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Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Human Performance
P = B + R
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
What is the “Next Level” we hear so much about?
Courtesy of OSHA Training Institute, Des Plaines, IL
“You keep using those words but I do not think they mean what you think they mean…”
Aneigo Montoya, Princess Bride
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Generations of Levels
First Level
Trailing Indicators
OSHA 300 Logs
EMRsCourtesy of OSHA Training Institute, Des Plaines, IL
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Generations of Levels
Second Level
Weighted Audits, Surveys & Observations
Systems can be sided by their own terms
Courtesy of OSHA Training Institute, Des Plaines, IL
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Generations of Levels
Third Level
Predictive Audits (Risk Rating)
Combination of weighted audits, surveys & observations to provide a set of risks likely to result in events.
Courtesy of OSHA Training Institute, Des Plaines, IL
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Generations of Levels
Next Level
Based on Aristotle
“We are what we repeatedly do, Excellence, then, is not an act but a habit.”
Courtesy of OSHA Training Institute, Des Plaines, IL
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Generations of Levels
Next Level
To understand, we have a formula:
Given P = B + R, then Re + Md → ᴓE
Courtesy of OSHA Training Institute, Des Plaines, IL
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Human Error is normal
It is provoked by conflicting management &
leadership priorities and by weakness in the
organization, processes and culture.
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Behavior can be seen and heard
Results are measureable
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Human Performance
We must look at what is an accident or event .
What is it?
Injury?
Near Miss?
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Human Performance
Cutting plastic sheeting with a knife.
Standing too close.
Girl Scouts Know Better!
First time
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Human Performance
Cutting plastic sheeting with a knife.
Standing too close.
Girl Scouts Know Better!
Second time
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Human Performance
Cutting plastic sheeting with a knife.
Standing too close.
Girl Scouts Know Better!
Third time
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Human Performance
The Accident or Event is the action which may or may not result in injury.
The Initiating Action was based on a choice, a human choice. Choice was
manifested in Behavior. The measurable Result was observable.
P = B + R
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Human Performance
How many of these choices might be made by a human in your
organization?
How many are bad choices (errors)?
How many do we make in a minute?
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Human Performance
How many do we make in hour?
How many in a week?
How many in a year?
By how many employees?
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Human Performance
How many do we make in hour?
How many in a week?
How many in a year?
By how many employees?
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Human Performance
How many, statistically, will be bad choices?
(errors)
How many may result in serious injury?
What about acts of God?
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
EventsCauses:
Image courtesy of INPO
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Reducing Error
Re
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Common Traps of Human Nature
StressMental Strain Avoidance
Assumptions HabitConfirmation BiasSimilarity
BiasFrequency Bias
Availability BiasLimited Perspective Fatigue
Motivated Toward Goal AccomplishmentDifficulty Seeing One’s Own Error
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Common Traps of Human Nature
Pride Hero
Fatalistic Summit Fever
Invulnerability Pollyanna
Bald Tire
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Slips, Lapses, Mistakes and Errors
People tend not to err intentionally.
Line employees tend to make Active Errors – have an immediate effect
Managers tend to have Latent Errors-have a delayed effect
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Violations
Why?
Low detection potential No Boss aroundPeer pressure Not correctedPerceived authority Boss doesn’t careConflicting demandsCompetitionLack of training Precedent
Emulation of role models!!!!!!!
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Violations
People sometimes violate procedures, for evil or for good.
Honest intent to deviate from procedure to achieve a greater good
Hostile acts (over time, good intentioned deviation may become hostile)
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Fundamental Prevention Tools
Situational Awareness Task Preview
Pre-job Briefing Peer-Checking
Questioning Attitude Flagging
Procedure Use Placekeeping
3-way Communication Phonetic Alphabet
Validate Assumptions Signature
Concurrent Verification (Honey Do’s)
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Positive Control
Many errors can be accounted for if an employee has positive control of their tool or work situation.
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Clear Expectations for HU Tools
Specific
Observable
Objective
Doable
Active
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Critical Steps
Used to prepare for a work activity
Summarize the critical steps
Anticipate errors for each critical step
Foresee probable results of error for each step
Evaluate controls at each critical step
Review previous experience and lessons learned to each critical step
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Competence vs. Control
Respecting Human Fallibility
Positive Control means what is intended to happen is what happens, and that is all that happens.
Built in checks are not an accusation on competence!
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
At-Risk Practices
Basic Safety Risks
First and Second Level Generation Items
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Selecting and Adapting HU Tools
See:
Human Performance Tools, November, 2007; Department of Energy
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Work Execution
Work Preparation
Work Performance
Work Feedback
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Managing Defenses
Md
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Defense-In-Depth
Engineering Controls
Administrative Controls
Cultural Controls
Oversight Controls
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Managing Defenses
Plan
Do
Check
Adjust
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Beware of Latent Errors
They do not fade away, they collect!
“Liberation and mobilization of human energies-rather than symmetry and harmony-constitute the purposes of organization. Human performance is its goal and its test.”
Peter Drucker
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Finding & Correcting Latent Weakness
Self-assessmentsKPIs & TrendingBenchmarkingIndependent OversightBehavior ObservationsProblem ReportingCausal AnalysisManagement OversightSurveys & QuestionnairesCorrective Action ProgramChange Management
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Performance Model w/ Defenses
Image courtesy of INPO
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Results in and of a Zero Event Culture
→ ᴓE
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Safety Culture
Must cultivate a Questioning Attitude!
Events often result from a shared assumption, value and/or belief of the organization.
All must be watchful and question the established culture at all times.
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Leadership
ANY individual who takes personal responsibility for his or her performance as well as the organization's performance AND attempts to influence the improvement of the organization that supports that performance.
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Key Leadership Practices
Facilitate open communication
Promote Team Work
Reinforce desired behavior, appropriately
Eliminate Latent organizational weakness
Value prevention of errors
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
HU Fundamentals
1. People are fallible, and even the best people make mistakes
2. Error likely situations are predictable, manageable, and preventable
3. Individual behaviors are influenced by organizational processes and values
4. People achieve high levels of performance largely because of the encouragement received from leaders, peers, and subordinates.
5. Events can be avoided through an understanding of the reasons mistakes occur and application of the reasons learned from past
events (or error).
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Resources
Human Performance Reference Manual, Oct., 2006: Institute of Nuclear Power Operations (INPO).
Human Performance Tools: For Individuals, Work Teams, and Management, Nov., 2007: Department of Energy, Human Performance Center.
Instructor Notes
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPCIP
Re + Md → ᴓE
Pete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIPPete Engelbert, CSP, RPIH, CHST, CET, CIT, CSSM, CIP
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