1. Management Overview on Human Performance Improvement
Facilitators:
Shane Bush, INL
Brian Baskette, INPO

2. Purpose of Workshop
Provide an overview of the principles, concepts, and benefits of Human Performance Improvement, or HPI (morning session, 9:00-12:00 noon)
Provide an overview of the bases of HPI, and practical tools for implementing HPI (afternoon session, 1:00-4:30 pm)

3. Minimize the frequency and severity of events (i.e., occurrences)
Purpose of Human Performance Improvement
Events
Minimize the frequency and severity of events (i.e., occurrences)
.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
Strategic Goals –
Minimize the frequency and severity of events.
Refer students to Desk Reference glossary.

4. Why HPI in commercial nuclear?
Now, let’s shift gears to talk about some of the developments at INPO that have occurred over the last year.
21 out of 26 fuel-damaging accidents due to human error
Three out of four significant events due to human error
Greatest contributor to costs ?
70 percent of causes due to weaknesses in Organization
Significant Events – all events judged by INPO’s event screening process, I.e., events that caused or had the potential to cause significant consequences. (have screening criteria handy)
Significant events also include those determined significant by others, significant repeat report, and significant to the plant.
No. HU – Number of events triggered by human performance whether worker, supervisor, or manager, staff, or engineer.
Conclusions:
Number of significant events have decreased over last five years in the U.S.
Number of significant events triggered by human performance problems decreased over last five years in U.S.
Percentage of significant events triggered by human performance has steadily increased and is roughly stable in low 80’s.
Over the last five years, three of every four events were triggered by human error.
Causes:
Significant events only: 71% organizational or non-work practice (up from 64% in 1996)
All events: 68%
NRC Data: (source: NRC Program on Human Performance in Nuclear Power Plant Safety, SECY , February 29, 2000)
Of 48 events with conditional core damage frequency >1.0E-5 being studied in accident sequence precursor (ASP) program (risk models), 79% involved human performance issues.
Note the last bullet in particular. Let me explain what this is communicating. Of all the events with HU as the root cause, 70% were not the individual workers behavour, but the organizations behavior. Now what does that mean?
At the Farley Nuclear Power plant they have what are called the “Human Performance Review Boards”. Once a week they will take all the events that occurred the previous week and pick one too evaluate for HU issues.
The week we were there doing this training, they allowed us to attend a board to see how they were ran. The board went as follows:
Introductions were made
They went a list of rules, ie: not here to punish, looking for answers,etc
The plant manager then made everyone in the room refer to the HU principles before going any further and he read them.
The employee involved now walked us through what happened. Here it is in a nut shell.
He came into work on the morning of the event and was given a work order to take the #2 service water and associated ‘D’ battery charger Out of Service for some maintenance. During the pre-job some questions were raised as to whether the work order had the correct numbers on it. Someone thought it should have been the #4 Service Water Battery and the associated ‘D’ charger. The job was put on hold and the worker was given another assignment to work on. At about 2:00 p.m. the foreman again approached the worker and said the work order was correct, it is not #4 & ‘D’ and to go do the job.
The worker and an apprentice proceeded to do the job. The worker said he went up to the room and walked right over to the #4 Battery and ‘D’ charger and placed them out of service. He admitted that he just plain screwed up. The work order said #2 and ‘B’ but he didn’t have the work order out at the time like required/
Now most of us would end the story here and conclude the root cause is employee failure to follow procedure. But what happened next is what HU is all about. The plant manager said he appreciated the employees honesty and straight fowardness. The plant manger then said I now know 30% of HU (individual) reasons this happened. I now want to know the 70% (organizational) of the HU attributing causes.
The worker was asked why he hadn’t removed the work order from his pocket as required. He responded by saying that he had done this job so many times he didn’t feel there was a potential for problems. His apprentice was also asked if he had verified the actions and he said no because it seemed like such a simple job. Then the forman said the most incriminating thing of all: “I have told these guys a hundred times to start using the work orders in the field and to verify the actions!”
What did this foreman just admit to?????
Several organizational things were brought up like the fact that the numbering of the equipment is not consistent, #’s versus Letters. Also these workers had just came off midnight shift and there were no compensations for this issue. The last thing they heard when they left for the job was #4 & ‘D’. Instead of the appropriate #2 & ‘B’. They were squeezing this job in between others. The pre-job was held in the morning five assignments ago.

5. Significant Events (commercial nuclear) Annual Industry Averages
Data Source: U.S. Nuclear Regulatory Commission
(Core Damage Potential)
This information was provided by the NRC.
There are approximately 100 commercial Nuclear Power Plants in the U.S. today. This slide communicates that there were 2.38 events per unit in 1985, 3 significant events for all 100 units in As noted there has been a sizable reduction in Significant events over the last years 15. While .003 sounds impressive, is 3 events per year with potential core damage acceptable?
If you had to sell this to the general public, could you convince them we are there. Quite often we see how much progress we have made and want to accept them as having arrived.

6. Is 99.9% Good Enough? 1 hour of unsafe drinking water per month
2 unsafe landings per day in Atlanta, GA.
50 dropped babies per day
116,000 lost pieces of mail per hour
20,000 incorrect drug prescriptions per year
22,000 checks deposited in wrong accounts per hour
Would you accept 99.9%. Just as you wouldn’t accept the above, you shouldn’t accept safety and health statistics as OK. We must continually be working for continous improvement.
Sometime we jokingly accept certain stats. Finish this sentence, “You not a good carpenter until you have cut off a ……….” Answer is finger. Do we really believe this? If your son wanted to be a carpenter would you give him this advise?

7. DOE Occurrence Reports and Occurrences 1995-2000.
This slide shows that we have reduced the number of Occurrences/Occurrence Reports over the last five years.
This reduction can be attributed to many things, but for what ever reason, the point of this slide is to show that in % of these were Human performance related, and in 2000 you still had 90% related to Human Performance.
We have not approached the main contributor “Human Performance!” You can only tweek process and procedures so far, you can only fine tune instruments so far, until you finally have to look at the Human Performance attributes.
90% Involve Human Behavior
(National Safety Council)

8. Dateline clip on medical mistakes

9. What do you Manage? Assets: people & the plant Hazard: human error
Exposure: “People touching equipment”
Risk: probability and consequences
Control: error rate and defense-in-depth
To stay in business, the key assets of the organization must be protected.
people’s health and well-being (which includes employees and the general public) and
the safety and productivity of the power plant
The hazard to these assets is “human error;” you, your direct reports, and the workforce.
These assets are exposed to this hazard at the interface between the machine and the people who “touch” it.
Exposure of the asset to the hazard creates risk, which occurs when people touch the equipment; close proximity.
Risk is measured in terms of probability and consequence.
To reduce the probability, the frequency of events must be driven down.
To reduce the consequences, the severity of events must be minimized.
Frequency of events is driven primarily by error rate.
The severity of an event is always a function of the integrity of defenses and barriers.
Error rate and defense-in-depth are the two things that must be managed.
The strategy stems from these two challenges.

