sk ds Ta an sor ec s pr

sk ds Ta an sor ec s pr sor ec ur ur pr s em D H N um at an ur e Error-likely Situation ur ec pr t En W vi o ro rk nm en s al du es vi iti di bil In a ap C sor ur ec sor s pr Human Performance Fundamentals An error about to happen due to error precursors

Performance Modes Knowledge Based Attention (to task) High 1: 2 Inaccurate Mental Model Rule Based Misinterpretation Inattention 1: 1 K 1: 10 K Low Human Performance Fundamentals Familiarity (w/ task) Skill Based High

Dual Behaviors Front-line Worker Management Mission Vision Goals Values Objectives Processes Attitudes Beliefs Behavior (Production) (Protection) Results Source: Tosti, Donald. “Changing Organizational Culture” (course), Vanguard Consulting, Inc. Human Performance Fundamentals

Protection & Production r nk a t up cy B e h op t Ca Production Human Performance Fundamentals str a Source: Reason

Error Precursors (short list) Human Performance Fundamentals

Anatomy of an Event Flawed Defenses Vision, Beliefs, & Values on Missi Goals es Polici es ss Proce s am Progr Event Initiating Action Latent Organizational Weaknesses Error Precursors Human Performance Fundamentals Vision, Beliefs, & Values

Equipment Ergonomics & Human Factors Environmental Work-arounds & Housekeeping Conditions Inconveniences RWPs Worker Knowledge, Skill, & Proficiency Personal Motives Procedure / Work Package Quality Morale Values & Beliefs Foreign Material Exclusion Lockout / Tagout Fitnessfor-Duty Flagging Turnover Clearance Walkdown Equipment Labeling & Condition Tool Quality & Availability Intolerance for Error Traps Pre-job Briefing Critical Parameters Just-in-time Operating Experience Procedure Use & Adherence Self-Checking Task Preview JOB-SITE CONDITIONS Place-Keeping Task Qualification Task Assignment Performance Feedback Motivation Leadership Safety Philosophy Strategic HU Plans Design & Configuration Control Staffing Task Allocation OE Clear Expectations Scheduling / Sequencing Simple / Effective Problem. Processes Solving Accountability Self-Assessment Work Planning Change Mgmt. Communication Practices & Plan Socialization Benchmarking Labor Corrective Action Relations Program Management Practices Human Performance Fundamentals Trend Analysis Recognizing Error Traps Team Skills Stop When Uncertain Independent Verification Courage & Integrity Forcing Functions Personal Interlocks Protective FME Equipment Alarms Proper Reactions Compelling Vision ORGANIZATION PROCESSES & VALUES Rigor of Execution Peer-Checking QC Hold Points Healthy Relationships Handoffs Supervision Reinforcement HP Surveys Role Models Problem-solving Methodology Respect for Others High Standards Walkdowns Reviews & Approvals Management Monitoring Conservative Decision-Making WORKER BEHAVIOR Questioning Attitude Coaching Compatible Goals & Priorities 3 -Part Communication Double (dual) Verification Uneasy Attitude Roles & Responsibilities Training Procedure Revisions Rewards & Meetings Reinforcement Questioning Attitude Challenge Example Open & Honest Communication Post-job Critiques Problem Root Cause Reporting Analysis Independent Oversight Performance Indicators PLANT RESULTS Reactor Protection Systems Equipment Reliability Safeguards Equipment Containment Performance Model Functions of Defenses Recover Create awareness Contain Detect and warn Enable escape Protect

Task Preview a job-site strategy Job Site Conditions Task Demands Work Environment Individual Capabilities Critical Steps Task Preview Before & During Prejob Briefing Human Nature Error-likely Situations Potential Consequences Prejob Briefing A Dialogue Worker Behavior Flawed Defenses Dialogue Organizational Processes & Values Human Performance Fundamentals Worker & Supervisor Feedback Plant Results

Task Preview Task Demands Work Environment Individual Capabilities Human Nature Human Performance Fundamentals Task Preview SAFE Dialogue S – Summarize critical steps A – Anticipate error traps F – Foresee consequences E – Evaluate defenses R – Review operating experience Critical Steps Error-likely Situations Potential Consequences Flawed Defenses

Performance Model a systems perspective Job-Site Conditions Worker Behaviors Leadership Org’l Processes & Values Physical Plant Results Source: Rummler and Brache. Improving Performance, 1990. Human Performance Fundamentals

“The significant problems we face cannot be solved at the same level of thinking we were at when we created them. ” Albert Einstein Human Performance Fundamentals

“Given this task to perform under these circumstances, this person will probably make errors at around this point. . ” Dr. James Reason Human Performance Fundamentals

“Just because the river is calm do not think the crocodiles are gone. ” Chinese Proverb Human Performance Fundamentals

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. Human Performance Fundamentals