Human Performance Fundamentals 4 Hour Human Performance Fundamentals
- Slides: 23
Human Performance Fundamentals 4 Hour Human Performance Fundamentals T. Shane Bush (208) 221 -9378 2020 Stosich Lane Idaho Falls, ID 83402 Bush. Co@cableone. net Bush. Co
Purpose of Course To proactively prevent “Unwanted Outcomes” triggered by human error. Unwanted Outcomes
Part I: Why a Human Performance Improvement Approach? Human Errors Occurrences 70% Latent Organization Weaknesses 80% Human Error 20% Equipment Failures 30% Individual
Industry Event Causes due to human performance 806 = Individual behavior (32%) 1, 676 = Org behavior (68%)
Facts about Human Error • It thrives in every industry • It is a major contributor to events and unwanted outcomes • It is costly, adverse to safety and hinders productivity • The greatest cause of human error is weaknesses in the organization, not lack of skill or knowledge • Error rates can never be reduced to zero • Consequences of errors can be eliminated
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.
MEDICAL ERRORS AND MISTAKES
Error Precursors short list Task Demands • Time pressure (in a hurry) • High Workload (memory requirements) • Simultaneous, multiple tasks • Repetitive actions, monotonous • Irrecoverable acts • Interpretation requirements • Unclear goals, roles, & responsibilities • Lack of or unclear standards Work Environment • Distractions / Interruptions • Changes / Departures from routine • Confusing displays or controls • Workarounds / OOS instruments • Hidden system response • Unexpected equipment conditions • Lack of alternative indication • Personality conflicts Individual Capabilities • Unfamiliarity w/ task / First time • Lack of knowledge (mental model) • New technique not used before • Imprecise communication habits • Lack of proficiency / Inexperience • Indistinct problem-solving skills • “Hazardous” attitude for critical task • Illness / Fatigue Human Nature • Stress (limits attention) • Habit patterns • Assumptions (inaccurate mental picture) • Complacency / Overconfidence • Mindset (“tuned” to see) • Inaccurate risk perception (Pollyanna) • Mental shortcuts (biases) • Limited short-term memory
Individual Plant Worker Processes Values
Limitations of Human Nature v Avoidance of mental strain v Inaccurate mental models v Limited working memory v Limited attention resources v Pollyanna effect v Mind set v Difficulty seeing own errors v Limited perspective v Susceptible to emotion v Focus on goal
Finished Files are the Result of Years of Scientific Study Combined With the Experience of Many Years.
Human Information Processing Shared Attention Resources Sensing Information Flow Path Thinking Acting Source: Wickens, 1992
Two Kinds of Error Active Error Latent Error
Human Performance Types of Errors Active Errors Latent Errors Who? Workers Managers, Engineers, Workers What? Equipment Paper, values, and beliefs When? Immediate Later or delayed Visible? Yes No
Culpability Decision Tree g, j,
Air Ontario Flight 363 Fokker F 28 Dryden, Canada March 10, 1989
Leadership
Performance Modes--Attending Problems Pa wl Attention (to task) tte ed rns ge -B Inaccurate Mental Picture as ed Ru le If - Misinterpretation Ba Th en se d Sk ill- Inattention Au to Ba se d Low Familiarity (w/ task) High Source: James Reason. Managing the Risks of Organizational Accidents, 1998. Kn o High
The Blame Cycle Human Error More flawed defenses & error precursors Latent organizational weaknesses persist Individual counseled and/or disciplined Blame Cycle Management less aware of jobsite conditions Reduced trust Less communication
Patterns of Failure At a particular moment in time, behavior that does not live up to some standard may look like complacency or negligence. But deviance may have become the new norm across an entire operation or organization. Illustration from: The Field Guide to Human Error Investigations
Human Performance Tools • • • Critical Steps Enhanced Pre-Job Briefing Peer Check Self Check Independent Verification Error Traps Just Culture Effective Communication Questioning Attitude Feeling of Uneasiness • • • Enhanced Turnover 3 way communication Error Precursors Performance/Error Modes Devils Advocate Place keeping Poka Yoke SAFE Dialogue Discovery Clock STAR Training
What is the Organizations Role? • Support the Education and Implementation of the HPI process • Encourage Accountability and the Development of a Just Culture • Encourage the use of the HPI tools What are the Employee’s Responsibilities? • Have a Questioning Attitude • Develop a strong sense of Accountability • Use of the HPI tools, Use the HPI tools
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