2b-Human Performance Fundamentals: Participant Handout



Human Performance Fundamentals Participant Handout86360010985500IntroductionPurpose of this TrainingYOUR COMPANY NAME values safety and we want to ensure all of our employees are safe on the job. With this course, we intend to reduce both the frequency and severity of events and improve our operational performance.ActivityWhat do you think of when you read the quotes on the slide? (Write your thoughts in the spaces below and prepare to share with the group.)Training ObjectivesBy the end of this course, you will be able to Describe the types and causes of human errorDescribe human performance concepts and principlesApply the principles of human performance in a case studyIdentify the human performance toolsApply the appropriate tools in work situationsActivityCircle the two objectives you would like to focus on during this course. Add any thoughts or additional focus areas in the section below. Indicate your expectations of this course. Types and Causes of Human ErrorThe Science of Human PerformanceWhat causes events?Statistics show that approximately 36% of accidents are attributed to work practices. Our industry is responding by emphasizing tools to improve the human performance of tasks. It became clear that another major factor to the production of errors was conditions present within the organization. The study of Human performance is really the study of individual, leader, and organizational behaviors. The success of error prevention depends on the entire organization.This is why we have to look at behavior. (Fill in the blanks as your instructor shares the information.)The difference between error and event is ________________The average person commits __________ errors per hour. We can see how it makes sense to report and investigate non-consequential errors. The lower your number of non-consequential errors, the longer it will take you to reach the higher levels of the pyramid.DefinitionsAn error is an undesirable and unintended happening which departs from an expected behavior. Most errors, result in little or no consequence, and may go unnoticed.An event is an undesirable and unintended happening such as an accident, injury or equipment damage. These include incidents OSHA defines as “recordable.” They differ from an event in the degree of consequence.The YOUR COMPANY NAME error free event-clock is based on events.Layers of Responsibility Contributing to Human PerformanceHuman Performance Improvement uses a three-tiered perspective to explain how human performance can be improved.Individual – An employee in any position in the organization.Leader – Managers and supervisors are in positions of responsibility but may not exhibit leadership behaviors. Workers, although not in positions of responsibility, may be very influential leaders. Organization – A group of people with a shared mission, resources, and plan that directs people's behavior toward safe and reliable operation. An organization directs people's behavior in a predictable way, through its processes, values and belief systems. Four Elements that Impact Human PerformanceHuman performance is a system of interdependencies between people, processes, cultures, and values. Understanding organizational systems, processes, and leadership is important to effective management of human performance.The performance element model illustrates a network of elements that function together to produce an outcome. It will help identify opportunities for improving the workers performance.ActivityRecord the four elements as your instructor provides them.What is the other factor that influences these elements?1. Organizational Processes and ValuesThese are processes and shared values support how the work gets done. Processes are the outcome of the organization’s mission and planning. Values indicate manager behaviors and their priorities. Processes and values set the stage for how a job is performed and its eventual outcome. 2. Work ConditionsThis is related to the job-site conditions that CAN provoke error. ActivityWhat are some job-site conditions that might impact performance?3. Worker BehaviorsThese are the actions (or inactions) by an individual worker during the performance of a task. 4. Job ResultsThese are the outcomes to the physical equipment or personnel parison of results with expectations (assessment and event investigation) guides appropriate changes (corrective actions) in the organization.LeadershipProduction behaviors will always compete with prevention behaviors. Without aggressive leadership, production will tend to preempt prevention. Production is goal-directed. Prevention is value-directed. Leadership refers to those in positions to influence worker beliefs, values, attitudes, and behavior, as well as system performance and organizational