1. Human Performance Fundamentals
BushCo
T. Shane Bush
(208)
2020 Stosich Lane
Idaho Falls, ID

2. To proactively prevent “Unwanted Outcomes” triggered by human error.
Purpose of Course
To proactively prevent “Unwanted Outcomes” triggered by human error.
Unwanted
Outcomes
.Note that the course is not a program.
.State course content is a way of thinking.
“Given this task to perform under these circumstances, this person will probably make errors at around this point . . .” James Reason
ASK will human performance problems ever go away? NO
INPO Strategic Goals –
Minimize the frequency and severity of plant events.
We are going to be using the terms “Occurrences” and “Events” interchangeably. Occurrences is how how DOE defines their events.
In either case don’t get caught up in trying to define whether or not to apply the HU philosophy, it works for anything that is incorrect.
Note the definition talks describes this as being proactive. We will be introducing tools and models that will aid you in identifying “Error likely Events”.

3. Human Performance Part One – Why A Human Performance Approach
Part Two – Individual
Part Three – Organization
Part Four – Leader
Part Five – Case Studies, Implementation, & Review
This training will be in five parts. The first part will introduce you to some tools and models that will be used throughout the day. The majority of the time will be spent on Parts 2, 3, & 4 where the actual application of the “Human Performance Process” is taught.
Part five will allow us to apply what has been taught. Part five will also give you the opportunity to give feedback to the us about the course.

4. Objectives Unwanted Outcomes 1. Explain what constitutes an
2. Describe why the applications of
Human Performance are important
in reducing the frequency &
severity of unwanted outcomes
3. Explain how individual behavior
affects the frequency &
4. Explain how Organizational
Processes and Values
Unwanted
Outcomes
Review the objectives.

5. Objectives Unwanted Outcomes 5. Explain how leader behavior
affects the frequency & severity
of unwanted outcomes
6. List the error prevention tools
available to help anticipate and
prevent error likely situations
7. Given a case study as a guide,
explain the attributes of a
successful Human Performance
Improvement Process
8. Explain what we can do
individually and as a company
to meet the objectives of this
course
Unwanted
Outcomes
Review the objectives

6. Leadership

7. Performance outcome Y is a
A Simple Model
Performance outcome Y is a
function of factors X.
Performance
Outcome
Y = f (x)
Factors Affecting
Outcome Y

9. Y = f (x1, x2, x3, x4, x5, … xn)
Little or no effect on y
Positive effect on y
Negative effect on y
The real challenge is to identify those factors
that do and don’t drive performance.
Captain Marty McDonough

10. The Challenge: Identifying what factors affect people performance

11. Part I: Why a Human Performance Improvement Approach?
Human Errors
Occurrences
70% Latent Organization Weaknesses
80% Human Error
30%
Individual
20% Equipment Failures

12. Industry Event Causes due to human performance
806 = Individual behavior (32%)
1,676 = Org behavior (68%)
Ask if front-line workers account for the bulk of causes of significant events. True or False?
If you were looking at the raw data here what would you conclude?
Ask if all other cause categories were added, what do we have? Organizational and management factors. Direct attention to the pie chart in the "Student Notebook."
Nonwork practices: In the chart, 68% of causes of all significant events are attributable to organization and leadership.
Fact: Other sources indicate that the division is 80% organization and 20% individual (Rummler & Brache).

13. Facts about Human Error
It thrives in every industry
It is a major contributor to events and unwanted outcomes
It is costly, adverse to safety and hinders productivity
The greatest cause of human error is weaknesses in the organization, not lack of skill or knowledge
Error rates can never be reduced to zero
Consequences of errors can be eliminated

14. A lot of organizations are wrestling this same issue and trying their best not to get bit. Let’s take a look at one of those businesses.
Show Alligator Video Watch videotape and ask the group to share their feelings about the tape. Ask the class what parallels they can draw between this tape and our nuclear environment. The most obvious parallels are the fact that we too have alligators in our plants (energized circuits, steam, rotating equipment, high radiation areas, combustible, toxic, or inert atmospheres, high energy radioactive nuclear core) and we also tend to focus heavily on the Kennys in our plant. Another parallel is that this initiative seeks to instill in us an uneasiness toward human fallibility and vulnerability.
Are initial response is to say that the root cause here is the worker was stupid. Who would put their head in an alligators mouth. But did the organization know Kenny was doing this? Die they promote or encourage it?
YES! Kenny met goals for the company!!!
Quite often we don’t acknowledge how much the organizations values and processes influence our employees behaviors.

