1. Behavior Based Safety and Human Performance
Ideas for Improving Safety Performance
Presented by:
Dan Klimek
Sisk & Company

2. Behavior Based Safety -- Per PEC
Focuses on a Behavior Based HSE Observation Program
Note: the Safety Plus card used as an example includes a Behavior Observation Checklist, Hazard ID, Near Miss, and First Aid observations as well as positive recognition.
A Behavior Based Safety program is intended to enable company employees to record safety observations, most importantly, stopping of work that is unsafe.

3. This card is also used for
Example:
Behavior-Based
Observation
Card
This card is also used for
Near Miss, Hazard ID, First Aid and Health, Safety or Environmental events.
Data can easily be gathered and trended.

4. Too often behavior observation cards are filled out without proper discussion. They are filled out just to meet a quota and there is not real thought given to how can gain a long term benefit.

5. recognized and controlled they will continue until
If unsafe acts are not
recognized and controlled
they will continue until
an incident results.
Why do people do
unsafe things?

6. This is the result of an unsafe act
This is the result of an unsafe act. Several crew members stood by and watched as he tried to move pipe by hand. After the incident all of them said, “I wished I had stopped the activity and talked about a better way to do the job.”

7. Fighting Complacency Complacency is a natural brain function
Inattention is partly the result of the brains need for efficiency
Our brains use 20% of our energy and oxygen
Compare your recollection of the 1st time you drove a car -vs- the 1000th time you drove a car.
Experience leads to automatic actions, but the trade off is we tend not to pay attention to detail. Again, think about driving home – we make the trip and do not recall making a turn or passing a landmark.
The brain is hard wired to sort info and to rank items so we do not pay attention to routine activities
What do we pay attention to -vs- what do we ignore

8. There are clearly limits as to what we can focus on.
passing the ball.flv

9. What did you see in the video?
Anything unusual?
Number of times the white shirt team passed the ball?

10. What did you see in the video?
Anything unusual?
Gorilla
Curtain changed color
1 black shirt walked off the screen
Number of times the white shirt team passed the ball? 16

11. ID tasks where people are likely to be complacent
Experienced workers – have done this 1000’s of times
Optimism bias if no bad past experience
New employee – Inexperience and Optimism bias
excited about job, no negative experience to compare it to and not familiar with equipment or procedures, or equipment locations
Supervisors / management
Pressure on employees to do more, keep busy, work faster
No past incidents, so do not stop to consider new risks or re-evaluate ongoing risks
Distractions caused by changing work scope, job demands, etc.

12. Let’s Look at some Human Performance Concepts

13. The People Side of Safety and Performance
People are fallible and even the best people make mistakes.
People achieve high levels of performance due to encouragement and reinforcement from leaders, peers and subordinates.
Individual behavior is influenced by organizational processes and values.
Events can be avoided by understanding the reasons mistakes occur and applying the lessons learned from past events or errors.

14. Two Kinds of Errors Active Error Latent Error
do something or make a change that triggers immediate undesirable consequences.
Latent Error
an error results in some situation or unnoticed condition and lies dormant.

15. Chances of Not Getting Injured
By reducing the number of near misses, where no injury was sustained, we can hope to reduce the numbers of damage, minor and more serious incidents This confirms the importance of investigating ALL accidents/incidents. All represent failures in safety management and have valuable learning opportunities 1 10 30
600
Sub Standard Acts
Sub Standard Conditions
Serious/Major Injury
Minor Injury
Property Damage
Near Miss

16. Inaccurate Mental Picture
Control Mechanisms
Performance Modes
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
Error Modes: SB – Inattention; RB – Misinterpretation; KB – Inaccurate mental model/picture
KB: unfamiliarity ­, anxiety ­, stress ­, search for patterns, ­, assumptions ­, trial & error, panic, event or value-added progress. Conscious, directed thinking can exclude outside sensory information - could miss important information.
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. 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
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)
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
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