10. 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.

11. Studies of Visual Awareness
[ Video Exercise ]

12. Defining Human Performance5 4 3 2 1 5 4 3 2 1
Security guards are participating in the annual firearms re-certification. One of the tasks was to rapidly fire five shots at the bull's-eye from the prone position with a rifle supported. No additional instructions were provided. Immediate feedback on where their shots hit the target was not provided. The goal is to hit the bulls eye five times.
Based on the results of the guard's performance as shown below on the target, develop your conclusions in the following areas:
the better performance
suspected behaviors (while firing the weapon)
the better results
observed performance (target)
observable and non-observable behaviors (while firing the weapon)
potential reasons for performance
possible ways to improve performance
Who do you want working for you?
The shooter for target no.2. This person’s behavior is consistent and thus easier to modify.
Human performance is the combination of behavior and results, you need both.
Write on flip chart HU = B + R
Note: A task is an assignment to achieve a specified result according to specified standards (quality, quantity, timeliness, limitations, or costs).
Error = Delta Behavior/ standard or expectation
Show Parking lot example
Target No.1
Target No.2

13. Active Error Latent Error Two Kinds of Error
Definition of human error: an action (behavior) that unintentionally departs from an expected behavior (see Glossary) Write on flip chart Error = Delta Behavior/standard or expectation.
A violation involves a deliberate deviation from specified behavior (management expectations). This course does not deal with violations. However, we need to ask if the observed behavior was a violation? What is the true expectation? What we always do and has been accepted maybe the true expectation, not what we say. Or what is specified in administrative or other procedure.
.Fact: Error is defined by the behavior (B) not the result (R). NOTE: The same behavior can have little or no consequences or have great consequences. Error is classified based upon result.
.Two kinds of error (based upon the kinds of results they obtain)
.Active errors – errors(delta behavior/standard) that change equipment, system, plant state, or peoples 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.
Latent errors create latent conditions, for example ….
.Compare and contrast the who, what, when, and visibility 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
.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 closely. 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.
.Direct attention the the definition of an error. Delta behavior/standard of expectation
Latent Error
(leading to latent conditions)

14. Anatomy of an Event Event Flawed Defenses Initiating Action
Vision, Beliefs, &
Values
Vision, Beliefs, &
Values
Latent Organizational Weaknesses
Mission
Goals
Policies
Processes
Programs
This model is one of the key aspects of human performance that describes the overall context of the initiative. (Briefly explain it. Note that precursors to error can be internal or external to the individual. It’s simply meant to provide a basic concept of the kinds of things that can lead to human error.. Everyone has an impact. We’re really talking Organizational Performance.) This model isn’t only applicable to the nuclear industry. It comes from research which examined many businesses that focus on human performance. Work Through a traffic accident to point out the pieces of the model.
Discuss visions, values and beliefs.
. Ask what an event is. an undesirable consequence to the plant generally in terms of reduced safety margin.
. Ask what initiates a human performance event. initiating action
Emphasize the aspect of human involvement. Action may be exactly what procedure calls for, yet it is inappropriate because of plant conditions.
Define error precursors and flawed defenses. Emphasize that precursors provoke error while flawed defenses allow the consequences of the act to propagate. ERROR PRECURSORS Unfavorable factors embedded in the job site that increase the chances of error during the performance of a specific task by a particular individual. (See also human nature, individual capabilities, task demands, and work environment)
FLAWED DEFENSES Defects with administrative or physical defensive measures that, under the right circumstances, may fail to:
·        Protect plant equipment or people against hazards
·        Prevent the occurrence of active errors
·        Mitigate the consequences of error
. Ask what causes or creates these precursors and flawed defenses? latent organizational weaknesses
NOTE: The values of the individual need to match the values of the organization.
Event
Error Precursors
Ask will time pressure ever go away?
Event - an undesirable consequence (change in state of structures, systems, and components) to the plant generally in terms of reduced safety margin; Other definitions: an outcome that must be undone; any plant condition that does not achieve its goals; a difference between what is and what ought to be
Initiating Action - an action (behavior) by an individual, either correct or in error, that results in a plant event (includes active errors that have immediate, observable, undesirable outcomes in the physical plant)
Error Precursors – (direct attention to yellow cards) undesirable conditions, prior to the action, that reduce the opportunity for successful behavior at the jobsite, prompting behavior different than intended or required, i.e., provoke or drive errant behaviors; usually embedded in task demands, work environment, individual capabilities, and human nature. Ask which of these can we effect or change?
Flawed Defenses - defects with defensive measures that, under the right circumstances, may fail to protect plant equipment or people against hazards, and fail to prevent the occurrence of active errors, violations, or at-risk behaviors.
Latent Organizational Weaknesses - undetected deficiencies in the management control processes (e.g., strategy, policies, work control, training, and resource allocation) or values (shared beliefs, attitudes, norms, and assumptions) creating workplace conditions that either provoke error (precursors) or degrade the integrity of defenses (flawed defenses)
Dual Strategy
1) Anticipate and prevent active errors (reduce number of shots on goal). (Prevents one event) 2) Discover and eliminate latent organizational weaknesses (proactive and offensive). (May prevent many events)
What’s manageable? (occur before the error and event in time) “Events are not typically the outcome of one person’s action. More commonly, it is the result of a combination of faults in management and organizational activities.” (Turner & Pidgeon, Man-Made Disasters, p.89)

15. Insert DOE Example to illustrate Anatomy

16. Re + Md  ØE Strategic Approach
Anticipate and prevent active error (Re) at the job-site.
Identify and eliminate latent organizational weaknesses (Md).
These statements represent the goals we are headed for in this industry and with this training.