15. Principles 1. People are fallible, and even the best make mistakes.
2. Error-likely situations are predictable, manageable, and preventable.
3. Individual behavior is influenced by organizational processes and values.
4. People achieve high levels of performance based largely on the encouragement and reinforcement received from leaders, peers, and subordinates.
5. Events can be avoided by understanding the reasons mistakes occur and applying the lessons learned from past events.

16. MEDICAL ERRORS AND MISTAKES

17. Individual Plant Worker Processes Values
We will be covering objective
3. Explain how individual behavior affects the frequency & severity of an event.
Goal. to recognize when you are increasing the odds (for error) against yourself.
REVIEW model
Plant – the centerpiece of human performance: to accomplish tasks with optimum efficiency, within design bases. Includes physical components, paper plant (i.e., design bases documentation), and personnel safety.
Worker – that location where human action can alter either the physical or paper plant. Jobsite performance should be characterized with:
a sense of uneasiness toward human activity (fallibility and vulnerability)
rigorous application of error-prevention tools to maintain situational awareness and to prevent or mitigate the results of error.
active communication between peers and between bosses and subordinates
application of a structured mental framework toward human activities
Processes – the tangible structures established via procedures, processes, policies, etc., aimed at directing the behavior of individuals in a predictable, repeatable fashion; the transfer of information about what is expected, acceptable, and unacceptable behavior. “Built-in” error-prevention to deny people the opportunity to err for anticipated work situations.
Values – the relationships established within an organization to influence the beliefs and values of individuals to create a sense of uneasiness at the point of “touching” the plant, especially for unanticipated, novel work situations. The management of “meanings.”
Introduce “shots on goal” analogy. Make a point that the hockey player is a goalie(last line of defense). The workers are the ones whose actions may initiate events and who interact directly with the plant.
.goalie = worker (the last defense)
.defensemen = supervisors (prevent shots on goal)
.wingers/center = management (best defense is a good offense)
State the whole team has to play together to be effective.

18. Error Precursors short list
Limited short-term memory
Personality conflicts
Mental shortcuts (biases)
Lack of alternative indication
Inaccurate risk perception (Pollyanna)
Unexpected equipment conditions
Mindset (“tuned” to see)
Hidden system response
Complacency / Overconfidence
Workarounds / OOS instruments
Assumptions (inaccurate mental picture)
Confusing displays or controls
Habit patterns
Changes / Departures from routine
Stress (limits attention)
Distractions / Interruptions
Human Nature
Work Environment
Illness / Fatigue
Lack of or unclear standards
“Hazardous” attitude for critical task
Unclear goals, roles, & responsibilities
Indistinct problem-solving skills
Interpretation requirements
Lack of proficiency / Inexperience
Irrecoverable acts
Imprecise communication habits
Repetitive actions, monotonous
New technique not used before
Simultaneous, multiple tasks
Lack of knowledge (mental model)
High Workload (memory requirements)
Unfamiliarity w/ task / First time
Time pressure (in a hurry)
Individual Capabilities
Task Demands

19. Limitations of Human Nature
Avoidance of mental strain
Inaccurate mental models
Limited working memory
Limited attention resources
Pollyanna effect
Mind set
Difficulty seeing own errors
Limited perspective
Susceptible to emotion
Focus on goal
These characteristics of human nature, among many others, are encountered whenever people perform complex tasks in a complex work environment. Consequently, there is always the chance for error.
See the quotation in the desk reference Page _______
“Safety is a continuous fight with human nature.”
Dr. E. Scott Geller
Author: The Psychology of Safety 9

