes of human errors and provides specific tools to help eliminate them
Empowers employees, regardless of title or tenure, to contribute equally to the safety and operation excellence of an organization
Creates an open questioning environment

8. Principles of Human Performance
April 17
Humans are fallible.
Error is predictable.
Organization influences behavior.
Behaviors are reinforced.
Events are avoidable.

9. Human Performance is NOT
April 17
NOT a Performance Management Tool
NOT an excuse for not holding workers accountable
NOT a substitute for existing Operational Excellence efforts
NOT A SUBSTITUE FOR EXISTING SAFETY EFFORTS!!!

10. What is Human Performance?
April 17
Human Performance is Understanding Why we do What we do the Way we do it.
Tim Autrey
Paradigm Shift
Reduce our Errors by Managing our Defenses to leads us to Zero Events
Minimize the frequency and severity of plant events

11. Severity Pyramid
April 17

12. Why use Human Performance?
April 17
In 2014, OSHA states
there were 4,679 workers
killed on the job!
Almost 90 deaths a week
13 deaths every day

13. Anatomy of Events
April 17

14. What is an Error?
April 17

15. Accident Investigation
April 17
Traditional View
Human error is a cause of accidents
To explain failure, the investigations must find failures of systems or parts of the systems
New View
Human error is a symptom of trouble deeper inside a system
To explain failure, do not stop at where people went wrong...
Instead, find out how peoples’ actions and assessments made sense at the time given the circumstances that surrounded them.

16. Performance Modes
April 17
“Mistakes arise directly from the way the mind handles information, not through stupidity or carelessness.”
Edward de Bono PhD

17. Performance Modes
April 17
Information processing operates in one or more of three modes–
Skill-Based (SB)
Rule-Based (RB)
Knowledge-Based (KB)
They are based on the level of familiarity an individual has with a specific task
And the level of attention (degree of information processing) a person applies to the activity.

18. Performance Modes
April 17

19. Skill Based Performance Mode
April 17
Highly practiced actions (routine activity)
Usually executed from memory without significant conscious thought in a familiar situation.
Behavior governed by preprogrammed instructions developed by either training or experience.
Actions guided by subconscious mind possess 10 times the capacity of conscious thought.
Error Mode
Inappropriate act due to lack of attention
Error Rate
1 in 10,000

20. Use your skills…
April 17
Count the F’s in the statement below…
FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF MANY YEARS
Count the F’s in the statement below…
FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF MANY YEARS

21. What are some tasks that you do that are SKILL BASED?
Skill Based Events
April 17
What are some tasks that you do that are SKILL BASED?
Daily - Driving to and from Work
Do you always remember your trip?
Weekly – Pumping gas
Have you ever not put the cap on and closed the cover? Or…

22. Inappropriate act due to lack of attention Error Rate: 1 in 10,000
Skill Based Event
April 17
Inappropriate act due to lack of attention Error Rate: 1 in 10,000

23. Rule Based Performance Mode
April 17
Task performed by using existing rules from procedures, training, or experience.
Prepackaged action determined by recognition of familiar problem.
Behavior based upon selection of stored rules derived from one’s recognition of the situation; follows IF (symptom X), THEN (situation Y) logic.
The problem, although possibly familiar, is usually unanticipated.
Error Mode
Not recognizing changes in task requirements, system response, or equipment conditions associated with task due to some preoccupation. Or, so intent on task that pertinent information is not detected, i.e., over attentive.
Error Rate
1 in 1,000

24. During Dry Conditions STATIC ELECTRICITY can IGNITE FUMES
Rule Based Event
April 17
Not recognizing changes in task requirements, system response, or equipment conditions associated with task due to some preoccupation
During Dry Conditions STATIC ELECTRICITY can IGNITE FUMES
Error Rate: 1 in 1,000

25. Knowledge Based Performance Mode
April 17
Unfamiliar situation exists requiring worker to apply analytical skills and judgment
Behavior in response to a totally unfamiliar situation (no skill or rule recognizable to the individual) relying on one’s understanding and recollection of knowledge of the system, system’s present state, and scientific principles and fundamental theory related to the system…
Error Mode
Diagnosis errors - flaws in problem-solving & decision-making typically based upon insufficient information of the true system or equipment status.
Error Rate
1 in 10

26. Knowledge Based Event Error Rate: 1 in 10
April 17
Diagnosis errors - flaws in problem-solving and decision-making
What would you do if static started a fire?
Pull the hose out of the tank?
Error Rate: 1 in 10

27. Human Perfomance What is your STOP Criteria?
April 17
Error Rate: 1 in 10,000
Changing the Mode you are in
The Hardest part is identifying the change in Mode
What is your STOP Criteria?
Error Rate: 1 in 1,000
Changing the Mode you are in
Error Rate: 1 in 10

28. Human Performance Error Rate Pyramid
April 17 1 10
1,000
10,000
Event
Knowledge Based
Rule Based
Skill Based

29. Performance Modes
April 17
Information processing operates in one or more of three modes–
Skill-Based (SB)
Rule-Based (RB)
Knowledge-Based (KB)
They are based on the level of familiarity an individual has with a specific task
And the level of attention (degree of information processing) a person applies to the activity.

30. Error Precursors (Short list) to Events
April 17
Error Traps

31. What Error Trap will you fall in?
April 17
First working Day
after time off > 4 Days
Poor
Communications
Overconfidence
Distractions
End of a Shift
or Week
High work
load
Stress
Vague or Poor
Work Guidance
Infrequent or
First Time Task
Time Pressure

32. Are you Stressed?
April 17

33. High Work Load?
April 17

34. Time Pressure to get the job done?
April 17

35. Are you Distracted?
April 17

36. Vague or Poor Work Guidance?
April 17

37. Poor Communications?
April 17

38. Overconfidence?
April 17

39. Infrequent or First Time Task?
April 17

40. First Work Day after Time Off > 4 Days?
April 17

41. End of a Shift or Work Week?
April 17

42. How Human Performance Can Help?
April 17
The tools are not designed to teach people how to do their job, just how to THINK about it!
Methodically focuses us on the task at hand.
Teaches us how to ask the right questions.
Provides guidance on planning work.
Demonstrates “thinking compliance” instead of blindly proceeding.
Makes it okay to STOP if unsure.

43. Tools Pre-Job Brief What are you going to do?
April 17
Pre-Job Brief
What are you going to do?
Are there documents to follow or reference?
What Mode are you in?
Has there been an accident doing this task?
What Error traps apply?
What can go wrong?
Can you prevent if from going wrong?
Every one participates

44. Tools
April 17
STOP the job Card
The job has become non routine - DOCUMENT the ISSUE
Now outside the procedures, parameters, process or situation.
No SOP or procedure
In Knowledge Based Mode – Trouble shooting
Upset condition
New Crew members
Lack of consensus of the crew on how to proceed
Feel “Rushed”
Personal Safety/Health Concern
The Card then has steps to help resolve the issue
Agree on a solution

45. Anatomy of an Event
April 17

46. What would you do different if you were doing this job?
April 17

47. Principles of Human Performance
April 17
Humans are fallible .
Error is predictable.
Organization influences behavior.
Behaviors are reinforced.
Events are avoidable.

48. Are you ready?
April 17

49. Questions? Thank you. Kate Chepeleff
April 17
Questions? Thank you.
Kate Chepeleff
Phone: (315) x 28