# Presentation: 484773

## Richland Human Performance Improvement/FR Perspective

**Mat Irwin**
**Facility Representative T/L, DOE-RL**
**2007 Facility Representative Workshop**

## Principles of Human Performance

***Principles ******of Human Performance***

**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.**

## Slide 3

**Notes:**
80% of events are due to human error with 70% of those (56% total) were attributed to latent organizational weaknesses and 30% to individual error

## Error Rate

- In executing behaviors, human beings make mistakes  .......
- at an average error rate of 5/hour.
- These errors are unintentional.
- Most errors have no consequence.

## All Facility Representatives provided with 8 hour introductory training and 4-day practitioner training to establish baseline knowledge consistent with contractor

FR participation in HPI skits to foster applied knowledge

Select FR participation in HPI investigation approach

**All Facility Representatives provided with 8 hour introductory training and 4-day practitioner training to establish baseline knowledge consistent with contractor**
**FR participation in HPI skits to foster applied knowledge**
**Select FR participation in HPI investigation approach**

## Use of 4 Key Questions

Incorporation of Safety Conscious Work Environment into Lines of Inquiry

Use of HPI feedback (e.g. critical steps, error precursors, barriers) in FR feedback

Positive reinforcement for conservative reporting and resolution of organizational weaknesses

**Incorporation of Safety Conscious Work Environment into Lines of Inquiry**
**Use of HPI feedback (e.g. critical steps, error precursors, barriers) in FR feedback**
**Positive reinforcement for conservative reporting and resolution of organizational weaknesses**

* **FR Integration of HPI Tools*

**Notes:**
Initial RL approach to be aware of error precursors and identify them when observed during prejob meetings, during performance of work, during investigations.
Start looking at functional areas (self-assessment, pre-jobs, procedures/critical steps, event investigation) and provide informal reinforcement to foster HPI evolution.  Examples include:
Contractor Fostering the adoption of error precursors into self-assessment procedures
Contractor Revising the procedure definitions to be consistent with Human Performance

## Routine FR use of Four Key Questions

**What are the critical steps or phases of this task?**
**How can we make a mistake at that point?**
**What is the worst thing that can go wrong?**
**What barriers or defenses are needed?**

## Four Key Question Results

**Embraced by contractor**
**Improved average performance of prejob information exchange**
**Identification of error precursors/issues to consider that were historically not consistently discussed**
**Observed increase and quality of worker feedback **

## Root Cause – From Outside of the Event

***Root Cause – From Outside of the Event***
- If they had not done “A” or B”, then the event would have been prevented –

- HPI – From Inside of the Event
- Follow the process as it was implemented and look for error-likely situations that, if error-prevention tools were applied, the outcome of this, and other events, could be prevented – Why did the actions taken make sense to the people implementing them?

- A

- B

**Notes:**
Hindsight is typically 20/20 to those who were not directly involved in the event.  How could they be so dumb.
In order to successfully identify latent organizational weaknesses, it is critical to understand the “context” of the people involved.  Why did the decisions make sense to them at the time?
In the immortal words of Shane Bush, Strive to understand why it sucked to be them. 
Standard event investigation
Review from hindsight point of view – judging each critical step in view of the final outcome
Investigate to find where personnel went wrong 
Often look at events as a problem with people, procedures and training
HPI event investigation
Review from the perspective of the people involved in the event (context)
Evaluate the organization as event unfolds 
The event is the effect or symptom of deeper trouble in the organization, thus not random

## HPI Event Investigation Process

**Have participants tell the story of the event from their point of view (one-on-one interviews)**
**Identify (together with the participant) the critical junctures in the sequence of events**
**Rebuild the world as it looked to participants at each juncture**
**What did the participant observe?**
**What knowledge was used to deal with the situation?**
**What did the participants expect was going to happen?**
**What options did the participants think they had?**
**How did other influences effect their decisions?**

**Notes:**
Add Slides on investigation techniques
Add Slide of interview questions
FR benefits of the techniques

## Validate critical elements of the participants’ story to distinguish fact from opinion

Reconstruct the sequence of events (this is where event investigation typically starts)

