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Human Performance for Safety Professionals
“Taking Science to Application”
John Wellisch MTD Master Trainer
Human Performance Improvement
(208) 351-4523
"There was an error in the Dear Abby
column that was published on Monday.
In the fifth paragraph, the second
sentence stated that Charlie's hiccups
were cured temporarily through the use
of carbon monoxide. It should have read
carbon dioxide.“
--Anchorage Daily News
BOTH WILL STOP HICCUPS
To proactively prevent “Unwanted
Outcomes” triggered by human error.
Purpose of Human Performance Improvement
Unwanted
Outcomes
Why a Human Performance
Improvement Approach?
80% Human Error 30%
Individual
20% Equipment
Failures
Human Error
Unwanted Outcomes
70% Latent
Organization
Weaknesses
DOE 1-10
Cheering
HPI Principle 4 • People achieve high levels of performance based largely
on the encouragement and reinforcement received from
leaders, peers, and subordinates.
HPI Principle 5 • Events can be avoided by understanding the reasons
mistakes occur and applying the lessons learned from
past events.
“Events are not so much the result
of error-prone workers as they are
the outcome of error-prone tasks
and error-prone work
environments, which are
controlled by the Organization.”
James Reason, Managing the Risks of Organizational Accidents
Dr. Lucian Leape
Question:
Very tricky math! Note: This must be done in your
head only. Do NOT use paper and pencil or a calculator. Try it.
Take 1000 and add 40 to it. Now add
another 1000. Now add 30. Add another
1000. Now add 20. Now add another 1000
Now add 10. What is the total?
Answer: The correct answer is actually 4100.
“Punishing people for their errors
is emotionally satisfying but
remedially useless.”
James Reason, Managing Maintenance Error, pg 97
DOE2 96-97
Blame Cycle
Human
Error
Less
communication
Management less
aware of jobsite
conditions
Reduced trust Latent organizational
weaknesses persist
Individual counseled
and/or disciplined
More flawed defenses
& error precursors
DOE1 4-23
Who makes the worst mistakes?
• Front-line workers
• Technical Staff/Knowledge
Workers
• Supervisors
• Managers
• Directors
• Corporate
• Limited short-term memory • Personality conflicts
• Mental shortcuts (biases) • Lack of alternative indication
• Inaccurate risk perception (Pollyanna) • Unexpected equipment conditions
• Mindset (“tuned” to see) • Hidden system response
• Complacency / Overconfidence • Workarounds / OOS instruments
• Assumptions (inaccurate mental picture) • Confusing displays or controls
• Habit patterns • Changes / Departures from routine
• Stress (limits attention) • Distractions / Interruptions
Human Nature Work Environment
• Illness / Fatigue • Lack of or unclear standards
• “Hazardous” attitude for critical task • Unclear goals, roles, & responsibilities
• Indistinct problem-solving skills • Interpretation requirements
• Lack of proficiency / Inexperience • Irrecoverable acts
• Imprecise communication habits • Repetitive actions, monotonous
• New technique not used before • Simultaneous, multiple tasks
• Lack of knowledge (mental model) • High Workload (memory requirements)
• Unfamiliarity w/ task / First time • Time pressure (in a hurry)
Individual Capabilities Task Demands
Error Precursors short list
DOE1 2-32
True or False 1. __ If there are no events, there is no human
performance problems
2. __ Training is the solution to performance
problems
3. __ Self-checking means good human
performance
4. __ Accountability is all that is necessary
5. __ Event significance determines culpability
6. __ Experienced workers make mistakes
7. __ Errors cause significant events
8. __ Errors are a fact of life
Facts about Human Error • It thrives in every industry
• It is a major contributor to events and unwanted
outcomes
• It is costly, adverse to safety, and hinders
productivity
• The greatest cause of human error is weakness in
the organization, not the lack of skill or knowledge
• Error rates can never be reduced to zero
• Consequences of errors can be eliminated
Common Traps of Human Nature 1. Stress
2. Avoidance of mental strain
3. Limited working memory
4. Limited attention resources
5. Mind set
6. Difficulty seeing own errors
7. Limited perspective
8. Susceptible to emotion
9. Fatigue (Sleep Deprivation)
10. Presenteeism
4+ 5 8 DOE1 2-1
Critical Steps If done incorrectly will take a significant
amount of time and money to recover from.
Human Performance Tools
• Task Preview
• Job Site Review
• Questioning Attitude
• Pause when Unsure
• Self Checking
• Procedure Use and Adherence
• Place Keeping
• Do Not Disturb Sign
• Pre-Job Briefing
• Flagging
• Turnover
• Post Job Review
• Project Planning
• Benchmarking
• Observations
• Performance Indicators
• Independent Oversight
• Investigating Events
Triggered by Human Error
• Change Management
• Culpability Decision Tree
See DOE Book 2 Checklists
How You React to Failure Will Influence What You
Know About Failure • Listen First
o Shut Up!
• Repeat back to ensure understanding
• Focus on actual behavior rather than judgment
and evaluation
Requests • Make requests, not demands
o Use positive action language
o Leave their autonomy intact
o Would you be willing?
When a person hears a demand from us, they see two options: to submit or to rebel. Marshal Rosenberg
The man who is bigger than his job
keeps his cool. He does not lose his
head, he refuses to become rattled, to
fly off in a temper. The man who
controls others must first be able to
control himself. There is something
admirable, something inspiring,
something soul-stirring about a man who
displays coolness and courage under
extremely trying circumstances
B.C. Forbes