20. Hazardous Attitudes Pride - “Don’t insult my intelligence.”
Heroic - “I’ll get it done, hook or by crook.”
Invulnerable - “That can’t happen to me.”
Fatalistic - “What’s the use?”
Bald Tire - “Got 60K miles and haven’t had a flat yet.”
Summit Fever - “We’re almost done.”
Pollyanna - “Nothing bad will happen.”
Our internal attitudes can help set us up for errors.
My sons both love to drive fast and what feels to me to be dangerously. Even after some serious accidents in our family, they always seem to be pushing the limits.
Pride - Excessively high opinion of one’s ability; arrogant; hubris; control vs. competence; “Pride goes before destruction.” Psalms 16:18
Heroic - Exaggerated sense of courage and aggressiveness. Adm Farragut syndrome: “damn the torpedoes, full speed ahead.” Extreme focus on goal without consideration of what to avoid.
Invulnerable - Immunity to error, failure, or injury. 1 Corinthians 10:12 - “Therefore, let him who thinks he stands take heed lest he fall.” AND Principle No. 1: Walking fallibility (even the best people make the worst mistakes)
Fatalistic - Belief that all events are predetermined and inevitable. “Give up, why be hardheaded.” or “Let the chips fall as they may.”
Bald Tire - We’ve haven’t had any problems in the past.” “I’ve got 60,000 miles on this set of tires and haven’t had a flat yet.” Belief that past is sufficient justification for not changing (improving) existing practices or conditions.
Summit Fever - Zeal to finish the nearer one gets to goal; Into Thin Air, Jon Krakauer; Nearness to goal achievement tends to cause disregard of important conditions or factors important to safety, e.g., running a red light. A runner’s or swimmer’s kick near the end of a race.
Pollyanna - “what can go wrong?” Belief that all is well in the world (plant); “Routine” - since nothing can go wrong, attention to offnormal or unusual conditions is low and unrecognized.

21. Error Prevention at the jobsite
Machine
Other People
Myself
Machines. Equipment can be designed ergonomically to catch anticipated errors. For instance, computer software can be designed to ask the user if he/she is sure they want to delete an electronic file after it has been selected for deletion. This challenge gives the user an opportunity to think again if that is the right thing to do.
Other People. Co-workers and supervisors are excellent resources to prevent or catch errors especially in light of the traps of human nature. Peer-checking, challenge, concurrent verification, independent verification, etc. are examples of techniques that require two people. Don't be fooled into thinking that just because two people are used to prevent errors that it will be successful every time. People are fallible. Team errors occur more often than we would like.
Individuals. Lastly, the individual can catch his/her own error before or after they occur. Since catching errors depends solely upon the individual, it is the least reliable of the three ways of catching errors. Again, humans are fallible.

22. Finished Files are the Result of Years of Scientific Study Combined
With the Experience of Many Years.
Prior to showing this slide hand out the HU tool that states the following:
“Make sure to look for all the F’s and f’s.”
Only give this tool to half the class.
Show the slide for 10 seconds and have the class count how many F’s there are
(Don’t say this but they should be counting both the capitol F’s and small f’s.)
Black out the screen and ask how many people saw. Write on the board “With Tool” and “Without Tool”. Tally the numbers accordingly.
Point to be made:
We can predict this is going to be an “error likely event”. As humans we are fallible to this kind of task. By acknowledging this in advance (predict error) I can compensate by giving you a tool. The students with the tool on average do much better than those without the tool.

