im human performance excellence introduction - how to prevent events august 2012

IM Human Performance Excellence Introduction - How to Prevent Events August 2012

2 Proprietary & Confidential Information

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


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)


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


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


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.


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”


• 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


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.


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


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


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“Work Site Huddle/ Communications” • Clarifies expectations between work groups during

cross-functional tasks


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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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Flawed Defenses


ErrorPrecursors

Event

The last action (correct or incorrect) by an individual.


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Flawed Defenses


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


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Flawed Defenses


ErrorPrecursors

LatentWeaknesses(management)

Event


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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Flawed Defenses


ErrorPrecursors

Event


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


Flawed Defenses


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


• 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 –

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Q & A

im human performance excellence introduction - how to prevent events august 2012

Documents

events human performance

root cause human performance

high levels of performance

midyear performance

outage events

ytd slide

efor events pgd hp

nuclear industry program