1. Human Performance, the Event Free Clock & Breaking the Safety Cycle
Introducing Leading Indicators to Break
The “Safety Cycle”

2. How To Measure Safety Performance?
Where to Focus Safety Efforts?

3. The Safety Cycle
Injuries
Time
Upper Limit
Lower Limit

4. Fewer Accidents? Safety Meetings
Safety Initiatives
Rules
Discipline
Training
Fewer Accidents?
Regulations
Awards
Safety Meetings
Pre-Job Brief

6. Five Basic Facts
People are fallible and even the best will make mistakes.
All consequential errors that could lead to injuries are preventable.
No worker would intentionally injure themselves.
If there is a method that could free a worker from being injured without undue burden, they would adopt it.
Fast improvement can only be achieved in an open, non-punitive, and constant learning workplace.

7. Human Performance
Basic Human Performance concepts focus on identifying and improving:
Human Errors
Reduce the chances of errors occurring, and
Reduce the effects of errors resulting in injury and/or system disturbances
Failed or Insufficient Layers of Protection
Latent Organizational Weaknesses

8. Layers of Protection

9. Unwanted Outcomes (Events)
Equipment Failure – 20%
Individual Errors – 30%
Latent errors result in hidden organization-related weaknesses or equipment flaws that lie dormant. Such errors go unnoticed at the time they occur and have no immediate apparent outcome to the facility or to personnel. Latent conditions include actions, directives, and decisions that either create the preconditions for error or fail to prevent, catch, or mitigate the effects of error on the physical facility. Latent errors typically manifest themselves as degradations in defense mechanisms, such as weaknesses in processes, inefficiencies, and undesirable changes in values and practices. Latent conditions include design defects, manufacturing defects, maintenance failures, clumsy automation, defective tools, training shortcomings, and so on. Managers, supervisors, and technical staff, as well as front-line workers, are capable of creating latent conditions. Inaccuracies become embedded in paper-based directives, such as procedures, policies, drawings, and design bases documentation. Workers unknowingly alter the integrity of equipment, such as the installation of an incorrect gasket, mispositioning a valve, misidentification of a circuit, hanging a danger tag on the wrong component, or attaching an incorrect label.
Human Errors - 80%
Latent Organizational Weaknesses – 70%

10. Human Performance What is Human Performance?
A series of behaviors executed to accomplish specific tasks.
The focus on and reinforcement of desired behaviors during all processes and phases of every operation. 
These behaviors become the basis for our principles that drive safe, reliable and event free operations within APS.
Excellent Human Performance is possible when everyone embraces the principles about Human Performance.

11. Human Performance Improve Human Performance
&
YOU WILL
Improve Operational Performance
The focus on and reinforcement of desired behaviors during all processes and phases of every operation. 
These behaviors become the basis for our principles that drive safe, reliable and event free operations (“operations” in the broadest sense) within APS.
Excellent Human Performance is possible when everyone embraces the principles about Human Performance.

16. THE THREE TYPES OF HUMAN ERRORS ARE:
Knowledge-based Errors
These tasks are new, unfamiliar or unique to the performer
They depend heavily upon the performer’s fundamental knowledge, diagnosis, and analysis skills
Best described as trial and error or literally “I don’t know”
This an error category is typically associated with a lack of training and/or knowledge that would have prevented the error.

17. THE THREE TYPES OF BEHAVIOR BASED ERRORS ARE:
Rule-based Errors
These tasks are familiar to the performer
Upon correct recognition of a situation or condition, the performer can apply a stored rule to steer towards a known end goal
Tasks in this domain tend to follow if-then logic
Rule Based Errors are unexpected results that are a different outcome than what was expected when the action was taken. “I thought it was going do this when I did it but instead it did that.”
This is the error type that occurs with being to comfortable or being complacent with a situation or task. For example, bicycle riding is considered a skill-based behavior in which very little attention is required for control once the skill is acquired.