23. Human Information Processing
Shared Attention Resources
.Chunking Exercise
.Ask group to memorize, without writing it down, the number: “ ” stated one digit at a time.
.Chunk into smaller, more familiar segments; easier to remember:
“1941,” “double oh seven,” and “1776”
.Fact: Most error is associated with our limitations in processing information.
.Fact: Humans possess tendency to look for patterns which is especially error-provoking when we talk about the knowledge-based mode of information processing.
Perception - visual, audible, and other senses engaged to detect and recognize available information in one’s immediate proximity; displays, signals, or cues from immediate environment.
Decision - mental activities to decide what to do with the information; interaction between one’s working memory and long-term memory (capabilities: knowledge, opinions, attitudes)
Action - physical response to change the state of the environment either by manipulation or verbal statements; skills to apply appropriate force and timing to carry out action (e.g.., swinging a bat to hit a baseball); controls or tools
Attention Resources - a pool of resources available for various mental activities to function effectively; defines workload; for example: driving an automobile - one can do something in all four channels:
visual - road, instrument cluster, vistas
audible - radio, traffic, passenger
mental - interpreting traffic flow and signals, home, family, work, radio
physical - steering wheel, braking, accelerating, talking
However, some activities must cease to attend to other activities, such as stopping a conversation to look for a critical roadsign in high-speed traffic. Error is enhance if attempting to do more than one activity in each channel, e.g.., listening to radio and passenger simultaneously. Error likely to occur if workload exceeded. Limitation - can attend to around two or three channels of information maximum to be effective. (Psychology Today)
Path of Least Mental Effort; avoidance of mental strain; tendency to apply prepackaged solutions to recurring situations
Sensing
Thinking
Acting
Information Flow Path
Source: Wickens, 1992 5

24. Organization What have you picked up so far that can help you??
Facilitate a short review of the following:
Anatomy Of Event Model. Ask what is the importance of understanding the model.
Human performance principles. Ask what principles we have covered thus far and what examples do we have of each one.
Error-likely situations. Ask when an error‑likely situation exists.
INTRODUCTION
State that this module shifts in perspective from near-term (prior to work) to long-term prevention. (The emphasis shifts to making latent conditions visible.)
Goal. Influencing organizational improvement (learning) to eliminate conditions that provoke human error while reinforcing defenses.
Make a point the the hockey player is not a goalie(last line of defense) but is a defenseman or winger/center.
Workers are not free agents. Procedures, policies, programs, training, and even the culture direct their behavior. All of these are outgrowths of organization.
No one will deny that front-line workers make mistakes; and, occasionally undesirable consequences can ensue – facility events. Investigative reports about the causes of events initiated by human error typically document the root causes as due to “inappropriate actions” by front-line workers. However, human error occurs within the context of the organization, which either fosters or resists it. Plant events triggered by human error are better characterized as system failures, where the system is defined by the entire organization. Consequently, the greatest room for improvement in human performance lies not only in the continued improvement of front-line worker performance, but mainly in the identification and elimination of weaknesses in the organizational and managerial domains that contribute to worker performance at the job site.

25. “Events are not so much the result of error-prone workers as they are the outcome of error-prone tasks and error-prone work environments, which are controlled by the Organization.”
James Reason, Managing the Risks of Organizational Accidents

26. Competing Resources Prevention Production tn Bankruptcy Accident t0
Defenses
Bankruptcy
Prevention
Production
Why aren’t there “Think Schedule Adherence” signs in the plant or on the plant access road vs “Think Safety”?
Illustration shows what may happen if distribution of resources (priority) is too much in one or the other basket.
Production - positive reinforcer; temptation to make production-oriented decisions over safety in the near term; when you do production you get $, schedule adherence, etc. (tangible)
Prevention is a negative reinforcer, punisher, or ignored; complacency builds in when nothing bad happens after taking short cuts; people do prevention, such as self-checking, and OE, to avoid undesirable outcomes like events; when you do prevention, you get nothing (no error or events). (intangible)
Long-term vs. Near-term: The temptation is in the near-term when people are tempted to take shortcuts to achieve due dates or the work schedule. Prevention will in the long-term enhance the productivity of the plant.
“Almost every day, line managers and supervisors have to choose whether or not to cut safety corners in order to meet deadlines or other operational demands. For the most part, such short-cuts bring no bad effects and so can become an habitual part of routine work practices. Unfortunately, this gradual reduction in the systems safety margins renders it increasingly vulnerable to particular combinations of accident-causing factors.”
For in-depth information on Production vs Protection, see Managing the Risks of Organizational Accidents by James Reason (1998), pp. 3-7.
new plant state
plant event
Accident t0
Source: James Reason. Managing the Risks of Organizational Accidents, 1997 (in press).

