Human Performance Factors

Matthew D.M. Watsonof

9m Consulting

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401000

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Answer Is?

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401000

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Process Example

Beginning Step 1 Step 2 Step 3 Complet

e

Process Deviation

Beginning Step 1 Step 2 Step 3 Complet

e

Step 2 Deviati

onStep 3

Abnormal Work Stoppa

ge

HPF Defined

• Human Performance Factors (HPF)

• Circumstances the affect a series of behaviors performed by an individual to accomplish specific tasks

• Environmental conditions that drive positive or negative performance

When Errors Occur

Incident

Process Oriented

Root Cause Analysis

HPF Not Analyzed

Analysis is Shallow In-

Depth

Ineffective Corrective

Actions

Ideal Problem Analysis Model

Lessons Learned Shared

& Applied

Team Created Correctiv

e Actions

Process Root

Cause Analysis

HPF Root Cause

Analysis

Switch Theory

Engineering

Tech

nical W

ork D

ocum

ent

Supervisi

on

Training

Quality A

ssura

nce

Worker

INCIDENT

Switch Theory - Open

Engineering

Tech

nical W

ork D

ocum

ent

Supervisi

on

Training

Quality A

ssura

nce

Worker

INCIDENT

Human PerformanceMain Focus Areas

Incident Example

• {Outline a customized example of an incident the organization experienced}

What Was The Root Cause

• {Outline the identified root cause from the incident}

Corrective Actions

• {Outline the corrective actions developed to resolve the incident}

Error Precursor Examples

Task Demands Individual Capabilities

1. 1.

2. 2.

Work Environment Human Nature

1. 1.

2. 2.

Pattern Seeking

Cognitive Bias & Pattern Seeking Video

Case Study

• Break into 3 groups• Read the front page article and initial press

release

• Take 15 minutes to outline the following• Root causal analysis• Corrective actions

• {Case Study is Available Upon Request}

Case Study Answers

• Root Cause Analysis:

• Corrective Actions:

Closing Questions

• How well do you understand your organizations quality defenses?

• Human Performance Areas where you are vulnerable?

• How will you address these vulnerabilities?

References

• "Analyzing Performance Problems" Mager & Pipe

• "Managing Maintenance Error" Reason & Hobbs

• "Apollo Root Cause Analysis" Gano