17. Examples of Error-prevention Techniques
Self-checking
Peer-checking
Three-way communication
Procedure use & adherence
Stop when unsure
Pre-job briefing
Turnover
Supervision
Placekeeping
Questioning attitude
Error-prevention techniques are defensive measures aimed at preventing and catching active errors. These functions are implied in the Anatomy of an Event as the causal link between “flawed defenses” and the “initiating action.”
Ask when do we use these? Which ones?
Choose a few to talk about from the list below:
Conservative Decision Making. Conservative decision-making is a rule-based (RB) and knowledge-based (KB) performance strategy that places the safety needs of the physical plant, in particular the reactor core, above the near-term production goals of the organization.
Change Management. Change management is typically reserved for large-scale organizational change and is usually not considered for day-to-day management activities. However, most day-to-day management involves change.
Communication. The aim of communication is to achieve mutual understanding between two or more individuals involving speaking and listening.
Concurrent (Double) Verification. Concurrent verification (CV) is the act by a second qualified individual of verifying a component's position before and during component repositioning. CV aims to prevent errors. Should be used with irrecoverable act.
Independent Verification. Peer-checking and concurrent verification are designed to catch errors before they are made. Independent verification (IV), on the other hand, catches errors after they have been made.
Meetings. Meetings are conducted to solve problems that cannot be handled as well by an individual. Errors can be made during meetings (knowledge-based and rule-based) due mostly to inaccurate mental models and misinterpretation of information.
Peer Checking. Peer checking provides an individual the opportunity to get a second qualified person on an informal basis to verify the correct component is selected for manipulation before the act.
Placekeeping involves the physical act of reliably marking steps in a procedure that have been completed or not applicable (skipped).
Pre-job Briefing. There are two primary purposes of the pre-job briefing: 1) to prepare workers for what is to be accomplished, and 2) to sensitize them for what is to be avoided.
Problem Solving: Without guidance, human beings do not usually solve problems rigorously, methodically, and painstakingly. Consequently, the chance for error increases dramatically in a knowledge-based work situation. Therefore, people need to work with others and apply a disciplined approach to problem solving.

18. Examples of Defenses Training Self assessment Procedures
Planning and Scheduling
Management oversight
Regulatory oversight
Problem reporting
Engineered safety features
Personnel protective equipment
Containment
Review and approval
Performance indicators

19. Relationships Leadership Practices 1. Facilitate open communication
2. Promote teamwork
3. Reinforce desired behaviors
4. Eliminate latent organizational weaknesses
5. Value prevention of errors
Relationships
Behaviors that support these opportunities can set example and help prevent errors.
Facilitate communication efforts - communication blockages, the prevalent flawed defense in major disasters; blame-free atmosphere (Allinson)
Promote Teamwork
Reinforce desired job-site behaviors - using performance management techniques (Daniels)
Identify & eliminate latent organizational flaws - revise policies, practices, & processes to proactively eliminate latent organizational errors that:
inhibit desired job-site behavior (individual)
establish conditions that promote error or violation (individual)
inhibit effectiveness of defenses (against the consequences of error)
Promote a sense of vulnerability & need for interdependency - due to the following:
human fallibility - we will make mistakes; every task is opportunity for error
complex technological environment - tight coupling & opaque systems
fast-paced operational tempo - time pressure
latent organizational flaws - even managers & engineers make mistakes
Ongoing basis - as or more important than production efforts; high-level attention vs. assumed (Embrey) .
BREAKOUT SESSION - ENABLER BEHAVIORS
Divide the class into five groups and assign each group a particular enabler.
Ask each group to identify what a leader could be seen doing or heard saying for the specific enabler.
Also report how behaviors relate to the human performance system. Pretend you are a video camera with audio. Tell exactly what you see and hear the person doing. Use the course reference and the Excellence in Human Performance to help.
.Follow the format below for each group’s report:
Present ideas to class one group at a time.
Discuss concepts (specified in remainder of this lesson plan) associated with specific enabler.
Relate enabler to human performance system.

20. Q&A Wrap-up

21. [Add constant sorrow clip]
Welcome back!
[Add constant sorrow clip]

22. Job Site and the Individual

23. [ Things Made in October ]
Inattention to Detail
[ Things Made in October ]

24. Traps of Human Nature Stress Avoidance of mental strain
Inaccurate mental models
Limited working memory
Limited attention resources
Mind set
Difficulty seeing own errors
Limited perspective
Susceptible to emotion
Focus on goal
Fatigue 9

25. Phrase Recall Exercise
What if human reliability has to be 100%?
PARIS IN THE THE SPRING
BIRD IN THE THE HAND
ONCE IN A A LIFETIME
Purpose of Exercise: to illustrate the vulnerability of human beings to conditions (internal and external to the individual) that almost guarantee failure.
WORKING INDEPENDENTLY YOU WILL HAVE FIVE SECONDS TO SEE THREE PHRASES> YOU WILL HAVE ALL THE TIME YOU NEED TO WRITE THEM DOWN WORD PERFECT>
Hit the left mouse button and it is automatic.
Directions: Using this as an transparency, give participants five seconds to view slide. Ask participants (individually) to write down what they saw. Success is defined as three phrases, word perfect. Expected success rate is about 1 in 20. Cause? “Inattention to detail” (I thought this group was the “best” in the station.)
ASK: So what do the Phrases really say? SHOW NEXT SLIDE

26. nonconsequential mishaps1 10 30
600
The error that caused a major accident and the error that is one of hundreds with no consequence can be the same error that has historically been overlooked or uncorrected. Significance is determined by degree of consequence to the core process, the physical plant. Therefore, for a significant event to occur, breakdowns in multiple defenses have to occur. The existence of so many flawed defenses can only be an outcome of faults in the organization or management control domains. (Frank Bird, Jr., Practical Loss Control Leadership, Det Norske Veritas (formerly International Loss Control Institute), 1969.)
major accident
significant events
mishaps
nonconsequential mishaps
Error-likely Situation The Devil in the Details
Error
likely
Situation
Job-Site Conditions:
Task
Individual
Error - unintended departure from a preferred behavior according to a standard (DB); e.g., driving out of my lane on an interstate highway. (active error - errors by those who touch the physical plant (core process) in an immediate, observable, undesired way)
Examine yellow cards for task characteristics that could apply to the Jenga Exercise.
OPTIONAL:
Draw above pyramid on flip chart
provide examples of each level
discuss change in behavior / error
Error-likely situation is a mismatch in job-site conditions. Task Characteristics – mismatches between the capabilities of the individual and the mental, physical and social demands required to perform the task or evolution successfully.
Unintentional
deviation from
preferred behavior
Degree of mismatch due to:
error precursors
Source: Swain & Guttmann. Handbook of Human Reliability Analysis with Emphasis on Nuclear Power Plant Applications. U.S. Nuclear Regulatory Commission (NUREG/CR-1278), 1983.