27. Human Performance Fundamentals
Victims of our own Success
Quote the paragraph on page 108 and explain (CHANGE TO PROCESS ORIENTED).
Review the Horse Kicks (page 109) which demonstrate that when you only measure the horse kicks, (negative outcome) it only reveals the negative outcome of safety. It only records moments of Vulnerability

28. Human Performance Fundamentals
Defenses
Hard -
Soft -
Most defensive functions are achieved through a combination of hard and soft defenses.
Hard defenses are Engineered safety functions, barriers, alarms, interlocks, etc.
Soft defenses are usually a combination of paper and people:Legislation, procedures, licensing, oversight,
In the early days workers involvement was mainly productive – they made or did things, that led directly to commercial profit. And thus were directly in contact with hazards.
Now computers and technology have changed the workers involvement to that of planners, managers, maintainers of systems and processes. Ie operators, pilots, and removed them in a lot of cases from being directly involved with the hazards.
This results in defense in depth which is a mixed blessing. This makes the system more complex and Opaque.
This results in the build up of latent conditions.

29. Active Error Latent Error Two Kinds of Error
Definition of human error: an action (behavior) that unintentionally departs from an expected behavior (see Glossary)
A violation involves a deliberate deviation from specified behavior (management expectations).
.Fact: Error is defined by the behavior (B) not the result (R). Error is classified based upon result.
.Two kinds of error (based upon the kinds of results they obtain)
.Active errors - errors that change equipment, system, or plant state triggering immediate undesired consequences.
.Latent errors (typically by management and staff) - errors resulting in undetected organization-related weaknesses or equipment flaws that lie dormant.
.Compare and contrast the who, what, when, and visible for these two types of error. Have chart made up on flip chart. Leave answers blank. Facilitate responses from participants.
Characteristics Active Latent
Who? front-line workers management & staff
What? change plant state change paper, policies, values
When? Immediate dormant
Visible? yes no
.Emphasize: Kind of error is determined by the state of the plant rather than the morality of the action.
.Error classification sprint - HANDOUT
.Instructions:
Take one minute to check the appropriate column on the exercise sheet
Move quickly. Identify whether the action is an active or a latent error.
.Review the results of a few with the participants.
Make sure to review 4 and 10. They are related. ASK: did the I&C technician in 10 make an active error. If he did what is it? Note: It depends on the expectations of the station. Strict Procedure/schedule compliance or know the system.
.Explain any differences using the criteria on the transparency.
Latent Error

30. Culpability Decision Tree
g, j,

31. Air Ontario Flight 363 Fokker F28 Dryden, Canada March 10, 1989
Case Study
Air Ontario Flight 363 Fokker F28 Dryden, Canada March 10, 1989