17. Performance Modes Three performance modes Knowledge based Rule based
Analysis / reasoning
Error rate highest (1/10 –1/2)
No rule to follow
Proceed based on experience (you don’t know what you don’t know)
Rule based
Procedures / checklists
Error rate higher (1/100)
Poor or inappropriate rules
Misinterpretation of the rules
Inadequate training
Skill based
Habit; little thought
Low error rate (1/1000)
Forgot something (know how; just forgot)
Distraction / interruption

18. Error-Traps Task Demands Individual Capabilities Work Environment
Performance Reliability:
increases as number of error precursors decrease
decreases as number of error precursors increase
Error-Traps
Task Demands
Individual Capabilities
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
Illness / Fatigue
Lack of or unclear standards
Hazardous “Can-do” attitude for critical tasks
Unclear goals, roles, & responsibilities
Indistinct problem-solving skills
Interpretation requirements
Lack of proficiency / Inexperience
Irrecoverable acts (Recognize Critical Steps)
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)
Work Environment
Human Nature

19. Top Ten Human Performance Tools
Job Brief (JSA)
Self-Check
Peer-Check
Procedure Use
Place-Keeping
Effective Communication
Questioning Attitude
Knowledge/Training
Coaching
Turnover
ERROR

20. Self Checking STAR STOP THINK Pause to enhance attention to details.
Eliminate present or future distractions
Focus on the task at hand
THINK
Understand specifically what is to be done
Question the situation using SAFER
Do not proceed in the face of uncertainty

21. Self-Checking STAR ACT REVIEW
Physically touch or point to correct components
Read aloud from procedures, instructions, labels
Perform the intended action correctly and safely
Take preventative actions as anticipated
REVIEW
Verify the actual response is what was intended
Ensure all actions serve to reduce injury and error
Step back and do a “sanity check” of the results

22. Peer Checking (Mentoring for SSE)
Explain intentions and agree on actions and expected results before taking action
Confirm action is appropriate and in accordance with written instructions, authorizations, etc.
Perform the action
Agree that results are what was expected
Like self-checking using STAR, Peer Checking is a simple yet effective barrier to human error. Practicing these techniques over time will help them to become ingrained in our safety culture both at work and at home.

23. Questioning Attitude
Think about what we are doing in sufficient detail to identify areas of confusion or concern
When areas of confusion or concern are identified, raise the issue and take the time necessary to resolve it
Go into each job confident, but not overconfident
Develop a healthy uneasiness about what might be hidden or different today

24. Accidents are failures of fore thought
Accidents are failures of fore thought. The personnel involved when asked say “I just didn’t see it coming.”

25. What are People Rewarded for?
The problem all companies have is doing what the safety manual / safety rules state
There are always pressures on you and sometimes following safety “procedures” is . . .
It is likely that a procedure has been violated many times before an accident occurs

26. Your Role to Help Employees Perform Safely
Take Away
Your Role to Help Employees Perform Safely
Make sure employees are highly trained and retrained
Really do maintenance
Implement redundancy in processes, instruction and equipment
Encourage self checking and peer checking – especially critical or infrequent tasks
Supervisors – stand back and watch – actually oversee the work

27. Integrate Safety Into Production
Take Away
Integrate Safety Into Production
People are fallible and even the best people make mistakes.
Review and following safety rules
People achieve high levels of performance due to encouragement and reinforcement from leaders, peers and subordinates.
When co-workers look at compliance and talk about safety – 2 people benefit
Individual behavior is influenced by organizational processes and values.
Putting safety talk into action builds a positive environment

28. So how does this fit into driving?
We all drive
There is lot going on and we do not think about our driving.
Complacency - Experience leads to automatic actions, but we tend not to pay attention to detail
Optimism bias -- we all rate ourselves as better than average drivers
Enforce safe driving rules and other procedures
Get info about accidents and use at frequent safety meetings

29. Questions?
Discussion?