# Presentation: 700217

## Whole Brain ThinkingFor Future Leaders  

**T. Shane Bush **

## 1.	Leadership Attributes

- 1.	Leadership Attributes
- 2.	Human Performance
-    	Fundamentals
- 3.	Becoming a Leader in
- 	Human Performance

## Slide 3

## 2010

-     2.4 billion/yr on candles
-     4 billion downloading ring tones
-     GM, Art, entertainment and mobile sculpture,
-     13% homes purchased were 2nd homes
-     17 billion self storage
-     Trash bags (90 other countries Everything)

- We Live in a World of Abundance

## CEREBRAL

**CEREBRAL**

**RIGHT**

**LEFT**

- Analytical
- Math
- Compliance
- Regulated
- Mandatory
- Text
- Logical
- Factual

- Creative
- Synergistic
- Imaginative
- Holistic
- Contextual
- Futuristic
- Intuitive
- Feelings

## Whole Brain ThinkingFor the Future of Leadership 

**Whole Brain Thinking****For the Future of Leadership **

**Human Performance****Safety Leadership **

## Leaders Challenge: Identifying what factors affect people performance

- By permission of
- Jerry Harbour

## A Simple Model

- Performance *outcome* Y is a
- function of *factors* X.

**Performance**
**Outcome**

**Factors Affecting**
**Outcome Y**

**Y = *****f***** (x)**

- By permission of
- Jerry Harbour

## Are People a Critical X?

- By permission of
- Jerry Harbour

## Tangible vs. Intangible Assets

**%**

**Source: Blair and Cochran, 2001**

**17%**

**69%**

**83%**

**31%**

## Y = f (x1, x2, x3, x4, x5, ... xn) 

**Positive effect on y**

**Little or no effect on y**

**The real challenge is to identify those factors**
** ****that do **_**and**_** don’t drive performance.**

**Negative effect on y**

- By Permission of
- Dr. Jerry Harbour

## 	“In order to identify the elusive recipe for outstanding leadership, we have reviewed data ranging from leaders neurology to measures of the emotional climate that a leader creates.”  Outstanding leaders seem to have one common characteristic trait........
						Daniel Goleman, Ph.D
						Richard Boyatzis, Ph.D
						Annie McKee, Ph.D

- 						Daniel Goleman, Ph.D
- 						Richard Boyatzis, Ph.D
- 						Annie McKee, Ph.D

## What are the top 3 or 4 

- Attributes of a great leader
- you have worked for?

## Emotional Intelligence

- What is Emotional Intelligence?

- An adeptness at managing ourselves
- and our interactions with others.
- It is _HOW_ to Lead......

## Most of the material on successful leaders seem to capture three reoccurring principles on what to lead...

- 1.Set expectations
- Assess performance
- Reinforce behaviors
-           (What)

- Set expectations
- Assess performance
- Reinforce behaviors
-              (What)

- Emotional
- Intelligence
-    (How)

- +

- Leadership

- =

- The true measure of Leadership is.....

- Influence!

- Nothing More, Nothing Less.

## Fundamental Techniques in 

- The big secret of dealing with people

*Fundamental Techniques in *
*Handling People*

**If you want to gather honey, **
**don’t kick over the beehive**

## Gettysburg, 

- If you want to gather honey, don’t kick over the beehive

*Fundamental Techniques in *
*Handling People*

- Gettysburg,
- July 4, 1863
- General Lee
- General Meade

## Fundamental Techniques in 

- If you want to gather honey, don’t kick over the beehive

*Fundamental Techniques in *
*Handling People*

- “My Dear General,
- I do not believe you appreciate the magnitude of the misfortune involved in Lees escape.  He was within our easy grasp, and to have closed upon him would, in connection with our other late successes, have ended the  war.  As it is, the war will be prolonged indefinitely.  If you could not safely attack Lee last Monday, how can you possibly do so south of the river, when you can take with you very few – no more than two-thirds of the force you then had in hand?  It would be unreasonable to expect that you can now effect much.  Your golden opportunity is gone, and I am distressed immeasurably because of it”
- 						Abraham Lincoln

## If you have a topic for the new HSE news, we would like

- to hear from you.  Contact us at jdrake@ABC.org

- Mr. Drake,
- I would like to submit an article about Human Performance .....
- Sincerely, Timothy Shane Bush

- Tim,
- Thanks for your interest.  I will forward your note to the appropriate
- folks.
- Jane _MISS_ Drake!

