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Agenda
Why a Human Performance Excellence Program
Human Performance Tools/Techniques
How do Events Happen?
Anatomy of an Event - Understanding that multiple issues cause an “event”
Mindset – these techniques help us “back each other up” Next steps for departments and teams
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Human Performance Excellence is part of the Way We Work: Our Quality Culture in providing “Secure, Rock Solid IT”
Proprietary & Confidential Information
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Since starting program in 2008, Human Performance continues to be a positive factor in PGD’s overall EFOR* improvement
HP is a Nuclear industry program. PGD adopted the program to reduce their EFOR events
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FPL / TH&S Performance 2005 - 2011
HP Events
PGD HP forced outage events continue to improve
* Equivalent Forced Outage Rate (EFOR)
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IM Human Performance Program Structure
Senior leadership selected across IM to establish the program Sponsors – Anita Sharma, Phil Prugnarola IMB - Danny Lizano/Eddie Cardelles, Kristi Baldwin Nuclear - Tom Beneduci, Alex Guerrero, Amolien Chery IME - Art Ruiz, Bryan O’Sullivan, Sue Gampfer (Program coordinator) IMO - Mauricio Gonzalez, Nancy Mulshine, Rick Vinton IMT - Grace Kurian, Paul Carpenter, Dean Hertzog, Linda Cassulo Info Sec - Roland Miller IMP - Cecilia Lim (Quality rep), Denise Cormier, Ken Grafe
Formed 3 sub teams to integrate with IM’s quality / process improvement efforts Team 1 – Critical Tools Identification / CBT materials Team 2 – How do we measure success Team 3 - Rollout approach / Workshop and Leaders Guides
We established a steering committee to frame out this program for IM using PGD and Nuclear programs as guides
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Our 2012 midyear performance review shows 35% of our events are attributed to Human Performance
• Root Cause• Revised coding structure as part of the Human Performance initiative• High Bars (as of mid May) – Software and Human Performance
•Root Cause Sub Codes• High Bar (as of mid May) – SW Bug, Process not Followed, Accident,
HW Failure, Training Inadequate, Communication Gap
Count 31 30 12 10 1 1Percent 36.5 35.3 14.1 11.8 1.2 1.2Cum % 36.5 71.8 85.9 97.6 98.8 100.0
Root Cause
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Pareto Chart of Root Cause
2012 Root Cause / Human Performance April YTD
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The events caused by human performance were not done on purpose - People are fallible and even the best make mistakes
1. People are fallible and even the best people make mistakes
2. Error likely situations are predictable, manageable and preventable
3. Individual behaviors are influenced by organizational processes and values
4. People achieve high levels of performance because of the encouragement and reinforcement received from leaders, peers and subordinates
5. Events can be avoided through an understanding of the reasons mistakes occur and application of the lessons learned from past errors or events
Five Principles of Human Performance
Human Performance Excellence is a team effort at all levels of our organization.
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Reducing Errors and Preventing Events
Human Performance Tools can help us reduce the occurrence of errors as well as manage the integrity of the defenses we put in place
Re + Md = ØE
Reducing active errors (Re) and managing defenses (Md) leads to zero significant events (ØE).
Because there are both human and organization aspects to human performance, event free performance requires a strategic approach .
The strategy is expressed in the formula
We want to build a culture around “preventing errors”
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• Why are we doing this program? • Program Goal – Prevent Events
• To reduce the opportunity for and the frequency of human error • To target improvements to our “defenses” to help preclude significant events
• When do we use these tools / techniques? • Addressing critical activities when a mistake has significant impact
• Planned changes to production applications under SLA• Where we have had near misses that caused the team to work heroically • Making sure you are working on the right equipment/right environment
• We use many of these techniques today –so what is the difference? • Being pro active - think about what could go wrong and plan for it
• Recognize when results are not what was expected to stop and get help • Recognizing when you/team may be at risk for making an error
Our focus is on addressing critical activities in our work when mistakes are made, the impact is significant
IM Human Performance Excellence Program Concepts
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Human Performance Tools/ Techniques All Tools/Techniques1. Self Checking (STAR)2. Questioning attitude3. Peer checking4. Pre Job / Activity Briefing5. Three Way Communication 6. Procedure use and Adherence7. Place Keeping8. Task Preview9. Job-site review10. Stop when Unsure 11. Post Job review12. First check13. Phonetic Alphabet14. Concurrent Verification15. Independent Verification16. Turnover 17. Flagging
We focused on identifying the starter list of techniques which can have immediate benefits
IM Starter List 1. Self Checking (STAR)2. Questioning attitude3. Peer checking4. Pre Activity Briefing
We will introduce additional techniquesover the next year.