processes. ActivityFill in the blank. __________________ can take on the role of leader. Types of ErrorsError is defined by behavior; not result. Similar behaviors can have different results. Active Errors Active errors are observable, physical actions that change equipment, system, or state, resulting in immediate undesired consequences. Such actions may be either acts of omission or commission. Grievous errors may result in loss of life, major personal injury, or severe consequences to the physical system.Latent ErrorsLatent errors include actions, directives, and decisions that either create the conditions for error or fail to prevent, catch, or mitigate the effects of error on the physical plant. Latent errors result in hidden organization-related weaknesses or equipment flaws that lie dormant. Latent errors go unnoticed at the time they are made and have no immediate outcome to the system or personnel.Latent errors create flaws in programs and processes, inefficiencies, as well as unhealthy attitudes, beliefs, and values that erode the integrity of defenses.Latent errors are more sinister than active errors, making the system more vulnerable to events triggered by occasional mitting ErrorsWe won’t discuss violations at this time. We are more concerned with non-deliberate employee consequences.Mistakes relate to the adage: Fail to plan-Plan to fail. A good example of this is not verifying a telephone number and dialing it anyway. We can get an un-intended result from an intended action.It is difficult to prevent results we didn’t intend to achieve. Our fallibility or environmental conditions can cause an unintended result from an unintended action.ActivityFill in the blanks. Basic Error Types:4705355397500Performance ModesThere are categories from which we draw to perform a task: Knowledge BasedRules BasedSkills BasedWhen we become more familiar with tasks we reduce the need for attention which leads to complacency. 67818057912000Error Traps We have all heard the old job clichés; “He’s done this a hundred times.” “It’s a routine task.” Is there really ever a routine task? Are we the same people doing the task today as we were yesterday? Are the task and the environment it is being performed in, exactly like they were yesterday? We cannot confuse knowledge and capabilities and allow them to become one and the same. Human fallibility and vulnerability cannot be erased because of experience.The elements below categorize error tryour company name. When these are managed, and kept in balance, we minimize human error. Task Demands, the mental and physical requirements to complete the job.Examples: Work Environment, the conditions present in the workplace that influence performance. Examples:Individual CapabilitiesExamples:Human NatureOur capabilities and natures vary from day to day, and over time. What we can easily do today, under a given set of task demands, may seem overwhelming tomorrow or next year. Examples:To reduce errors we must maintain a balance between Task Demands / Individual Capabilities, and Work Environment / Human Nature. Error-likely Situations exist when these factors are out of balance. Our chances for success are diminished. Our best defense against error-likely situations, and our opportunity to maximize our success, is during pre-job briefings. (Discussed later in this guide.) The Accident Prevention Manual (APM) contains specific information and guidance regarding pre-job briefings (listed as Tailboard Conferences in the APM.) TAPEPRINCIPLES OF HUMAN PERFORMANCE1.People are fallible, and even the best people make mistakes.Neither manager nor worker is immune. It is human nature to be imprecise and to err. 2.Error-likely situations are predictable, manageable, and preventable.Despite the inevitability of human error, specific errors are preventable. Recognizing error likely-situations and actively communicating these hazards to others permits us to manage situations proactively and prevent the occurrence of error and events.3.Individual behavior is influenced by organizational processes and anizations are goal-directed. Processes and values are developed to direct the behavior of the individuals in the organization. 