1. Human Performance Improvement Principles
Facilities Division
Lawrence Berkeley National Laboratory
Janice Sexson

2. “Humans rather than technical failures now represent the greatest threat to complex and potentially hazardous systems”
James Reason, 1995

4. Why A Human Performance Improvement Approach?
To proactively prevent “occurrences” triggered by human error

5. Occurrence
A condition that adversely affects, or may adversely affect, DOE or contractor personnel, the public, property, environment or the DOE mission

7. Facts About Human Error
It thrives in every industry
It is a major contributor to events and occurrences
It is costly, adverse to safety and hinders productivity
The greatest cause of human error is weakness in the organization not the lack of skill or knowledge

8. 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 60 K miles and haven’t had a flat tire yet
Summit Fever-We’re almost done
Pollyanna-Nothing bad will happen

9. Individual Error-reduction tools
Human Error
Individual Error-reduction tools
Discussing Lessons Learned
Behavior based safety
Error-Precursor
Peer-Check
Enhanced Pre-Job Briefing
3 way communication

10. Latent Organizational Weaknesses
How to address latent organizational weakness
Understand Safety Principles
Align the organization’s values, attitudes, and “norms” to focus on continuously improving systems and processes
Encourage reporting of error-prone conditions and error-likely situations
Eliminate and mitigate
Communicate progress

12. Principles People are fallible, and even the best make mistakes
Error-likely situations are predictable, manageable, and preventable
Individual behavior is influenced by organization processes and values

13. Principles
People achieve high levels of performance based largely on the encouragement and reinforcement received from leaders, peers, and subordinates
An understanding of the reasons mistakes occur, and application of the lessons learned from past events can avoid future events

15. Blame Cycle A Human Error Happens
Worker is counseled and/or disciplined
Trust levels reduced because of managements actions
Worker no longer feels safe to communicate
Management is less aware of working conditions
Latent organization weakness persist
Error likely workplace exists

16. Human Performance
“Event 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.”

17. Human Beings

18. Notable Organizational Behaviors
Managers foster a culture that values prevention of events
Managers strengthen the integrity of defenses to prevent or mitigate the consequences
Managers preclude the development of error-likely situations
Managers create a learning environment that promotes continuous improvement

19. Leadership Behavior Facilitate open communication
Promote teamwork to eliminate error-likely situations
and strengthen defenses
Search for and eliminate organizational weaknesses that create error-likely situations
Reinforce jobsite behaviors
Value the prevention of errors

20. Individual Tools Questioning attitude Clear communication techniques
Stop when unsure

21. Management Tools Solicit and act on feedback from worker
Determine fundamental causes
Monitor trends
Self-Assessment
Process mapping
Task Analysis
Benchmarking

22. Summary
Question
Communicate
Stop