- Miss Drake,
- I apologize for assuming.  By the way I go by _SHANE_.

## Fundamental Techniques in 

- The big secret of dealing with people

*Fundamental Techniques in *
*Handling People*

- “Everyone has a desire to feel important”
- 				Dr. John Dewey
- 				Dr. Sigmund Freud

- “This desire makes us want to wear the latest styles,
- drive the latest cars, and talk about our brilliant
- children.”				Dale Carnegie

## Fundamental Techniques in 

- The big secret of dealing with people

*Fundamental Techniques in *
*Handling People*

- Why would Dillinger announce who he was?

- Who Wanted to be Called;

- “His Mightiness, the President of the United States”

- Washington

- “Admiral of the Ocean and Viceroy of India”

- Columbus

- “Her Imperial Majesty”

- Catherine the Great

- “DOE Human Performance GuRu”

- Shane Bush

## Whole Brain Leadership

**Whole Brain Leadership**

**RIGHT**
**(How)**

**LEFT**
**(What)**

**1. Set Expectations**
**2. Assess Performance**
**3. Reinforce Behaviors**

**	****An adeptness at**
**	****managing ourselves**
**	****and our interactions**
**	****with others**

## Human Performance ImprovementA New Way of Thinking!

- Leaders are challenged to “detect the undetected”.
- Traditional walkabouts and assessments will not detect Latent Conditions.

**Illustration from:** *The Field Guide to Human Error Investigations*

- X

- Context

## Slide 27

## Active + Latent Factors = Adverse Event

**X247685WTZ**

**Active + Latent Factors = Adverse Event**

**Is this really just human error – inattention to detail?**

- By permission of
- Jerry Harbour

## Why a Human Performance Improvement Approach?

**80% Human Error**

**30% **
**Individual**** **

**20% Equipment Failures**

**   ****Human Errors**

**Occurrences**

**70% Latent Organization Weaknesses**

## Anatomy of an Event

**Notes:**
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.  

## Principles

*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.

## Just Culture

- Culpability

- Account for ones Actions or Behaviors

- Worthy of Blame

- _Just Culture_

## Two Kinds of Error

**(leading to latent conditions)**

**Notes:**
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

## Strategic Approach

- Anticipate and prevent active error (Re) at the job-site.
- Identify and eliminate latent organizational weaknesses (Md).

**R****e**** + M****d**** ******** ØE**

**Notes:**
These statements represent the goals we are headed for in this industry and with this training. 

## Stuff You Need to Know

_**Stuff You Need to Know**_

*Adverse events* are those events with real or potential negative consequences.
*Latent factors* are those “set-up” factors present prior to an adverse event.  Latent factors induce *vulnerability* into a system.
*Active factors* are those triggering, forcing, or initiating factors.  They “exploit” latent factors.
*Exacerbating factors* are those factors that made the consequences as bad as they were.
*Mitigating factors* are those factors that tend to keep the consequences from being more severe than they actually could have been.

**Adverse Event**
**Consequence**

**Exacerbating**
**Factors**

**Mitigating**
**Factors**

**+**

**Latent**
**Factors**

**Active**
**Factors**

**+**

**+**

- By permission of
- Jerry Harbour

## Two Views of Human Error

- The Old View of Human Error

- Human error is the cause of accidents
- To explain failure, you must seek failure.
- You must find people’s inaccurate assessments, wrong decisions, bad judgments

- The New View of Human Error

- Human error is a symptom of trouble deeper inside a system
- To explain failure, do not try to find where people went wrong.
- Instead, find how people’s assessments and actions made sense at the time, given the circumstances that surround them

- Dekker, 2002

**Notes:**
The Field Guide will encourage you to build a picture of
How a process and other circumstances unfolded around people
How peoples assessments and actions evolved in parralel with their changing situations
How features of peoples tools and tasks and organizational and operational environment influenced their assessments and actions

- Human Performance Simulator

- Distractions

- Time Pressure

- Latent Organizational Weaknesses

- Error Traps

- Confusing
- Displays

- Re + Md = 0

- Error
- Precursors

- Active
- Errors

- Latent
- Errors

- Critical
- Steps

## Latent Conditions: 

- Latent conditions are undetected deficiencies
- in processes or values that create work place
- conditions that either provoke error or degrade
- the integrity of defenses.

