Predicting Errors using Human Performance Measurement Tools

T. Shane Bush

Peggy S. Bush

(208) 221-9378

2020 Stosich Lane

Idaho Falls, ID 83402

BushCo@cableone.net

Human Performance

Fundamentals (2017)

BushCo

To proactively prevent “Unwanted

Outcomes” triggered by human error.

Purpose of Course

Unwanted

Outcomes

But there is one small problem: The quote actually

originated not with the late poet and civil rights champion,

but with a children' book author Joan Walsh

Error?Un-intentional Deviation from a

Preferred Behavior

Error?

Something you didn’t intend to do!

Reducing Errors should not be the primary focus.

It should be reducing the consequences of errors!

HENCE ZERO IS ACHIEVABLE!!!!!

Reducing Errors should not be the primary focus.

It should be reducing the consequences of errors!

HENCE ZERO IS ACHIEVABLE!!!!!

Human Performance

Part One – Why A Human Performance Approach

Part Two – Individual

Part Three – Organization

Part Four – Leader

Part Five – Case Studies, Implementation, & Review

Objectives

1. Explain what constitutes an

unwanted outcome

2. Describe why the applications of

Human Performance are important

in reducing the frequency &

severity of unwanted outcomes

3. Explain how individual behavior

affects the frequency &

severity of unwanted outcomes

4. Explain how Organizational

Processes and Values

affects the frequency &

severity of unwanted outcomes

Unwanted

Outcomes

Objectives5. Explain how leader behavior

affects the frequency & severity

of unwanted outcomes

6. List the error prevention tools

available to help anticipate and

prevent error likely situations

7. Given a case study as a guide,

explain the attributes of a

successful Human Performance

Improvement Process

8. Explain what we can do

individually and as a company

to meet the objectives of this

course

Unwanted

Outcomes

Leadership

CEREBRAL

RIGHTLEFT

Analytical

Math

Compliance

Regulated

Mandatory

Text

Logical

Factual

Creative

Synergistic

Imaginative

Holistic

Contextual

Futuristic

Intuitive

Feelings

30%

100%

Discretion of Employee

Per

cent

of

Eff

ort

Discretionary Effort

50%

A Simple Model

Performance outcome Y is a

function of factors X.

PerformanceOutcome

Factors AffectingOutcome Y

Y = f (x)

Y = f (x1, x2, x3, x4, x5, … xn)

Positive effect on y

Little or no effect on y

The real challenge is to identify those factorsthat do and don’t drive performance.

Captain Marty McDonough

Negative effect on y

Four Most Common Ways to Reinforce Behaviors:

1.

2.

3.

4.

Positive

Negative

Extinction, Nothingness

Punishment

The Challenge: Identifying what factors affect people performance

Why a Human Performance Improvement Approach?

80% Human Error 30%

Individual

20% Equipment

Failures

Human Error

Unwanted Outcomes

70% Latent

Organization

Weaknesses

Industry Event Causesdue to human performance

Source: INPO, Event Database, March 2000. For all events during 1998 and 1999.

215

26 3988

192

654

9 20

160

82

806

73118

0

100

200

300

400

500

600

700

800

900

Cha

nge

Man

agem

ent

Env

ironm

enta

l Con

ditio

ns

Hum

an-m

achine

Inte

rface

Sup

ervis

ory Met

hods

Wor

k O

rgan

izat

ion/

Plann

ing

Writ

ten

Proce

dure

Res

ourc

e Man

agem

ent

Wor

k Sch

edule

Tra

ining/

Qua

lifica

tion

Ver

bal C

omm

unicat

ions

Wor

k Pra

ctic

es

Man

ager

ial M

etho

ds

Oth

er/U

nkno

wn

Num

be

r o

f C

ause

s

1,676 = Org behavior (68%)

806 = Individual behavior (32%)

December 20, 2015

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 weaknesses in the organization, not lack of skill or knowledge

• Error rates can never be reduced to zero

• Consequences of errors can be eliminated

Principles1. 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.

Principles1. 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.