27. Individual Capabilities Work Environment Human Nature
Error Precursors
Task Demands
Individual Capabilities
Work Environment
Human Nature
Ability to detect error-likely situations to headoff preventable events depends largely on the extent these factors are understood regarding their role in human error. (Reason, Human Error, p4)
Errors occur mostly in association with information-handling
Task Demands - mismatches between the capabilities of the individual and the mental, physical, and social demands required to perform the task or evolution successfully.
Environmental Conditions - error-provoking conditions associated with task organization, workplace, leadership, and social customs.
Individual Capabilities -
Capabilities - unique mental, physical, and emotional abilities of the individual
Tendencies - characteristics generic of all human beings
Human Nature 2

28. Individual Capabilities
Performance Reliability: Probabilistic Science
increases as number of error precursors decrease
decreases as number of error precursors increase
Error Precursors
Limited short-term memory
Personality conflicts
Mental shortcuts (biases)
Lack of alternative indication
Inaccurate risk perception
Unexpected equipment conditions
Mind-set
Hidden system response
Complacency / Overconfidence
Workarounds / OOS instruments
Assumptions
Confusing displays or controls
Habit patterns
Changes / Departures from routine
Stress
Distractions / Interruptions
Human Nature
Work Environment
Illness / Fatigue
Lack of or unclear standards
“Unsafe” attitude for critical tasks
Unclear goals, roles, & responsibilities
Indistinct problem-solving skills
Interpretation requirements
Lack of proficiency / Inexperience
Irrecoverable acts
Imprecise communication habits
Repetitive actions / Monotony
New technique not used before
Simultaneous, multiple tasks
Lack of knowledge (mental model)
High Workload (high memory requirements)
Unfamiliarity w/ task / First time
Time pressure (in a hurry)
Individual Capabilities
Task Demands
Error Precursor - unfavorable prior conditions that reduce the opportunity for successful behavior at the jobsite; creates (exacerbates) the mismatch associated with task demands and the individual (error-likely situation/ELS). List derived from INPO event data base and several credible references associated with human performance.
Handout – “Lifted Leads” Newsletter
Have students read “ME- Out of Sync”
Identify error precursors (use yellow cards)
Facilitate a discussion.
Multiple error precursors - increase chances of error; change the situation
How do the above conditions change from normal on-line to outage
How many error precursors are necessary to cause error? None. Why?
Human performance is not rocket science, i.e., black and white.
Individual differences
Some people respond differently, or to a different degree, to error precursors.
You may have error prone people
OOS – out of service

29. 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.”
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.

30. ? D Performance Modes Attention (to task) Familiarity (w/ task) KB RB
Control Mechanisms
Type of errors that usually occur at upper echelons of organization; not observable KB
Patterns RB
If - Then SB
Auto
Familiarity (w/ task)
Low
High
Attention (to task)
Inattention
Misinterpretation
Inaccurate Mental Picture D ?
Type of errors that usually occur at human-machine interface; observable
Begin Note to Facilitators: 1. The material on this slide is complex; difficult to understand and difficult to explain. Before presenting this slide as part of the Human Performance Course, please read Source: James Reason. Managing the Risks of Organizational Accidents, The information in the book is very helpful in teaching Human Performance, as is this slide Consider drawing the diagram piece-by-piece on a flip chart rather than trying to explain all sections at once from the Ppt. Slide. End Note to Facilitators.
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?
Transitions: From SB: Delta - change in task/environment; Into KB: ? - uncertainty & doubt
Definitions of each performance mode (see Generic Error Model in HPF course 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)
Distribution of error industry wide: SB: 25%, RB: 60%, KB: 15% (Source: PII); Describe event in each mode.
Time spent in each mode: SB: 88-90%, RB/KB: 10-12% (Source: Hypnotherapy, Atlanta Constitution, 11/22/98)
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
Note: After illustrating each performance mode on the flip chart, refer to the Generic Error Modeling System (GEMS) model in the student notebook to reinforce student understanding of each performance mode.
Source: James Reason. Managing the Risks of Organizational Accidents, 1998.

32. Error-prevention Techniques
Self-checking
Peer-checking
Three-way communication
Procedure use & adherence
Stop when unsure
Pre-job briefing
Questioning attitude
Placekeeping
Flagging
Concurrent verification
Independent verification
Problem-solving
Conservative decision-making
Two-minute rule
Turnover
Supervision
Error-prevention techniques are defensive measures aimed at preventing and catching active errors. These functions are implied in the Anatomy of an Event as the causal link between “flawed defenses” and the “initiating action.”
Ask when do we use these? Which ones?
Choose a few to talk about from the list below:
Conservative Decision Making. Conservative decision-making is a rule-based (RB) and knowledge-based (KB) performance strategy that places the safety needs of the physical plant, in particular the reactor core, above the near-term production goals of the organization.
Change Management. Change management is typically reserved for large-scale organizational change and is usually not considered for day-to-day management activities. However, most day-to-day management involves change.
Communication. The aim of communication is to achieve mutual understanding between two or more individuals involving speaking and listening.
Concurrent (Double) Verification. Concurrent verification (CV) is the act by a second qualified individual of verifying a component's position before and during component repositioning. CV aims to prevent errors. Should be used with irrecoverable act.
Independent Verification. Peer-checking and concurrent verification are designed to catch errors before they are made. Independent verification (IV), on the other hand, catches errors after they have been made.
Meetings. Meetings are conducted to solve problems that cannot be handled as well by an individual. Errors can be made during meetings (knowledge-based and rule-based) due mostly to inaccurate mental models and misinterpretation of information.
Peer Checking. Peer checking provides an individual the opportunity to get a second qualified person on an informal basis to verify the correct component is selected for manipulation before the act.
Placekeeping involves the physical act of reliably marking steps in a procedure that have been completed or not applicable (skipped).
Pre-job Briefing. There are two primary purposes of the pre-job briefing: 1) to prepare workers for what is to be accomplished, and 2) to sensitize them for what is to be avoided.
Problem Solving: Without guidance, human beings do not usually solve problems rigorously, methodically, and painstakingly. Consequently, the chance for error increases dramatically in a knowledge-based work situation. Therefore, people need to work with others and apply a disciplined approach to problem solving.