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HPE Program – Computer Based Training
We updated corporate CBT about Human Performance with IM examples of HP events
• Provides overview of HPE (theory around HPE) and IM Examples• Overview / Job aid of starter tool set • CBT will be available in SAP – use it as a reference
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HPE Program – Job Aids
We have a job aid for our “starter” toolset showing purpose, when to use it and at risk practices to avoid.
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SELF CHECKING / STAR• reduces the frequency of errors during skill-based activities • STAR (Stop, Think, Act, and Review)
Let’s review a few techniques
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QUESTIONING ATTITUDE• reduces the frequency of errors made by the individual in
the performance of a rule-based activities
Let’s review a few techniques
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“Work Site Huddle/ Communications” • Clarifies expectations between work groups during
cross-functional tasks
Let’s review a few techniques
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How do Events Happen?
Flawed Defenses
InitiatingActionsONE WAY
ErrorPrecursors
LatentWeaknesses(Land mines)
Event
An Event is an occurrence for which the undesired effect is of high significance
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How do Events Happen?
Flawed Defenses
InitiatingActionsONE WAY
ErrorPrecursors
Event
The last action (correct or incorrect) by an individual.
LatentWeaknesses(Land mines)
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How do Events Happen?
Flawed Defenses
InitiatingActionsONE WAY
ErrorPrecursors
Event
Error-likely situations are predictable, manageable and preventable -
Undetected deficiencies in processes or values creating workplace conditions that degrade integrity of the defense Possible Landmines
Training CommunicationsPlanning and SchedulingMaintenance processesProcedure developmentGoals and Priorities
LatentWeaknesses(Land mines)
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How do Events Happen?
Flawed Defenses
InitiatingActionsONE WAY
ErrorPrecursors
LatentWeaknesses(management)
Event
Error-likely situations are predictable, manageable and preventable -
Unfavorable prior conditions that increase the probability for error when performing a specific task – Potential precursors
Time pressureDistracted EnvironmentMulti TaskingFirst time or performing infrequent task OverconfidenceVague or incorrect guidanceWork stress Fatigue
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LatentWeaknesses(Land mines)
How do Events Happen?
Flawed Defenses
InitiatingActionsONE WAY
ErrorPrecursors
Event
Error-likely situations are predictable, manageable and preventable -
Defenses are means or measures taken to catch human error or to mitigate the effect of human error. Flawed defenses, under the right circumstance, may inhibit the capability of defensive measures to protect. Potential Flaws
Inconsistent testingMissing alarmsIncomplete check sheetsLack of understanding full risks of activity
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The Swiss Cheese Model of Accident CausationHazards
Losses
Successive Layers of Defenses
Events don’t typically occur because of one single error...
Awareness of risk
Testing & Environments
Quality Assurance
Procedures/Check lists
Change Management
(errors, software defects, equipment failures, etc.)
(events)
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Preventing Events
LatentWeaknesses(Land mines)
Flawed Defenses
InitiatingActionsONE WAY
ErrorPrecursors
Event
Let’s do a case study so you can see how an event is usually caused by several errors or flaws
The approach to achieve event free performance requires us to reduce human error and manage the integrity of our defenses
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CASE STUDYEastern Airlines Flight 401
The Anatomy of an Event
As you watch the video – identify the anatomy of this event.
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CASE STUDYEastern Airlines Flight 401
The Anatomy of an Event
Let’s discuss – there were several times this event could have been averted…
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Land Mines Error Precursors Flawed Defenses Initiating Actions
No training on auto pilot disengagement
Time pressure No acknowledgement for altitude alarm
Bumped auto pilot off
Crew roles not clearly defined
Distractions Unable to verify position of landing gear
Controller’s role was limited
Unexpected equipment conditions
Captain stepped out of oversight role
No procedure for burned out bulb
Unclear goals, roles and responsibilities
Overconfidence (in autopilot)
Tunnel vision
Answer Key
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• Discuss a recent event and identify – Initiating Action– Error precursors – Landmines– Flawed defenses
• What was the event’s impact on the business?
• What was the impact on the team?
• Review tools - when/how could the team use one of the tools?
Team Discussion Points
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• Aug/Sept Goals – Launch program, understand how events happen• Program Kick off with IM Leaders – IM Leaders Meeting July 31 • Core team members start Workshop Deployment – due by September 30,
2012• IM Leaders meeting Aug 28 – new event cause category reporting • IM Communication Meeting September 11 - All employee launch
• Sept / Dec Goals – Review skill a month, communicate team successes and learning’s
• Sept – STAR• Oct – Questioning attitude• Nov – Peer checking• Dec – Pre activity brief• IM Communication Meeting - program progress – 2013 Stand up for quality
sessions
HPE Program – Rollout / Communication Plan
Share examples of how you/your team used the techniques
Our long term goal is make these behaviors second nature –