MEDICAL ERRORS AND MISTAKES

Plant

Worker

Processes Values

Individual

• 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 NatureWork 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 CapabilitiesTask Demands

Error Precursorsshort list

Limitations of Human Nature

❖ Avoidance of mental strain

❖ Inaccurate mental models

❖ Limited working memory

❖ Limited attention resources

❖ Pollyanna effect

❖ Mind set

❖ Difficulty seeing own errors

❖ Limited perspective

❖ Susceptible to emotion

❖ Focus on goal

Human Information Processing

Source: Wickens, 1992

Shared

Attention

Resources

ThinkingSensing Acting

Information

Flow Path

Organization

Human Performance Fundamentals

Victims of our own Success

Human Performance Fundamentals

Defenses

• Hard -

• Soft -

Two Kinds of Error

Active Error

Latent Error

Was the behavior

intended?

Yes

Were the

consequences

intended?

Yes

Intentional,

sabotage,

Medical

Restrictions?No

No

Were they

communicated

and clearly

understood?

Yes

System

induced

violation

No

Possible

intentional

violation

Yes

Did employee

knowingly violate

requirement?

No

Yes

Were requirements

available, workable

intelligible & correct?

Possible

intentional

Violation

Yes

System

induced

violation

No

Pass

substitution

test ?No-

Deficiencies

in training &

selection or

inexperience?

No

Possible

negligent

error

No Yes

System

induced

error

History

unsafe

acts?-Yes-

Corrective

training or

counseling

indicated

Yes

Blameless

error

No

(a)

(b)

(c)

(d)

(e)

(f) (g)

(h)

(i)

(j) (k)

(l)

(m)

(n)

(o)

(p)

(q)

(r)

g, j,

Culpability Decision Tree

Air Ontario Flight 363 Fokker F28Dryden, CanadaMarch 10, 1989

Performance Modes--Attending Problems

Familiarity (w/ task)Low High

High

Low

Att

en

tio

n (

to t

ask)

Sourc

e:

Jam

es R

eason.

Managin

g t

he R

isks

of

Org

aniz

atio

nal

Accid

ents

, 1998.

Inattention

Misinterpretation

Inaccurate

Mental Picture

Blame

Cycle

Human

Error

Less

communication

Management less

aware of jobsite

conditions

Reduced trustLatent organizational

weaknesses persist

Individual counseled

and/or disciplined

More flawed defenses

& error precursors

The Blame Cycle

Human Performance Tools

• Critical Steps

• Enhanced Pre-Job Briefing

• Peer Check

• Self Check

• Independent Verification

• Error Traps

• Just Culture

• Effective Communication

• Questioning Attitude

• Feeling of Uneasiness

• Enhanced Turnover

• 3 way communication

• Error Precursors

• Performance/Error Modes

• Devils Advocate

• Place keeping

• Poka Yoke

• SAFE Dialogue

• Discovery Clock

• STAR

• Training

What is the Organizations

Role?• Support the Education and

Implementation of the HPI

process

• Encourage Accountability and

the Development of a Just

Culture

• Encourage the use of the HPI

toolsWhat are the Employee’s

Responsibilities?• Have a Questioning Attitude

• Develop a strong sense of

Accountability

• Use of the HPI tools, Use the HPI

tools, Use the HPI tools

➢Stage 1: Obtain senior management commitment.

➢Stage 2: Establish a steering committee.

➢Stage 3: Perform a self-assessment of the current situation.

➢Stage 4: Develop a human performance improvement strategy and plan.

➢Stage 5: Communicate with and empower stakeholders.

➢Stage 6: Implement the strategy and plan.

➢Stage 7: Evaluate and improve the program.

➢Stage 8: Maintain the program.

HPI Implementation Plan

8 Initiative Areas1. Organization Structure

2. Expectations

3. Rewards and Reinforcement

4. Communication and Education

5. Training

6. Work Process & Incident Analysis

7. Assessments

8. Performance Monitoring

I. Error Rates

II. Discovery Clock Resets

III. Latent Condition Identification

IV. Error Precursor Trending

V. Re-work

VI. Culture Survey – Just Culture

VII. Critical Step Identification

VIII. Workforce Human Performance Education

IX. Enhanced Pre-Job Usage

X. Positive to Negative Reinforcement Ratio

XI. Human Performance Defense Usage

Human Performance Fundamentals

Leading Indicators

Drill

into conduit

Fire

Hydrant

Electrical

Panel

Back Into

Power Pole

Root

Cause

Root

Cause

Root

Cause

Root

Cause

Error PrecursorsTime Pressure Stress

Habit Patterns

ChangesAssumptions

Repetitive Actions

Simultaneous

Hidden System Response

Workarounds

Complacency

New TechniqueHazardous Attitude

Interpretation

Unclear Goals

Latent Organization Weaknesses

The Dirty Little Secret of Root Causes