1. Elements of an Effective HPI Program
HPWG
Elements of an Effective HPI Program
Rob Fisher
President, Fisher IT, Inc.
October 9, 2013
Copyright, Fisher IT, Inc.

2. Charles F. Kettering – Inventor & Philosopher
“A problem thoroughly understood is always fairly simple.”
“Found your opinions on facts, not prejudices. We know too many things that are not true.”
Charles F. Kettering – Inventor & Philosopher
“Why is the human skull as dense as it is? Nowadays we can send a message around the world in one-seventh of a second, but it takes years to drive an idea through a quarter-inch of human skull.”
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3. Understanding Human Performance
Systems model
Interconnectivity
Latent conditions
Need for multiple feedback loops
Need a systems approach to Human Performance
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4. Most problems in industry are related to Human Error…
True or False?
Most problems in industry are related to Human Error…
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5. The Program MUST be based on…
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
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6. Copyright, Fisher IT, Inc.
Definitions
We MUST learn
to separate the
ERRORS from the
EVENT
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
Errors and violations
are different things
We MUST pay attention
to all types of errors
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7. For Every Deviation From
A Definition…
Your Program Weakens!
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8. You cannot ‘correct’ your way to excellence
The Three Legged Stool
Prevention – How much emphasis do we put on keeping bad things from happening?
Detection – Are we looking at the right threshold to identify problems?
Correction – Do the things we do to fix problems:
Match the significance of the problem?
Take other, similar but worse problems into account?
Not cause problems of a different type?
You cannot ‘correct’ your way to excellence
Copyright, 2013, Fisher IT, Inc.

9. Copyright, Fisher IT, Inc.
Three Key Indicators…
Prevention
The number and quality of Pre-Task briefs should increase
Detection
The number and quality of MANAGEMENT observations should increase
Correction
The number and quality of non-injury (near miss, close call, etc.) should increase
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10. Human Performance Improvement is about improving our abilities
We are hired to do an OCCUPATION (operator, mechanic, mobile equipment operator, janitor)
These Occupations require us to do JOBS
These jobs contain TASKS
(sections in a procedure or checklist)
These tasks contain ACTIONS or Steps (lock-out-tag-out THIS pump
Hang tags on each electrical supply
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
Human Performance Improvement
is about improving our abilities
at the TASK and STEP level
Copyright 2013, Fisher IT, Inc.

11. Pre-Task Brief Measures
Number
Count them all
Segregate those with high risk and / or fatality-serious injury potential
Quality
Capability of supervisors to perform PTBs
Effectiveness of PTB in the field
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12. Organizational values influence individual behaviors…
True or False?
Organizational values influence individual behaviors…
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13. Management Observation Measures
Number
Again – count them all
Percentage of HRT / FSIP that get observed
Quality
Percent that are value based
Lessons learned
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14. Copyright, Fisher IT, Inc.
TRUE BUT….
The values of the small organization always trump the values of the big orgainzation related to individual behaviors…
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15. Near Miss Measures (and root cause measures)
Number
Do I need to say it again?
Ratio of near miss report to events
Quality
Event investigation tool checklist (or equivalent)
Do cause analyses follow the process?
Root Cause Corrective Action Reviews
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16. “We have good processes… If we could just get people
to follow them we would
be fine!”
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17. Copyright, Fisher IT, Inc.

18. Deviation Potential © Simplified
Difficulty
Deviation Potential =
Risk Observation
Copyright, 2012 Fisher IT, Inc.

19. Deviation Drift Rule Requirements (Believed Norm) Performance Gap
Investigation
Rule Requirements (Believed Norm)
Performance Gap
(discovered by
investigation)
Deviation Drift (New Norm)
Standards
Safety Threat
Incident T1 T2
Incident Date
Time (years)

20. Deviation Potential – Simplified
No Intent to Violate
Errors (>90%)
Physical
Mental
Unconscious Errors
Taught once -
must remember now
Stated earlier -
Difficult tasks
Unnecessary tasks
Unreasonable tasks
Easy to shortcut
Contact with
other organization
Has to stop and do
something else
Wrong rule
Misapply rule
Trying to comply and
taking a shortcut
Often tribal (a group)
Drift
Difficulty
Rule Based - 3 General Categories
Wrong Rule - Rule problem
Misapplication - Information problem
Just Don’t comply
Personal compliance issue
Deviation Potential © =
Perceived Risk + Observation
Personal
Peer
Injury
Personal financial
loss if caught
Equipment damage
Verbal reminders
Violations (<10%)
Conscious
Supervisor
Corporate
Just don’t comply
Accountability issue
personal compliance issue
Usually a single individual
(or underling)
Corporate financial
loss if caught
Equipment damage
Root Cause & Corrective actions
Intent to Violate
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21. Use this path to determine system failures
Deviation Analysis
Individual Driven
Violations
Was a safety rule or operating procedure knowingly violated?
Would other similarly qualified people have done the same thing in the situation?
Were the rules available, workable, intelligible, correct and consistently reinforced?
YES NO
Use this path to determine system failures
Are there deficiencies in:
Knowledge/skill
Training
Experience
Selection ?
Does the individual have a history of unsafe acts?
Yes
Use Deviation Potential Model
To determine whether “knowingly violated”
Violation – An action or inaction that intentionally deviates from a rule
or standard
Error – An action or inaction that unintentionally creates a problem or deviates from a rule or standard
AND
Use
Performance Mode Model
to assist
Use Performance Mode Model to assist
Individual & System Driven Violations & Errors
System Driven Errors
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22. Copyright, Fisher IT, Inc.
Root Cause Analysis
Should NOT be based on failed barriers
Should always analyze the WITH model
Should look for the REASON for a deviation using the models
Should determine the LATENT drivers (or causes)
Should not focus on the individual but on why the individual did what they did, and what systemic drivers made it feel right
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23. Copyright, 2012, Fisher IT, Inc.
Closing Summary
Organizations that integrate human performance concepts into their day-to-day work improve:
Performance in safety, quality, effectiveness & efficiency and
Communication which significantly improves overall engagement
Use the new language to describe errors, events, deviations and violations
Use the new knowledge to analyze problems
Recognize the performance mode you are in to minimize the error potential
Recognize the triggers that tell you a trap exists that increases the probability and potential for errors
Use the tools to avoid or minimize the impact of the traps
Copyright, 2012, Fisher IT, Inc.