Human Performance Conference Atlanta, Georgia, March 26-28, 2013

Transcription

1 Human Performance Conference Atlanta, Georgia, March 26-28, 2013 Strategic Approach to Managing g Human Performance (Hu) Risk Tony Muschara, CPT The Certified Performance Technologist (CPT) designation is awarded by the International Society for Performance Improvement (ISPI) to experienced practitioners in the field of organizational performance improvement whose work meets both the performance-based Standards of Performance Technology and application requirements. For more information, visit

2 Strategic Approach: Risk-Based* Safety is what you DO to ensure the integrity of assets: 1. Control: at Critical Steps SM Dr. James Reason 2. Learn: Land Mines and Latent System Weaknesses *Woods, D. et al. (2010), Behind Human Error (2 nd ed.), Ashgate, pp.38-39, 39,

3 is good enough most of the time. 3

4 Let s Align Our Beliefs* 1. To err is human. 2. To drift is human. 3. Risk is everywhere and dynamic. 4. Safety is a value and adaptive. 5. Systems govern results. * Adapted from Marx, David (2005), Cultural Change and Effective Safety Management. Transport Canada: PowerPoint. May

5 To Err is Human 3 to 4 errors per hour* * Source: Dr. Michael Frese (2008), Learning from Errors by Individuals and Organizations. Invited Talk at Association of Psychological Science (APS) Conference, May 28,

6 Video: To Drift is Human 6

7 Video: Risk is Dynamic 7

8 Safety is a Value* Safety is NOT the absence of accidents. Safety is the presence of fd defenses in your processes, procedures, facilities, methods, and practices. Safety is what you DO to ensure the integrity of assets using a variety of controls, barriers, and safeguards *Woods, D. et al. (2010), Behind Human Error (2 nd ed.), Ashgate, pp.38-39, 39,

9 System Accidents: Systems Govern Results* Defenses (LOP) Land Mines Losses (assets) Active Error Error Traps: (conditions people work in that tend to provoke error) Latent System Weaknesses: Management Systems Processes Plans Hardware Design Leadership Culture * Adapted from Reason, J. (1998), Managing the Risks of Organizational Accidents; p

10 Video: Fall Through Floor 10

11 Touching = Risk 11

12 TouchPoint A human interaction with an asset that changes the state of that asset through work Initiates a transfer of energy, mass, or information 12

13 Risk-Based Practices* AMRL Anticipate know what to expect Monitor know what to pay attention ti to Respond know what to do Learn know: what has happened what is happening what to change Touching = Risk * Adapted from Hollnagel, et al., Resilience Engineering,, (2006), p.350, and Resilience Engineering Perspectives, Vol. 2,, (2009), pp

14 Operations: Work Execution Process Positive Control! Assets (work output) CRITICAL STEP SM Preparation Error Traps Execution (work behavior) Land Mines Learning Real-time Performance: Sharp End Organization: Blunt End Organization

15 If 99% was Good Enough 15

16 Trolltunga Odda, Norway Is 99.9% good enough here? 16

17 CRITICAL STEP SM Point of No Return What MUST Go Right Single-Error Vulnerability Any human action that will trigger immediate, irreversible, intolerable harm to an asset (if that action or a preceding action is performed improperly) AMRL 17

18 Hu Tools 1. Pre-Job Briefing 2. Take a Minute 3. Self-Checking (STAR) Carving out 4. Stop When Unsure time to think 5. Peer-Checking 6. Three-Part communication 7. Procedure Use & Adherence Placekeeping 8. Conservative Decision-Making 9. After Action Review Reporting 18

19 RU-SAFE: Pre-Job Briefing 1. Review Task Purpose / Accomplishments. 2. Identify Asset(s) to Protect: t Recognize assets to protect and related hazards Understand lessons learned from experience Summarize critical steps and related risk-important important actions Anticipate errors traps and errors for each critical step Foresee consequences of errors at each critical step Evaluate Hu Tools, defenses, contingencies, and STOP work criteria 3. State End of Briefing. 19

20 Error Rate Reduction ror Ra ate Er Before Hu Tools After Randomness Time 20

21 Video: Highline Walker 21

22 Chronic Sense of Uneasiness* A Preoccupation with Failure Mindfulness toward assets: 1) one s capacity to err, i.e., error traps 2) the presence of hidden threats, t i.e., land mines AMRL how you perceive, think, and feel about assets and their hazards What else can I do to rise above my circumstances to get the results I desire? * Reason, J. (2008), The Human Contribution,, p The Oz Principle 22

23 Workers Role Control 1. Acknowledge human fallibility (hazard). 2. Know and understand the technology. 3. Know the assets to protect the Business. 4. Know CRITICAL STEPS SM Positive Control! 5. Be wary of error traps and land mines. 6. Stop when Unsure Get the Facts! 7. Avoid unsafe and at-risk practices. 8. Ask for and give feedback Don t know what 9. Report Don t live with problems! 10. Prove it Safe practice AMRL (hero). 23

24 Managing Drift and Accumulation* Hi Expectations: Work as Imagined Normal Practice: Work as Done Expectations Safe ety Real Margin for Error Error Mgmt Drift Normal Practice Da anger Hidden Conditions: hazards, threats, unusual conditions, & land mines Risk Mgmt Accumulation Inconspicuous and seemingly harmless buildup of unusual conditions, hazards, threats, at-risk priorities, etc., without warning Lo Time * Adapted from Dekker, S. (2007), The Field Guide to Understanding Human Error. 24

25 Managers Role Learn Manage integrate AMRL into systems; align around proactive accountability* (assets) 1. Manage Lead inculcate key beliefs into the culture; create reinforcing experiences 2. Lead 3. Organizational minimize minimize accumulation of flsw LSWs /l land mines; integrity it of fd defenses 4. Operational control control: avoid active errors at critical steps; minimize i i drift 5. Oversight monitor monitor: eliminate gaps between work as imagined and work as done * Connors, R. et al. (2004). The Oz Principle.. p

26 Managing Hu You cannot manage what you do not understand. -- Elliot Jacques, The Requisite it Organization Human performance is not common sense. 26

27 Strategic Approach* Safety is what you DO to ensure the integrity of assets: 1. Control: at Critical Steps SM 2. Learn: Land Mines and Latent System Weaknesses *Woods, D. et al. (2010), Behind Human Error (2 nd ed.), Ashgate, pp.38-39, 39,

28 The Passion 28