32. Performance Modes--Attending Problems
Control Mechanisms
Performance Modes--Attending Problems
Type of errors that usually occur at upper echelons of organization; not observable
High
Low
Attention (to task)
Inaccurate Mental Picture
Knowledge-Based
Type of errors that usually occur at human-machine interface; observable
Patterns
RB/KB involve conscious decision making; roughly 75% of errors made during activities that take roughly 10% of time (supposition - no empirical data to support)
Error Modes: SB – Inattention; RB – Misinterpretation; KB – Inaccurate mental model/picture
KB: unfamiliarity ­, anxiety ­, stress ­, search for patterns, ­, assumptions ­, trial & error (Easter egging) ­, panic (vagabonding or tunneling) ­, event or value-added progress. Conscious, directed thinking can exclude outside sensory information - could miss important information. (Restak, Brainscapes, p30)
Time Effects: As time to respond increases, the chance for error diminishes. Chance for error is highest when the unfamiliar situation (especially involving danger) strikes suddenly without warning and requires quick reaction. (Man Made Disasters, p33-34) WANT TO AVOID THIS!!!
Workers - SB and RB most often (prescriptive in nature); Managers - RB and KB (discretionary)
SB - Unconscious competence; RB - Conscious competence; KB - Conscious incompetence
PB - Unconscious incompetence (panic-based)
To improve importance - stimulate interest in the task; why job is critical to plant success; WIIFM
Biases take over in KB, e.g., pattern matching, frequency and confirmation biases
Review error precursors that are particularly potent for each error mode (SB - distractions, illness & fatigue, simultaneous tasks; RB - mind set, confusing procedure; KB - hidden system response, assumptions, lack of fundamental knowledge)
(see more information in Man-Made Disasters, p )
Error-Prevention Techniques: SB – self-checking, peer checking, slow down; RB – critical parameter, peer-checking, If2Then2; KB – team problem-solving, devil’s advocate, “buy time,”
Purpose of Task Preview - to identify method of best control; not to question competence
Automaticity.
Modes of information processing (performance modes) characterized as skill-based (SB), rule-based (RB), or knowledge-based (KB). Various attentions requirements
If I know how to perform a task, and I possess the ability to perform the task, then why do I sometimes err with simple tasks? Human Nature - not an excuse, but characteristic of human beings to be imprecise (expected reliability: .995 to .997 typically or ideally). What if task must have reliability of 1?
Premise: one individual performing a single task
Familiarity determines need for information about task, which drives degree of attention or concentration. (Chart based on information need - Man-Made Disasters, p )
Transitions: From SB: D - change in task/environment; Into KB: ? - uncertainty & doubt
Definitions of each performance mode (see Generic Error Model in HPF Desk Reference). Include examples from both every day life and plant activities. Recall example events for each mode. (Human Error, p61) Mental States: Auto, If-Then, Patterns
Reliability or Chances for error: SB - 1:10K (ideal conditions); RB - 1:1K (nominal); KB - 1:2 (urgent) (chances for success improve in KB performance mode as time to make a decision increases)
Rule Based
If - Then
Misinterpretation
Skill-Based
Auto
Source: James Reason. Managing the Risks of Organizational Accidents, 1998.
Inattention
Familiarity (w/ task)
Low
High

33. Human Performance Fundamentals
Things aren’t always what they seem!
Show clip on Steering Wheel emphasizing things are always what they seem
The Human mind is prone to match like for like.
Disastrous outcomes = equally monstrous blunders
While accidents can happen from gapping holes in your defenses, we also know that accidents can happen from having small cracks in the system as well.
Three case studies to show how accidents can happen from gaping holes, cracks and organizational weaknesses.
Our goal is to look for those common things (principles) that will help us predict future conditions for accidents.
Read quote from Karl Weick top page 22.
Use VisCog DVD here to demonstrate

34. Blame Cycle The Blame Cycle Human Error Less communication
Management less
aware of jobsite
conditions
Reduced trust
Latent organizational
weaknesses persist
Individual counseled
and/or disciplined
More flawed defenses
& error precursors
Blame
Cycle
ASK: If you’re into blaming, what are the consequences to “open communications”

35. Why is Bad Apple Theory Popular?
Cheap and Easy
Saving Face
Personal Responsibility and the Illusion of Omnipotence
Local Rationality Principle
Have someone read the VIP story on pages 6 and 7
What do most Airplane accidents articles say in the Header?
When we ask “How could they not have known?” Or it just doesn’t make sense what they did. Basically when the story doesn’t seem right it probably isn’t.
Local Rationality PRINCIPLE
You have to assume that most people are trying to do the right thing.
Read article about Los Alomos firing so many

36. Counterfactual
Counterfactuals: Going back through a sequence, you wonder why people missed opportunities to direct events away from the eventual outcome. This, however, does not explain failure.
Illustration from: The Field Guide to Human Error Investigations
Remember even in this slide you are getting the 10,000 foot View.
Sharon making a peanut butter & jam sandwich

37. Patterns of Failure
At a particular moment in time, behavior that does not live up to some standard may look like complacency or negligence. But deviance may have become the new norm across an entire operation or organization.
Illustration from: The Field Guide to Human Error Investigations

38. Human Performance Tools
Critical Steps
Enhanced Pre-Job Briefing
Peer Check
Self Check
Independent Verification
Error Traps
Just Culture
Effective Communication
Questioning Attitude
Feeling of Uneasiness
Enhanced Turnover
3 way communication
Error Precursors
Performance/Error Modes
Devils Advocate
Place keeping
Poka Yoke
SAFE Dialogue
Discovery Clock
STAR
Training