Evaluate the performance of the organization at each critical juncture of the sequence

**Reconstruct the sequence of events (this is where event investigation typically starts)**
**Evaluate the performance of the organization at each critical juncture of the sequence**

**HPI Event Investigation Process Cont.**

## HPI Event Prevention Approach

**Primary elements are similar**
**Focus tends to look at the management system for error-likely situations and critical steps**
**No “root cause”****—****identify multiple causes that lined up to allow for the active error to trigger the event.**
**Evaluate each part of the management system that allowed for the event.**
**Look at the entire management system**
**To do otherwise risks creating a new hole in the system**
**Identify corrective actions to reduce consequence of human error**
**“****plug” the holes in each management system barrier**

## Root Cause Analysis vs HPI

| Cause
Analysis | Attributes | HPI 
Analysis |
| --- | --- | --- |
| X | Identify deltas between process expectations and actual event | X |
| X | Explore why the deltas occurred | X |
| X | Identify the causes to the deltas | X |
| X | Develop fixes (corrective actions) to break the cause and effect relationship (prevent recurrence). | X |
| X | Focuses on deficiencies that can be shown to have a cause and effect relationship to actual event |  |
|  | Identifies error-likely situations that can lead to future events | X |
|  | Applies error-prevention tools to reduce likelihood of future errors or the consequence of the error | X |

## HPI investigation approach has been applied to select events to supplement traditional investigation in the following three ways:
FR oversight of contractor performance of HPI investigation (most common)
FR participation with investigation team to supplement completed or in progress contractor investigation (more serious events)
FR leadership of independent team to investigate single or multiple events that imply need to identify organizational weaknesses

**FR oversight of contractor performance of HPI investigation (most common)**
**FR participation with investigation team to supplement completed or in progress contractor investigation (more serious events)**
**FR leadership of independent team to investigate single or multiple events that imply need to identify organizational weaknesses**

*FR Implications*

## Acknowledge and foster conservative reporting

HPI reinforcement through site policy and presentations/awards

DOE/Contractor alignment of metrics/POMCs with HPI

Promotion of culpability matrix and corresponding just culture

**Acknowledge and foster conservative reporting**
**HPI reinforcement through site policy and presentations/awards**
**DOE/Contractor alignment of metrics/POMCs with HPI**
**Promotion of culpability matrix and corresponding just culture**

## Culpability Evaluation Flowchart

- Were actions as intended?

- Knowingly violate expectation?

- Pass substitution test?
- (see note)

- History of human performance problems?

- Were expectations reasonable, available, workable, intelligible, and correct?

- Were the consequences intended?

- Deficiencies in training and selection or inexperience?

- Self-Reported

- Organization induced violation

- System induced error

- Blameless error

***Intentional act (not an error)***

***Corrective training or other intervention may be warranted***

***Possible reckless violation***

***Possible negligent error***

- Yes

- Yes

- Yes

- Yes

- Yes

- Yes

- No

- No

- No

- Yes

**Note:  Would other employees have made the same error?**

***Evaluate organizational processes and management/supervisory methods***

- No

- No

- No

- Yes

**Notes:**
Recognition of the need to foster a just culture and the fact that majority of errors are due to latent org weakneses and not intentional errors

## Continue to remain uninvolved in disciplinary action of personnel

Foster use of culpability matrix/substitution test to encourage identification of latent organizational weaknesses

Positive reinforcement of the identification and resolution of these issues

**Continue to remain uninvolved in disciplinary action of personnel**
**Foster use of culpability matrix/substitution test to encourage identification of latent organizational weaknesses**
**Positive reinforcement of the identification and resolution of these issues**

## Conclusion

**HPI provides a tool that complements and consolidates ISMS/VPP/Conduct of Operations/QA **
**HPI provides logical recognition of human potential for error that can be communicated and implemented across a broad audience**
**HPI provides error precursor techniques to identify and address leading indicators**