33. Engineer Human Performance Techniques
Pre-job briefing / Task Assignment
Procedure use & adherence
Questioning attitude
Review and Verification
Problem-solving & Decision-making
Design review meetings
Signature
Error-prevention techniques are defensive measures aimed at preventing and catching active errors. These functions are implied in the Anatomy of an Event as the causal link between “flawed defenses” and the “initiating action.”
Ask when do we use these? Which ones?
Choose a few to talk about from the list below:
Conservative Decision Making. Conservative decision-making is a rule-based (RB) and knowledge-based (KB) performance strategy that places the safety needs of the physical plant, in particular the reactor core, above the near-term production goals of the organization.
Change Management. Change management is typically reserved for large-scale organizational change and is usually not considered for day-to-day management activities. However, most day-to-day management involves change.
Communication. The aim of communication is to achieve mutual understanding between two or more individuals involving speaking and listening.
Concurrent (Double) Verification. Concurrent verification (CV) is the act by a second qualified individual of verifying a component's position before and during component repositioning. CV aims to prevent errors. Should be used with irrecoverable act.
Independent Verification. Peer-checking and concurrent verification are designed to catch errors before they are made. Independent verification (IV), on the other hand, catches errors after they have been made.
Meetings. Meetings are conducted to solve problems that cannot be handled as well by an individual. Errors can be made during meetings (knowledge-based and rule-based) due mostly to inaccurate mental models and misinterpretation of information.
Peer Checking. Peer checking provides an individual the opportunity to get a second qualified person on an informal basis to verify the correct component is selected for manipulation before the act.
Placekeeping involves the physical act of reliably marking steps in a procedure that have been completed or not applicable (skipped).
Pre-job Briefing. There are two primary purposes of the pre-job briefing: 1) to prepare workers for what is to be accomplished, and 2) to sensitize them for what is to be avoided.
Problem Solving: Without guidance, human beings do not usually solve problems rigorously, methodically, and painstakingly. Consequently, the chance for error increases dramatically in a knowledge-based work situation. Therefore, people need to work with others and apply a disciplined approach to problem solving.

34. Supervisor Techniques
Work planning
Walkdown
Task assignment
Pre-job briefing
Observation
Performance management
Post-job review

35. Team Errors “social loafing”
Halo Effect
Pilot / Co-pilot
Free Riding
Groupthink
Risky Shift
·        Halo Effect - blind trust in the “competence” of specific individuals because of their experience or position in an organization. Consequently, they drop their guard against error, and their vigilance to check the respected person's actions weakens.
·        Pilot/Co‑pilot - a subordinate person (co-pilot) is reluctant to, or does not feel it is his/her place to, challenge the opinions, decisions, or actions of a senior or more experienced person (pilot).[i] Subordinates may also express “excessive professional courtesy” when interacting with senior managers.[ii]
·        Free Riding - If one person takes the lead in an activity, peers may tend to tag along without actively scrutinizing the intent and actions of the person doing the work.
·        Groupthink - reluctance to share contradictory information about a problem for the sake of maintaining the harmony of the work group to the detriment of critical problem-solving.[iii] Usually, this is worsened by one or more dominate team members who possess considerable influence on the group's thinking. Consequently, critical information known within the group may remain unknown. Groupthink can also occur due to the existence of too much “professional courtesy;” subordinates passing on only “good news” or “sugar coating” bad news so as to not displease their boss or higher level manager.
·        Risky Shift - the tendency to gamble with decisions more as a group than they would if they were making the decision individually on their own.[iv] If two or more people agree together that they know a “better way” to do something, there is a good chance they will take the risk and disregard established procedure or policy. This is commonly referred to as a “herd mentality.”

36. The Organization

37. Dual Purposes
To consistently search for and eliminate conditions that provoke human error while reinforcing defenses.
Safety
To facilitate the accomplishment of the organization’s mission in accordance with its norms, values, and strategies.
If an organization only sees its purpose as production then what is its priority? What will it focus on?
In a business like commercial nuclear power where error can have significant consequences what must the purpose of the organization also be? Answer: Safety
Is safety complementary to or in conflict with production? Answer: A properly focused safety purpose is a long range production attitude. If an organization does not have significant events it will be a production success, assuming that it is producing (e.g. a dead man is pretty safe but he is not producing). The two purposes work together for success.
__________________
Activity:
Flip chart the production/protection “ROAD”

38. 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.

39. Defenses Physical Administrative Create Awareness Detect and Warn
Protect
Recover
Contain
Enable Escape
State that we talked yesterday about conditions provoking human error but what about defenses? If an organization is going to reinforce defenses, we need to know a little bit about them. If we are going to keep ourselves in the parity zone of protection vs. production, we need to periodically check and reinforce our defenses (rock the boat).
State that defenses fulfill the following functions:
to create awareness and understanding of the risks and hazards
to detect and warn of the presence of off-normal conditions or imminent dangers
to protect people and the environment from injury and damage
to recover from off-normal conditions and restore the system to a safe state
to contain the accidental release of harmful energy or substances
to enable potential victims to escape out-of-control hazards
.Fact: Defenses are both physical and administrative.
Ask for examples of physical defenses: engineered safety features,personal protective equipment
Ask for examples of administrative defenses. supervision,procedures, instructions, policies, standards,training, briefings
Defense Function Sprint - HANDOUT
Direct students take a minute to mark the defense function and mode of application for the items listed. (More than one box may be checked.)
Ask are there any defenses you want to review or discuss? Pick a few at random to promote discussion if the class does not respond.
Flawed defenses allow active errors or their consequences to occur.
Source: Maurino (1995)

40. Defense -in- Depth Challenges To the Plant EVENTS
VERBAL
COMMUNICATIONS
MANAGERIAL METHODS
DESIGN
One great thing about our business is that we have lots of protective layers. This means that some of these barriers can erode or break down and another layer in the chain can prevent an event from occurring. Other industries with defense in depth have this same benefit. The common problem we have with this is that since events are few and far between and since our organizations can tolerate erosion in some of our defenses without resulting in events, this is exactly what happens -- unless we’re proactive and vigilant. What happens when these defenses begin to erode is that we wind up thinking we have defense in depth when in fact we really have flawed defenses and broken barriers.
This is why it is important to examine near misses and keep an open mind about what may be flawed.
WRITTEN COMMUNICATIONS
TRAINING
WORK
PRACTICES
CHANGE
IMPLEMENTATION
WORK SCHEDULE
WORK ORGANIZATION OR
SUPERVISORY METHODS
ENVIRONMENTAL
FACTORS
EVENTS