**Management Assessments and Observations should**
**be all about the Latent Conditions!**

## 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 |

## Inattention to Details

- Vs
- Loss of Situational
- Awareness

## Limitations of Human Nature

- Avoidance of _mental strain_
- Inaccurate _mental models_
- Limited working _memory_
- Limited _attention_ resources
- _Pollyanna_ effect
- Mind _set_
- Difficulty _seeing_ own errors
- Limited _perspective_
- Susceptible to _emotion_
- Focus on _goal_

**Notes:**
These characteristics of human nature, among many others, are encountered whenever people perform complex tasks in a complex work environment.  Consequently, there is always the chance for error.

See the quotation in the desk reference Page _______

“Safety is a continuous fight with human nature.”
Dr. E. Scott Geller
Author: The Psychology of Safety

## Error Precursors

- Error Precursors

**OOS – out of service**

**Notes:**
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

## Performance Modes

- Source: James Reason. *Managing the Risks **of Organizational Accidents*, 1998.

**Notes:**
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, 1998. The information in the book is very helpful in teaching Human Performance, as is this slide.       2. 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 .9999 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, p113-115)
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.

## 
Defenses

Hard - 

Soft -

- _Defenses_
- Hard -
- Soft -

- (Defenses must be evaluated within ‘Context’)

**Notes:**
Most defensive functions are achieved through a combination of hard and soft defenses.
Hard defenses are Engineered safety functions, barriers, alarms, interlocks, etc.
Soft defenses are usually a combination of paper and people:Legislation, procedures, licensing, oversight,

In the early days workers involvement was mainly productive – they made or did things, that led directly to commercial profit.  And thus were directly in contact with hazards.
Now computers and technology have changed the workers involvement to that of  planners, managers, maintainers of systems and processes.  Ie operators, pilots, and removed them in a lot of cases from being directly involved with the hazards.

This results in defense in depth which is a mixed blessing.  This makes the system more complex and Opaque.

This results in the build up of latent conditions.

##  Chapter III
Dangerous Defenses

-  _Chapter III_
- Dangerous Defenses

**Notes:**
Can you have too many defenses?

What does it mean for them to become Opaque?

What is the number one thing to be cautious of when contemplating a defense?
Pose a case to the class.

## Regulators
Damned if they do and Damned if they Don’t 

Workload increased, resources slashed
Accused of being to close to the client, while the client see’s them as intrusive and obstructive
Accused of not being familiar with the operations,  but depend upon the client for this information
Usually technical specialists, while most accidents are due to the interaction between human and organizational factors

- _Regulators_
- _Damned if they do and Damned if they Don’t_
**Workload increased, resources slashed**
**Accused of being to close to the client, while the client see’s them as intrusive and obstructive**
**Accused of not being familiar with the operations,  but depend upon the client for this information**
**Usually technical specialists, while most accidents are due to the interaction between human and organizational factors**

## Contractor vs DOEPerspective  

**1. Color of dots........**
**2. Yellow dots disappearing**
**3. Color of Moons**
**4. Red up, Green Down**
**5. Yellow or Blue Dots moving?**

- Contractor vs DOEPerspective

## Re + Md = 0

- Major

- Minor

- First Aid

- Close Calls/Near Miss (hit)

- At-Risk Behavior
- Errors/Mistakes

- 5 errors/hr

## Victims of our Own Success

- Major

- Minor

- First Aid

- Close Calls
- Near Miss

- At-Risk Behavior
- Errors/Mistakes

## Major

- Minor

- First Aid

- Close Calls
- Near Miss

- At-Risk Behavior
- Errors/Mistakes

- Total Recordables
- Day Away Case Rate

- Error rates, Error Precursors,
- Latent Errors, LOW's, Critical Steps,
- Performance Modes, P+ - N- ratio,
- HPI Defenses, Critical Steps,

- Heart Attack?