# Presentation: 030717

## Human Performance Improvement

- Brian Harkins
- Office of River Protection

## 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

## Human Error

- To err or not to err is NOT the question -- we will err!

*People do not operate in a vacuum, where they can decide and act all-powerfully.  *
*To err or not to err is not a choice.  Instead, people's work is subject to and constrained by multiple factors.*
- 				-- Sidney Dekker

## Proactive Mental Framework

***Proactive Mental Framework***

## Existing conditions that increase human error rates
Grouped in 4 areas
Work Environment
Individual Capabilities
Task Demands
Human Nature

- Grouped in 4 areas
_**W**_ork Environment
_**I**_ndividual Capabilities
_**T**_ask Demands
_**H**_uman Nature

***Error Precursors***

## Error Precursors -- Short List

***Error Precursors -- Short List***

## Error Prevention Tools

- Self-checking
- Peer-checking
- Concurrent verification
- Independent verification
- Three-way    communication

- Place keeping
- Pre-job briefing
- Post-job briefing
- STAR

***Error Prevention Tools***

## What Error Precursors do you See?

***What Error Precursors do you See?***

## SAFER Dialogue

_**S**_ummarize
- Critical
- Steps

_**A**_nticipate Error
- Traps

_**F**_oresee
- Potential
- Consequences

_**E**_valuate
- Defenses

_**R**_eview
- Experience

- Task
- Preview
- Before & During
- Pre-job

- Pre-job
- Briefing
- A Dialogue

***SAFER****** Dialogue***

## Summarize Critical Steps

- Not all steps of a procedure are equally important
- Critical steps include things like:
- Actions aimed at changing the state of facility  structures, systems, or components
- Steps that are irrecoverable or actions that cannot be reversed
- Steps where the outcome of an error is intolerable for personnel or facility safety

## Anticipate Error Traps

- Review the job-site conditions using the error precursors list
- Some error precursors are particularly powerful, depending on the performance mode of the individual performing the action -- for instance:
- Skill-based performance -- strongly influenced by distractions, simultaneous tasks, and fatigue
- Rule-based performance -- strongly influenced mindset and confusing procedures
- Knowledge-based performance -- strongly influenced assumptions, first-time performance of the task, lack of knowledge, and inexperience

## If a mistake does occur at a critical step, 
What is the worst that can happen?  
What is likely to occur?
Consider the production goals that would not be achieved -- however, safety and prevention are more important that schedule
Intolerance for error-likely situations should prevail -- if the potential outcomes of an error are judged as too severe, the task should not proceed as presently planned

*What is the worst that can happen?  *
*What is likely to occur?*
- Consider the production goals that would not be achieved -- however, safety and prevention are **more** important that schedule
- Intolerance for error-likely situations should prevail -- if the potential outcomes of an error are judged as too severe, the task should **not** proceed as presently planned

_***F***_***oresee Potential Consequences ***

## Review Experience

- The first four elements of the task preview address what _might_ happen -- this step addresses what errors _have_ occurred with this activity in the past? How have people made mistakes with this task in the past?
- Choose operating experience that focuses on the critical steps of the task at hand

## What are the Critical Steps?

## Defenses Against Error

- In most cases, additional defenses employed to minimize the risk of an error or an event for a particular task will be administrative in nature, such as
- Additional supervision
- Use of error-prevention techniques
- Improvements in procedures or job aids
- Contingencies should consider defensive functions to enhance the individual's and plant's ability to recover from error, especially at the critical steps, to avert an event

## * Latent Organization Weakness – Hidden deficiencies in management control process or values creating workplace conditions that can provoke an error and/or degrade the integrity of defenses

## New Paradigm

*Individual  *
*+  *
*Organization & Processes  *
*=  *
*Performance *

## Latent Organizational Weaknesses

- Undetected deficiencies in organizational processes, values, or equipment flaws that create workplace conditions that provoke error or degrade the integrity of defenses

## Examples of Organizational Weaknesses

- Poor design
- Undetected manufacturing defects
- Maintenance failures
- Unworkable procedures
- Clumsy automation
- Shortfalls in training
- Inadequate tools and equipment

## Tools for Finding Latent Organizational Weaknesses

***Tools for Finding Latent Organizational Weaknesses***

- Self Assessment
- Benchmarking
- Post-job Critique
- Trending
- Surveys and Questionnaires
- Observation

- Event Investigation
- Issue Investigation
- Self Identification

## What Organizational Weakness do you See?

## First Annual FR Invitational Car Race

- 4 Race Teams (Teams A, B, C, & D)
- Team Boss
- Driver
- 2 Communicators
- 3 Additional Warm Bodies
- One person per team interacting as a FR

## First Annual FR Invitational Car Race

- Teams A vs. B -- C vs. D
- Loser out
- Winners of 1st race, race in 2nd race
- Rules
- Driver stays at starting line
- Radio operators communicate directions to driver
- Practice and walk down of course may be performed
- Use HPI training to be successful

## Post Job Review

- Error Precursors
- Critical Steps
- Organizational Weaknesses

## 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

## Handouts

- CD Containing
- Human Performance Reference Manual
- Human Performance tools for Workers
- Human Performance tools for Engineers
- Excellence in Human Performance
- Human Performance enhancement system
- Principles for Enhancing Professionalism of Nuclear Personnel
- Principles for a Strong Nuclear Safety Culture
- Excellence in Work Management