41. Leadership Performance Model JOB-SITE WORKER CONDITIONS BEHAVIOR PLANT
Equipment Labeling & Condition
Procedure / Work Package Quality
Worker Knowledge, Skill, & Proficiency
Fitness- for-Duty
Wary Attitude
Equipment Ergonomics & Human Factors
Tool Quality & Availability
Roles & Responsibilities
Housekeeping
Environmental Conditions
Foreign Material Exclusion
Lockout / Tagout
Personal Motives
Intolerance for Error Traps
Self-Checking
Place -
Keeping 3
Part Communication
Double
Verification
Procedure Use
& Adherence
Supervision
Management Monitoring
Stop When
Uncertain
Critical Parameters
Problem
Solving
Methodology
Conservative
Decision
Making
Team Skills
Peer-Checking
Pre-job Briefing
Just-in-time Operating Experience
Task Preview
Turnover
Clearance Walkdown
Leadership
Proper Reactions
High Standards
Reinforcement
Coaching
Questioning Attitude
Respect for Others
Open & Honest Communication
Compelling Vision
Healthy Relationships
Courage & Integrity
Motivation
Example
JOB-SITE
CONDITIONS
WORKER
BEHAVIOR
Defenses are established all along the way to pick up these flaws and actions (defense-in-depth).
At OR: use of OE and other feedback, reviews and approvals, change management, meetings, process handoffs, priority setting,
OR-to-JC: task assignment, reviews and approvals, procedures, task assignment, work document, work walkdown
At JC: labeling, worker knowledge & skill, procedure content & usability, tools, FFD
JC-to-WB: task preview, prejob briefing, operating experience
At WB: self-checking, procedure use and adherence, peer-checking, communication practices, questioning attitude
JB-to-PR: independent verification (self / peer check), interlocks
At PR: safeguards, containment, RPS
Point out that the defenses within the leadership area are relationship development behaviors.
Walkdowns
Performance Feedback
Task Assignment
HP Surveys
Task Qualification
QC Hold Points
Independent
Verification
Interlocks
Personal
Protective
Equipment
Alarms
Forcing
Functions
ORGANIZATION
PROCESSES
& VALUES
PLANT
RESULTS
Communication
Practices / Plan
Reviews &
Approvals
Change
Mgmt.
Problem
Solving
Scheduling /
Sequencing
Clear
Expectations
Role
Models
Safety
Philosophy
Task
Allocation
Meetings
Rewards & Reinforcement
Trend Analysis OE
Training
Handoffs
Accountability
Simple/effective
Process Philosophy
Procedure Revisions
Work Planning
Corrective Action
Self-
Assessment
Benchmarking
Safeguards
Equipment
Reactor
Protection
Systems
Containment
Postjob Reviews
Problem Reports
Root Cause Analysis
Performance Indicators
Performance Model

42. RECALL: Anatomy of an Event
Flawed Defenses
Initiating Action
Vision, Beliefs, &
Values
Vision, Beliefs, &
Values
Latent Organizational Weaknesses
Mission
Goals
Policies
Processes
Programs
This model is one of the key aspects of human performance that describes the overall context of the initiative. (Briefly explain it. Note that precursors to error can be internal or external to the individual. It’s simply meant to provide a basic concept of the kinds of things that can lead to human error.. Everyone has an impact. We’re really talking Organizational Performance.) This model isn’t only applicable to the nuclear industry. It comes from research which examined many businesses that focus on human performance. Work Through a traffic accident to point out the pieces of the model.
Discuss visions, values and beliefs.
. Ask what an event is. an undesirable consequence to the plant generally in terms of reduced safety margin.
. Ask what initiates a human performance event. initiating action
Emphasize the aspect of human involvement. Action may be exactly what procedure calls for, yet it is inappropriate because of plant conditions.
Define error precursors and flawed defenses. Emphasize that precursors provoke error while flawed defenses allow the consequences of the act to propagate. ERROR PRECURSORS Unfavorable factors embedded in the job site that increase the chances of error during the performance of a specific task by a particular individual. (See also human nature, individual capabilities, task demands, and work environment)
FLAWED DEFENSES Defects with administrative or physical defensive measures that, under the right circumstances, may fail to:
·        Protect plant equipment or people against hazards
·        Prevent the occurrence of active errors
·        Mitigate the consequences of error
. Ask what causes or creates these precursors and flawed defenses? latent organizational weaknesses
NOTE: The values of the individual need to match the values of the organization.
Event
Error Precursors
Ask will time pressure ever go away?
Event - an undesirable consequence (change in state of structures, systems, and components) to the plant generally in terms of reduced safety margin; Other definitions: an outcome that must be undone; any plant condition that does not achieve its goals; a difference between what is and what ought to be
Initiating Action - an action (behavior) by an individual, either correct or in error, that results in a plant event (includes active errors that have immediate, observable, undesirable outcomes in the physical plant)
Error Precursors – (direct attention to yellow cards) undesirable conditions, prior to the action, that reduce the opportunity for successful behavior at the jobsite, prompting behavior different than intended or required, i.e., provoke or drive errant behaviors; usually embedded in task demands, work environment, individual capabilities, and human nature. Ask which of these can we effect or change?
Flawed Defenses - defects with defensive measures that, under the right circumstances, may fail to protect plant equipment or people against hazards, and fail to prevent the occurrence of active errors, violations, or at-risk behaviors.
Latent Organizational Weaknesses - undetected deficiencies in the management control processes (e.g., strategy, policies, work control, training, and resource allocation) or values (shared beliefs, attitudes, norms, and assumptions) creating workplace conditions that either provoke error (precursors) or degrade the integrity of defenses (flawed defenses)
Dual Strategy
1) Anticipate and prevent active errors (reduce number of shots on goal). (Prevents one event) 2) Discover and eliminate latent organizational weaknesses (proactive and offensive). (May prevent many events)
What’s manageable? (occur before the error and event in time) “Events are not typically the outcome of one person’s action. More commonly, it is the result of a combination of faults in management and organizational activities.” (Turner & Pidgeon, Man-Made Disasters, p.89)

43. Latent Organizational Weaknesses (sources)
Processes (structure)
Work control
Training
Accountability policy
Reviews & approvals
Equipment design
Procedure development
Human resources
Values (relationships)
Priorities
Measures & controls
Critical incidents
Coaching & teamwork
Rewards & sanctions
Reinforcement
Promotions & terminations
Latent organizational weaknesses exercise hand out.

