HUMAN PERFORMANCE IMPROVEMENT HANDBOOK VOLUME 1: CONCEPTS AND ... - NERC

NOT MEASUREMENT SENSITIVE

DOE-HDBK-1028-2009

DOE STANDARD

HUMAN PERFORMANCE IMPROVEMENT HANDBOOK

VOLUME 1: CONCEPTS AND PRINCIPLES

U.S. Department of Energy Washington, D.C. 20585

AREA HFAC

DISTRIBUTION STATEMENT A. Approved for public release; distribution is unlimited.

Available on the Department of Energy Technical Standards Program Web site at

DOE-HDBK-1028-2009

VOLUME 1: CONCEPTS AND PRINCIPLES

PREFACE ....................................................................................................................... v Reading The Handbook ............................................................................................... vi

CHAPTER 1 - INTRODUCTION TO HUMAN PERFORMANCE..............1-1

OVERVIEW.................................................................................................................. 1-1 Perspective on Human Performance and Events................................................ 1-10 Human Performance for Engineers and Knowledge Workers ............................. 1-11 The Work Place................................................................................................... 1-11 Individuals, Leaders, and Organizations ............................................................. 1-12

HUMAN PERFORMANCE......................................................................................... 1-12 Behavior .............................................................................................................. 1-13

ANATOMY OF AN EVENT ........................................................................................ 1-14 Event ...................................................................................................................1-14 Initiating Action.................................................................................................... 1-14 Flawed Controls .................................................................................................. 1-15 Error Precursors.................................................................................................. 1-15 Latent Organizational Weaknesses..................................................................... 1-15

STRATEGIC APPROACH FOR HUMAN PERFORMANCE ..................................... 1-16 Reducing Error .................................................................................................... 1-16 Managing Controls .............................................................................................. 1-17

PRINCIPLES OF HUMAN PERFORMANCE ............................................................ 1-19 REFERENCES........................................................................................................... 1-21

CHAPTER 2 - REDUCING ERROR .........................................................2-1

HUMAN FALLIBILITY (Essential Reading) ............................................................... 2-1 Common Traps of Human Nature ......................................................................... 2-1 Unsafe Attitudes and At-Risk Behaviors ............................................................... 2-4 Slips, Lapses, Mistakes, Errors and Violations...................................................... 2-8 Active Errors.......................................................................................................... 2-8 Latent Errors ......................................................................................................... 2-9 Violations............................................................................................................. 2-10 Dependency and Team Errors ............................................................................ 2-11 Equipment Dependencies ................................................................................... 2-11

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DOE-HDBK-1028-2009

Team Errors ........................................................................................................ 2-12 Personal Dependencies ...................................................................................... 2-15 PERFORMANCE MODES (Essential Reading) ....................................................... 2-16 Information Processing, Memory, and Attention.................................................. 2-16 Generic Error Model System (GEMS) ................................................................. 2-20 Skill-Based Performance..................................................................................... 2-21 Examples of Skill-Based Activities ...................................................................... 2-22 Skill-Based Error Mode ? Inattention................................................................... 2-22 Rule-Based Performance .................................................................................... 2-23 Examples of Rule-Based Activities...................................................................... 2-23 Rule-Based Error Mode ...................................................................................... 2-24 Knowledge-Based Performance.......................................................................... 2-25 Examples of Knowledge-Based Activities ........................................................... 2-26 Knowledge-Based Error Mode ............................................................................ 2-26 How Performance Modes Can be Used .............................................................. 2-27 Mental Models.....................................................................................................2-28 Assumptions........................................................................................................ 2-29 Mental Biases ? Shortcuts................................................................................... 2-29 Conservative Decisions....................................................................................... 2-30 ERROR-LIKELY SITUATIONS (Essential Reading)................................................ 2-30 Error Precursors.................................................................................................. 2-31 Common Error Precursors .................................................................................. 2-32 ERROR-PREVENTION TOOLS.......................................................................... 2-33 ATTACHMENT A ? ERROR PRECURSORS............................................................ 2-35 ATTACHMENT B ? COMMON ERROR-PRECURSOR DESCRIPTIONS ................ 2-39 REFERENCES........................................................................................................... 2-45

CHAPTER 3 - MANAGING CONTROLS .................................................3-1

Controls................................................................................................................. 3-1 Severity of Events ................................................................................................. 3-3 The Organization's Role in Controls...................................................................... 3-3 Defense Functions ................................................................................................ 3-4 Reliability of Controls ............................................................................................ 3-4 DEFENSE-IN-DEPTH .................................................................................................. 3-5 Engineered Controls ............................................................................................. 3-5 Administrative Controls ......................................................................................... 3-6 Cultural Controls ? Values, Beliefs, Attitudes ........................................................ 3-8

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DOE-HDBK-1028-2009

Work Group Norms ............................................................................................... 3-9 Leadership Practices........................................................................................... 3-10 Common Flaws with Cultural Controls ................................................................ 3-10 Oversight Controls .............................................................................................. 3-10 Senior Management Team Focus on Human Performance ................................ 3-11 Performance Improvement Processes ................................................................ 3-11 Human Performance Improvement Plans ........................................................... 3-12 PERFORMANCE MODEL ......................................................................................... 3-12 Organizational Effectiveness............................................................................... 3-13 Organizational Factors ........................................................................................ 3-14 Job-Site Conditions ............................................................................................. 3-14 Worker Behaviors................................................................................................ 3-15 Plant Results ....................................................................................................... 3-15 MANAGING CONTROLS ? PERFORMANCE IMPROVEMENT MODEL................. 3-15 METHODS (Tools) FOR FINDING LATENT ORGANIZATIONAL CONDITIONS .... 3-17 Self-Assessments ............................................................................................... 3-18 Behavior Observations ........................................................................................ 3-18 Problem Reporting .............................................................................................. 3-19 Benchmarking ..................................................................................................... 3-19 Performance Indicators and Trending ................................................................. 3-20 Operating Experience ......................................................................................... 3-20 Independent Oversight ........................................................................................ 3-21 Problem Analysis ................................................................................................ 3-22 Management Oversight ....................................................................................... 3-23 Surveys and Questionnaires ............................................................................... 3-23 Corrective Action Program .................................................................................. 3-23 Change Management.......................................................................................... 3-24 APPENDIX A: WARNING FLAGS--FACTORS THAT DEFEAT CONTROLS ......... 3-25 REFERENCES........................................................................................................... 3-27

CHAPTER 4 - CULTURE AND LEADERSHIP ........................................4-1

ORGANIZATIONAL CULTURE................................................................................... 4-1 SAFETY CULTURE .....................................................................................................4-2

How Organizations Process Information ............................................................... 4-5 LEADERSHIP ............................................................................................................ 4-11

Leader's Role ...................................................................................................... 4-11 Production and Prevention: Competing Purposes............................................... 4-12

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