4.People achieve high levels of performance largely because of the encouragement and reinforcement received from leaders, peers, and subordinates.All behavior, good and bad, is reinforced, whether by immediate consequences or by past experience. A behavior is reinforced by the consequences that individual experiences when the behavior occurs. Human performance is a function of behavior. What happens to workers when they exhibit certain behaviors is an important factor in improving human performance.5.Events can be avoided through an understanding of the reasons mistakes occur and application of the lessons learned from past events (or errors).Improving human performance has been the result of corrective actions derived from an analysis of past events. Learning from our past mistakes is reactive. Anticipating how an event or error can be prevented is proactive. Proactive methods provide a more effective means of preventing events and problems from developing.Human Performance Concepts and PrinciplesWhat is Human Performance?Performance refers to quantifiable results. Results, good or bad, are the outcomes of behavior. Human performance is a series of behaviors executed to accomplish specific task objectives (results). B + R = PBehavior is what people do and say—a means to an end. Behavior is an observable act that can be measured. If it can be measured, it can be changed. Simply put, human Performance is Behavior plus Results (B+R=P). Good results can be achieved with in the short term with questionable behavior. Consistent positive behavior is necessary for consistent long term positive results.No matter how efficiently equipment functions; how good the training, supervision, and procedures are; and how well the best worker or manager performs his or her duties, people cannot perform better than the organization supporting them. Human error is caused not only by normal human fallibility, but also by management and leadership practices and weak organizational processes and values.ActivityWrite an example of when you have seen behavior + result = performance. This can be positive or negative. Discuss with the group.Functions of DefenseA defense by definition is anything that provides at least one of these functions:Create Awareness – to develop understanding of the risks and hazards.Detect & warn – to identify the presence of an off-normal condition and/or imminent danger.Protect – to protect people and/or equipment from injury or damage.Recover – to restore the system/component from an off-normal condition to safe state.Contain – To contain the accidental release of harmful energy or substances. Examples: tank berms, piping and valves, Load Buster.Escape – to enable the removal of potential victims from the presence of out-of-control hazards.Defense in DepthThe multiple layers of redundant checks that balance, and mitigate, the human error introduced into the system are often referred to as defense in depth.We must always strive to create, and depend on, defense in depth. Defense in depth assumes that there will be a failure in the technology or human interface. Failure is minimized by redundant and diverse layers of defense.Taking steps to maintain the integrity of our defenses is an important element in supporting our goal of zero accidents. Concepts to ConsiderDefenses are put in place to balance human fallibility and vulnerability.Defenses are only as good as we make them. Error tolerant systems tend to conceal error, talk about errors that do not cause events. Allow others to benefit from your experience – self identify and share through discussions.Close Call reportingUse Operating ExperienceOne great thing about our business is that we have lots of protective layers. This is called, defense in depth. ActivityWhat does the defense in depth look like in a visual representation?_____________________ Discuss why that is a good representation. It is important to examine near misses and keep an open mind about defenses that may be flawed.Latent Organizational WeaknessesLatent Organizational weaknesses do not cause an immediate event; instead they render defenses ineffective. They can promote error-likely situations. Processes (structure)Control of workTrainingAccountability policyEquipment designProcess developmentHuman resourcesValues (relationships)PrioritiesMeasures & controlsCoaching & TeamworkRewards & SanctionsReinforcementApplying the PrinciplesCase StudyAs you watch the video, jot notes to aid in your discussion.Latent Organizational Weaknesses:Defenses:Values/Organizational Beliefs:Error Traps:Contributing factors (layers of responsibility):Performance Modes:Error Types:Human Performance ToolsError-Prevention Tools Self Checking S.T.A.R.Stop -- Is my attention focused on the task?Think -- What action am I about to perform?Act – Am I performing correctly?Review – Did I get the expected results? Peer Checking – Team S.T.A.RUse a second set of eyes to detect and correct.Both individuals actively participate in task performance.Use prior to the performance of critical tasks. 