44. Finding Latent Organizational Weaknesses
Self-Assessments
Benchmarking
Post-job Reviews
Trending
Document Reviews
Surveys and Questionnaires
Observations
Root Cause Analysis

45. Leadership

46. Leader’s Role Leadership JOB-SITE WORKER CONDITIONS BEHAVIOR PLANT
Equipment Labeling & Condition
Procedure / Work Package Quality
Worker Knowledge, Skill, & Proficiency
Fitness- for-Duty
Wary Attitude
Equipment Ergonomics & Human Factors
Tool Quality & Availability
Roles & Responsibilities
Housekeeping
Environmental Conditions
Foreign Material Exclusion
Lockout / Tagout
Personal Motives
Intolerance for Error Traps
Self-Checking
Place -
Keeping 3
Part Communication
Double
Verification
Procedure Use
& Adherence
Supervision
Management Monitoring
Stop When
Uncertain
Critical Parameters
Problem
Solving
Methodology
Conservative
Decision
Making
Team Skills
Peer-Checking
Pre-job Briefing
Just-in-time Operating Experience
Task Preview
Turnover
Clearance Walkdown
Leadership
Proper Reactions
High Standards
Reinforcement
Coaching
Questioning Attitude
Respect for Others
Open & Honest Communication
Compelling Vision
Healthy Relationships
Courage & Integrity
Motivation
Example
JOB-SITE
CONDITIONS
WORKER
BEHAVIOR
Defenses are established all along the way to pick up these flaws and actions (defense-in-depth).
At OR: use of OE and other feedback, reviews and approvals, change management, meetings, process handoffs, priority setting,
OR-to-JC: task assignment, reviews and approvals, procedures, task assignment, work document, work walkdown
At JC: labeling, worker knowledge & skill, procedure content & usability, tools, FFD
JC-to-WB: task preview, prejob briefing, operating experience
At WB: self-checking, procedure use and adherence, peer-checking, communication practices, questioning attitude
JB-to-PR: independent verification (self / peer check), interlocks
At PR: safeguards, containment, RPS
Point out that the defenses within the leadership area are relationship development behaviors.
Walkdowns
Performance Feedback
Task Assignment
HP Surveys
Task Qualification
QC Hold Points
Independent
Verification
Interlocks
Personal
Protective
Equipment
Alarms
Forcing
Functions
ORGANIZATION
PROCESSES
& VALUES
PLANT
RESULTS
Communication
Practices / Plan
Reviews &
Approvals
Change
Mgmt.
Problem
Solving
Scheduling /
Sequencing
Clear
Expectations
Role
Models
Safety
Philosophy
Task
Allocation
Meetings
Rewards & Reinforcement
Trend Analysis OE
Training
Handoffs
Accountability
Simple/effective
Process Philosophy
Procedure Revisions
Work Planning
Corrective Action
Self-
Assessment
Benchmarking
Safeguards
Equipment
Reactor
Protection
Systems
Containment
Postjob Reviews
Problem Reports
Root Cause Analysis
Performance Indicators
Leader’s Role

47. Competing Resources Prevention Production tn Bankruptcy Accident t0
Defenses
Bankruptcy
Prevention
Production
Just Do It!
Why aren’t there “Think Megawatts” or “Think Schedule Adherence” signs in the plant or on the plant access road?
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.
Incubation of Disasters (Man-Made Disasters, Turner & Pidgeon, p88)
I. Existing set of beliefs and attitudes (shared?) about hazards and safe practices degraded (Pollyanna) II. Accumulation of unnoticed mishaps (unreported errors) and low-level events (at odds with original beliefs above; perceptions about safe practice and hazards depart from reality; values become differentiated through the workforce and management; complacency and shortcuts) III. Precipitating Event (outcomes that reveal true latent condition organization) IV. Immediate consequences of the event become evident. V. Rescue and salvage (first stage of readjustment in values due to shock of experience) VI. Full cultural readjustment (second stage involving review and revision of existing ideas about hazards and safe practices to avoid them)
For in-depth information, 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).

48. Relationships Leadership Practices 1. Facilitate open communication
2. Promote teamwork
3. Reinforce desired behaviors
4. Eliminate latent organizational weaknesses
5. Value prevention of errors
Relationships
Behaviors that support these opportunities can set example and help prevent errors.
Facilitate communication efforts - communication blockages, the prevalent flawed defense in major disasters; blame-free atmosphere (Allinson)
Promote Teamwork
Reinforce desired job-site behaviors - using performance management techniques (Daniels)
Identify & eliminate latent organizational flaws - revise policies, practices, & processes to proactively eliminate latent organizational errors that:
inhibit desired job-site behavior (individual)
establish conditions that promote error or violation (individual)
inhibit effectiveness of defenses (against the consequences of error)
Promote a sense of vulnerability & need for interdependency - due to the following:
human fallibility - we will make mistakes; every task is opportunity for error
complex technological environment - tight coupling & opaque systems
fast-paced operational tempo - time pressure
latent organizational flaws - even managers & engineers make mistakes
Ongoing basis - as or more important than production efforts; high-level attention vs. assumed (Embrey) .
BREAKOUT SESSION - ENABLER BEHAVIORS
Divide the class into five groups and assign each group a particular enabler.
Ask each group to identify what a leader could be seen doing or heard saying for the specific enabler.
Also report how behaviors relate to the human performance system. Pretend you are a video camera with audio. Tell exactly what you see and hear the person doing. Use the course reference and the Excellence in Human Performance to help.
.Follow the format below for each group’s report:
Present ideas to class one group at a time.
Discuss concepts (specified in remainder of this lesson plan) associated with specific enabler.
Relate enabler to human performance system.

49. Challenge to Communicate
Managers:
“Ask for what you need to hear, not for what you want to hear.”
Communication failure is the most prevalent cause of major disasters. (Allinson)
Cause for failures of foresight (Turner & Pidgeon, Man-Made Disasters)
.Fact: Communication is likely the most effective defensive measure against events.
.Guidelines for organizational communications:
Managers - “Ask for what you need to hear, not what you want to hear.”
Subordinates - “Tell your boss what they need to hear, not what you think they want to hear.” (Boisjoly)
.Ask what can happen to communication when the people who “touch things” get disciplined for honest mistakes.
Blame Cycle (next slide).
Subordinates:
“Tell your boss what they need to hear, not what you think they want to hear.”
--Roger Boisjoly Former chief engineer for Morton-Thiokol, Inc.