18. THE THREE TYPES OF BEHAVIOR BASED ERRORS ARE:
Skill-based Errors
These tasks are comprised of very familiar actions
Performed in comfortable surroundings
The human being is, or is close to, being on autopilot

19. Low - Familiarity - High
Task Error Model
Error Mode:
Inaccurate Mental Model
Error Rate 1:10
Rules, Standards, Checklist,
Written Procedures
Error Mode:
Misinterpretation
Error Rate 1:100
Memorization, Practice
High – Attention - Low
Knowledge based – Rule based – Skill based
Error Mode:
Inattention
Error Rate 1:1,000
Low - Familiarity - High

23. Error Trap Recognition (TAPE Method)
Error Traps
Error Trap Recognition (TAPE Method)
Time Specific Error Traps
Activity Specific Error Traps
Daily Cycle (time of day)
Inadequate Layers of Protection
Weekly Cycle (day of week)
Time Pressure Task
Monthly Cycle (summer effects, etc.)
Distractive Task
Holiday Effects
First Time or Infrequent Task
Person Specific Error Traps
Environment Specific Error Traps
Compromised Physical & Mental Conditions
Weather Conditions
Negative Personal & Age Effects
Unproven, Unseen, & Unauthorized Walk Paths
Inexperience
Sloping Footing/Terrain
Not Understanding or Complying with the Rules
Low Visibility
Error Precursors
Unfavorable conditions embedded in the job site that create mismatches between a task and the individual
Interfere with successful performance and increase the probability for error.
Exist before an error occurs.
Most are outcomes of latent organizational weaknesses
Can usually be corrected by addressing processes, programs, values, etc.
Multiple error precursors - increase chances of error; change the situation
We need to have an intolerance for error traps and change the job-site conditions to minimize the chance for error.

24. Some Human Performance Tools for Individuals
Questioning attitude
Stop when unsure
Self-checking
Procedure use and adherence
Three-way communication
Phonetic alphabet
Place-keeping
Two Minute Drill
Conservative Decision Making

25. Some Human Performance Tools for Teams
Pre-job briefing (Tailboard)
Peer check
Flagging
Turnover
Post-job review
Concurrent Verification

26. Some Human Performance Tools for Leaders and Management
Observations & Feedback
Self-Assessments
Operating experience

27. What is an Event Clock?
A real time Human Performance tool to effectively communicate current human performance status relating to safety and reliability.
Qualifying Events reset the clock to zero
Helps improve safety and reliability by being a vehicle to share lessons learned following Qualifying Events so that we engrain the HP tools into how we do business.

28. 2012 Event Clock Criteria Fatalities Amputations Loss of Consciousness
Electrical Contacts with Injury
Arc Flashes with Injury
Fractures (non-dental)
Lost-time Injuries
Switching Order & Clearance Errors (resulting in an event)
Motor Vehicle Accidents greater than $5K damage
Unplanned Significant Outages (with feeder breaker trip)
OSHA Violations with an event

29. Event Clock Resetting Types
Avoidable:
Total # Events
Fatalities
Lost Times 5
Fractures 2
Amputations
Loss of Consciousness
Electrical Contacts w/ Injury
Arc Flashes w/ Injury
Switching & Clearance Events 3
Motor Vehicle Accidents >$5,000
Unplanned Feeder Outages Sub Breaker) 6
Events with OSHA Violations  1
Total Event Clock Resets 20

30. ED/CS/RR Event Clock
Organization
2012 Resets
2012 Incentive Threshold
Energy Delivery 19
Customer Service 1
Rates & Regulatory
Total 20 32
Days Since Last Reset 44
Average Days Between Resets 18

31. Organization
Days Since Last Reset
# 2012 EFC Resets
Last Resetting Event
Last Reset Date
Atwell - Tot Transmission Construction 70  3
32603 
7/13/2012
Lucas/Tetlow - Total ED Power Ops & Maint 68
 11
32596 
7/15/2012
Easterly - Total Rural AZ Delivery 37
32701 
8/15/2012
Smith - Total ED Asset Mgmt & Plng
1856  0
26223 
8/23/2007
McElmury - Total Safety&Perf Excellence
331
31796 
10/26/2011  
Daniel - Total Distribution Constr 60  2
32628 
7/23/2012
Froetscher - Total Energy Delivery
 19
Orlick - Marketing
None
None 
Goguen - Total Cust Svc Ops
795
30350 
7/19/2010
Loveridge - Total Meter Operations
146  1
32381 
4/28/2012
Casuga - Total Cmty Dev/Cust Offices
780
30393 
8/3/2010
McLeod - Total Customer Service
Guldner - Total Rates & Regulation
1134
29162
8/14/2009
Total ED/CS/RR
 20
32701

33. Breaking the “Safety Cycle”
Injuries
Time
Trend

34. Close Calls are a gift from God

35. (602) 371-7873 Charles.Thomack@aps.com Section Leader, Safety
Presented by: Chuck Thomack, CSP
Section Leader, Safety
(602)
Date: September 28, 2012