3-Way CommunicationHelps you verify that the correct information is transferred.Used during the execution of critical steps to formalize the communication.Repeat-back is required when obtaining a clearance or a switching order. (APM 12-2D)Regulatory requirement in certain situations.Safety sensitive activities Pre-job Briefings (AKA Tailboard Conferences)What is the task to be accomplished?Who is doing what?How will we communicate?What safety equipment do I need?What is the worst thing that could happen and how am I going to prevent it? STOP if UnsureIf you have a feeling something is not right – stop!If you are not positive of the course of action or the outcome of your actions – stop! Two-minute DrillProvides an opportunity to perform an at the workplace assessment.Use after a break or distraction.Helps to reset and verify work conditions.Provides a chance to assess changing workplace hazards. Questioning AttitudeChallenges Assumptions.Stimulates a healthy skepticism.Vigilance when things don’t seem right.Being open to challenges by others.Use when uncertain, confused, or doubtful. TurnoverInformation/awareness continuity.Accurate transfers.Transferring responsibilities.Over-communicate; don’t assume.Record information; ensure accuracy.Ask clarifying questions. Place KeepingPrevents step duplication or omission.Records step completed and yet to be performed.Use during Switching and Clearance procedures.Circle & Slash the step number, sign or initial a blank, or check a box. FlaggingCorrect equipment identification.Alerts others that equipment is unavailable.Shields components from inadvertent use.Used on similar-looking equipment.Mandates use of peer and self-checking.Remains in place until work is done. Phonetic AlphabetProvides understandable difference between letters.Use when letters might sound alike.Use in high noise areas.Use at times of poor radio/telephone reception. Conservative Decision MakingDeliberate and methodical.Clarifies goals and options.Planning.Resources and expertise.Minimize uncertainty.Facts only – challenge assumptions.Procedure Use and AdherenceUnderstand procedure intent and purpose.Follow directions.Perform all actions as written.Stop if procedure cannot be used as written.Procedure may be corrected before continuing.Expectation: frequent document use instead of memory/recall. Concurrent VerificationSeparate confirmation by two individuals.Error prevention on equipment status/condition changes.Independent conclusions by all parties.Verifier takes no cues from performer.Not peer checking. Post-job ReviewIdentifies what went well.Identifies potential improvements.Invites feedback from active participants.Identifies actual vs. planned outcome.Determines future changes in similar tasks.Reviews lessons learned.Management ToolsObservationsSelf-AssessmentsOperating ExperienceApplying the ToolsCase StudiesAs you watch the videos, jot notes to aid in your discussion.Situation One: How Valuable is Good Communication?Situation:Unused Tools:Situation Two: Little League FootballSituation:Unused Tools:Wrap UpBelow are some things I will do to improve my work performance that will help reduce the frequency and severity of errors and events:Human Performance Word SearchH K E V Q Y A H R E A C T I V E R U T A N F S D T S A V L A T E N T O V I Y C S E S S E C O R P F R E L L Y M D X X A P E R F O R M A N C E O E A X A I L A P S E P D E T E C T I O N I R E S U L T S P T U N I X M E R A O O U A D T S M S R S L I V L S I N O I T A C I N U M M O C U A M U T I H A R A I L I I S P N T N V T O V Y P B S C R B A L B E O N I N T E R D E P E N D E N C I E S L O U K L W G O B T A S E S D U R E I N F O R C E M E N T E A N G A E Z S D T I F Q M H T C P T N N S D R N E R O L P N I E I N S E V E R I T Y N E V E U E A K D I O A T N N C E L F C G S O P B O U I K M P C C S T Z C I A K T V A N S A P N L I C Q R O G O I A E A W C O G A A E A H S R R N O R L E O V N R F B S L W I N R E B I R E E U I O S C A S N O I T I D N O C D A O W L Y U V N O O I E F N N M R T E N E E I U E L N P E L E A E C R S S R O O E P A D G E F V L N F M A C N M C R N I I S E I C N E I C I F E D T T O O R T U A G A E T V I Q T K T O T K S H D B U C Y Y I H F E I W U I I M U A V I G I L A N C E R C A O S R O I V A H E B O E V V U L N E R A B L E Q N G E F A C T O R S Q T N I T A H I C Z A M I R H J T R D W I S P P R O A C T I V E C N A H C E R T N Y W T O L E R A N T I Y O H I X D E W A L F O I D E N N A L P T K E H H C M O D N A R I E V S R See next page for list of words to search for.AccidentActiveAnatomyAwarenessBehaviorsBeliefsCapabilitiesChanceCluesCommunicationComplianceConditionsConsequencesContributorsCultureDefensesDeficienciesDemandsDetectionEncouragementEnvironmentErrorEventsExpected CircumventionFactorsFallibleFeedbackFlawedFrequencyGoalsHumanInitiatingIntentionalInterdependenciesInterfaceInterventionLyour company nameeLatentMissesMistakeMotivationalNatureNonconsequentialNormsOrganizationalPerformancePlannedPredictablePreventionPrioritiesProactiveProcessesProvokeRandomReactiveReinforcementReliableResultsRewardsRootSeveritySignificantSituationSlipTolerantTryour company nameUnintentionalUnreportedValuesVigilanceViolationVisionVulnerableWeaknesses ................
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