50. Four goals in any communication:
Have the message received.
Have the message understood.
To initiate action.
To maintain or enhance the relationship.
“ I didn’t say she stole the money.”
State that the burden of communicating lies primarily
Discuss goals.
Emphasize importance on voice inflection & pitch & nonverbal in communication. Read the statement

51. Team Skills Ladder COMMUNICATION TRUST Critique Performance
Inquiry
Advocacy
Leadership
Conflict Management
Critique Performance
COMMUNICATION
.Ask why teamwork is needed.
working with complex technology - nuclear power
existing adverse organizational weaknesses (latent conditions) in the plant
fallible human beings working in the plant
.Aim of teamwork:
Work together to identify error-likely situations and/or flawed defenses (collaborate).
Raise collective IQ of group.
Overcome individual fallibility.
Make visible all assumptions and latent conditions.
.Team skills ladder(explain or provide example of each):
inquiry
advocacy
leadership
conflict management
critique performance
.Ask what essential elements hold the rungs of the ladder together.
Communication (side rail)
Trust, specifically confidence and competence (side rail)
Ownership (glue)
TRUST
Difficulty increases as you “climb” the ladder!

52. Consequences that Decrease Behavior Consequences that Increase
Reinforcement
Consequences that Decrease Behavior
Behavior
BEHAVIOR INCREASES
Consequences that Increase
1. GET SOMETHING YOU WANT
2. AVOID SOMETHING YOU DON’T WANT
1. GET SOMETHING YOU DON’T WANT
2 . LOSE SOMETHING THAT YOU HAVE
BEHAVIOR DECREASES
.Ask: What is human performance? B + R
How can a leader get someone to do the desired behavior once?; quick change (for example, directives, verbal orders, training, signs, procedures, messages, or threats)
How can a leader can get someone to repeat the desired behavior (for example, positive consequences, graphs of results, rewards, threat of punishment, or recognition)
.Law of Human Nature: People tend to seek things they like (pleasure, rewards) and avoid things they don’t like (punishment, negative situations, being ignored)
.Effect of consequences on behavior [9]
positive reinforcement (R+) - personal satisfaction after successfully troubleshooting and repairing a failed instrument
negative reinforcement (R-) - taking foot off the accelerator of your car when you see a highway patrolman
punishment (P) - burning your finger when touching a hot stove top
extinction (X) - not receiving a snack after inserting 50 cents into a vending machine .
Source: Daniels, Bringing Out the Best in People, 1989.

53. Insert Terry Tate clip

54. Behavior can be: Desirable; want more of it – the Good
People need feedback to know if their behavior is acceptable.
Desirable; want more of it – the Good
Acceptable or unacceptable; improvement is wanted – the Bad
Unsafe, at-risk, or unsatisfactory; want it to stop now – the Ugly
Communication is the requisite skill for correcting, coaching, and reinforcing.
Are you competent:
Understanding the situation? (jumping to conclusions
Overcoming feedback anxiety? (self doubt in expertise, friends
Listening
Facts vs. Assumptions
Why is it in your best interest to correct, coach, and reinforce work practices?
Your people perform better
You look good
Quality of life (less demands on off time, more time to tackle projects)
Keep a job (plant runs better, makes more $)
Feedback:
Sincere – Mean what you say; honesty
Specific –Tell person exactly what behavior was done correctly. Avoid, “Good job.”
Immediate – specific behavior easier to pinpoint, preferably in the act; recognition done late must be very specific to the behavior
Personal – Expressed in terms of how you feel, not as a member of the company. Also, focus on the person’s behavior. “I know what you did, and I know who you are.”
What does excellence require?

55. Blame Cycle Human Error Individual counseled and/or disciplined
More flawed defenses & error precursors
Blame Cycle
Trust erodes.
Information flow diminishes.
Good people leave organization.
An “us vs. them” culture evolves.
People want justice, not necessarily a blame-free environment (Reason)
.Error should be seen as opportunity to learn.
.When listening, notice how people feel about something as well as what they are saying; “be here now.”
Reduced trust
Latent organizational
weaknesses persist
Management less aware of jobsite conditions
Less communication
Source: Reason, Managing the Risks of Organizational Accidents, pp

56. Eliminating Latent Organizational Weaknesses
Solicit and act on feedback from workers
Determine fundamental causes
Monitor trends
Observe work in the field
Conduct surveys and use questionnaires
Perform process mapping
Conduct task analysis
Perform benchmarking
Mosquito analogy:
ever-present nuisance in the summer
unable to eliminate them with one application of insect repellent;
destroyed whenever they land within slapping distance, one-by-one (separate events or errors)
constant vigilance or continuous, recurring applications of insect repellent to prevent a bite
Best solution is to drain the swamp that breeds them (organizational weaknesses) [34] - organizational processes, policies, and procedures
Aggressive oversight and self-assessment followed by rigorous execution of corrective action program.

57. Behaviors that influence values & beliefs
Enabler 5, Slide 1: Value Prevention of Errors
Behaviors that influence values & beliefs
Management Body Language 101
Socialization, the process by which members acquire the core (values) of the (plant’s) culture.
Ed Schein,
Organizational Culture and Leadership, p.231
What leaders pay attention to, measure, or control
Reactions to critical incidents or crisis
Criteria used to allocate scarce resources
Deliberate attempts at role modeling, teaching, and coaching
Criteria for reinforcement and discipline
Criteria used to select, promote, or terminate employees
Tools are presented in order of effectiveness
These are leader behaviors, body language, most likely to influence values and beliefs of subordinates.
Values and beliefs about hazards (safety culture) will emerge/evolve from persistent application of principles via the socialization process (relationships). (Schein, Organizational Culture and Leadership)
Bypasses organizational filters.
Formal statements of organizational philosophy, creeds, and charters are attempts by management to state explicitly what their values and assumptions are. However, this is the least effective way of defining the organization’s culture. (Organizational Culture and Leadership, p252)
Casual remarks and questions; what leaders don’t pay attention to. “…what I ask questions about sends clear signals to my audience (subordinates) about my priorities, values, and beliefs.” (Schein. Organizational Culture and Leadership, 1992, p232)
Leader behaviors that express what you pay attention to with respect to human performance:
Facilitate open communication
Promote teamwork
Eliminate latent organizational weaknesses
Reinforce preferred preventive behaviors
Value error prevention
Source: Schein, Edgar H. Organizational Culture and Leadership, Jossey-Bass, 1992, p231.
Relationships
Create intensity of imagination and creativity!
(about hazards, productivity, & efficiency)

58. Q&A Wrap-up Thanks!