Human Performance, Zero Harm and the Siemens Safety Journey

Greetings from St. Petersburg, Florida Photos courtesy of the city of St. Petersburg, FL Page 2

Human Performance To err is human Most errors have minimal consequences Page 3

Human Performance To err is human Most errors have minimal consequences Page 4

Human Performance To err is human Most errors have minimal consequences Page 5

Human Performance Medical Aviation Military What is common among these industries? Petrochemical Nuclear Page 6

Human Performance Medical Aviation Military All are critical outcome industries Petrochemical Nuclear Page 7

Human Performance Medical Aviation Military The smallest human error (that is allowed to progress) is usually the contributing factor for all incidents Petrochemical Nuclear Page 8

Human Performance Medical Aviation Military And, they all don t necessarily get it right Petrochemical Nuclear Page 9

Examples 1986 Space Shuttle Challenger 1986 Chernobyl Nuclear 1988 Piper Alpha ~85% of all incidents are the result of human performance 1989 Exxon Valdez Oil Spill 2003 Space Shuttle Columbia 2010 BP Deepwater Horizon Page 10

Opportunity 210,000 400,000* *Journal of Patent Safety deaths per year who seek medical care http://www.iom.edu/reports/1999/to-err-is-human-building-a-safer-health-system.aspx Page 11

Some get it right! ~100,000,000 cognitive errors but very few incidents Page 12

Human Performance Vocabulary Error refers to the cognitive act Event the outcome Incident unintended or undesired outcome Human Violation the intentional or willful act Organization the business, from leadership to the shop floor, that directs the activities of employees Human Performance Program the application of human factors, loss control, and risk management to achieve an organization s goals HuP involves both the individual and the organization Page 13

HuP Introduction Discussion A quote from the first page of Managing Maintenance Error By James Reason and Alan Hobbs Page 14

HuP Introduction Discussion If some evil genius were given the job of creating an activity guaranteed to produce an abundance of errors, he or she would probably come up with something that involved the frequent removal and replacement of large numbers of varied components, often carried out in cramped and poorly lit spaces with less-than-adequate tools, and usually under severe time pressure the people that wrote the manuals and procedures rarely if ever carried out the activity under real-life conditions Page 15

HuP Introduction Discussion Those who started a job need not necessarily be the ones required to finish it (and) a number of different groups work on the same item of equipment either simultaneously or sequentially 1 1 J. Reason and Alan Hobbs, Managing Maintenance Error Page 16

Loss Reason for Action What we see and measure... What we don t see or measure... Page 17

The Big Picture Loss the reason for Action Human Action Human Performance Safety Tools / Processes Inputs Business Process Outputs Quality Information Risk Management Satisfaction Managing inputs is called Loss Control Page 18

HuP Loss Incidents Examples of Major Financial Loss Incidents Fuel lines were crossed during installation Loss = $1,500,000 Misread micrometer on critical rotor dimension Loss = $4,000,000 Page 19

The Connection between Human Error and Loss The purpose of Human Performance is to reduce losses and financial impact associated with safety, quality, and productivity errors Human performance is a program that uses specialized tools and practices to reduce the impact of human error and violation By reaching our Human Performance targets through improved Safety Quality Productivity we can meet the concerns of our customers Page 20

Our Truths No one comes to work to cause a Safety or Quality incident Past and current interpretations are no proof of truth Can t fix Safety by focusing on Safety People want to do a good job You can t stop cognitive errors, but you can be incident free People don t think and act alike Language is fateful Perception of risks varies and what is deemed acceptable varies from person to person Violation is a normal event which increases with experience Organizations are people, not machines Little things make a difference You can t fix people, but you can fix the systems that influence their behavior You can always intervene between error and an incident We forget to be afraid!... become risk tolerant Page 21

5 Principles of HuP Excellence People are fallible, and even the best make mistakes Individual behavior is influenced by organizational processes and values Error-likely situations are predictable, manageable, and preventable People achieve high levels of performance based largely on encouragement and reinforcement received from leaders, peers & subordinates An understanding of the reasons mistakes occur, and application of the lessons learned from past events, can avoid future events Page 22

Performance Modes Error Rates (Not inclusive of violation) Performance Mode Key Words Error Rate Skill Based Stored patterns of preprogrammed actions Acting out of habit without conscious thoughts HABIT Familiar (>50 times) Not Thinking 1 per 10,000 Rule Based Rules accumulated via experience and training Can be written or verbal There is a rule, and I KNOW there is a rule 1 per 100 Knowledge Based Using analytical processes and stored knowledge Has NOTHING to do with how smart you are! You are uncertain how to proceed You don t know WHAT you don t know! 1 in 2 TO 1 in 10 Page 23

The 3 Mental Modes Skill Based Recognition (misidentification, non-detection) or inattention Memory (encoding, storage, retrieval failure) Execution errors involving slips and omissions Rule Based Application of a bad rule (habits) Misapplication of a good rule Failure to apply a good rule (compliance issue) - violation Knowledge Based Inaccurate mental model Diagnosis errors due to confusion regarding system/plant state Page 24

Human Nature 1. Avoid mental strain 2. Limited working memory 3. Pollyanna/ invincibility effect 4. Limited attention / goal focus 5. Difficulty in seeing own error 6. Limited perspective /situation awareness 7. Prejudice and bias Page 25

12 Primary HuP Traps Human Performance Traps / Error Precursors Conditions, circumstances or occurrences that increase the potential for human error 1. Time pressure (in a hurry) 2. Distractions / interruptions 3. Unfamiliarity with task 4. Stress ( positive and negative) 5. High workload (memory requirements) 6. Changes / departure from routine 7. Lack of knowledge 8. Habit patterns 9. Simultaneous, multiple tasks 10. Confusing displays / controls 11. New techniques 12. Assumptions Page 26

Human Violation The intentional and willful act that could lead to an incident Necessary Reasons for Human Violation The job cannot be reasonably completed if the procedure, rule, or practice is followed as specified (checking car oil level daily) Practical Cowboy We always do it this way (Always drive10 mph over speed limit) Making your job more fun (It s more fun to drive 90 mph than 65 ) Malicious Messing with the system (Running from police) Sabotage Deliberate meaning to cause harm (driving into someone) Page 27

Human Error: Active vs. Latent Active Vs. Latent Errors that change equipment, system or product triggering immediate undesired consequences Errors resulting in undetected organizational-related or equipment flaws that lie dormant until challenged Page 28

Opposing Views of Human Error Historical View of Human Error Human error is the cause of many accidents. The system in which people work is basically safe; success is intrinsic. The chief threat to safety comes from the inherent unreliability of people. Progress on safety can be made by protecting the system from unreliable humans through selection, procedure creation, automation, training and discipline. Page 29

Opposing Views of Human Error Emerging View of Human Error Safety is not inherent in systems. The systems themselves are contradictions between multiple goals that people must pursue simultaneously. People have to create safety. Human error that is allowed to progress to an incident is a symptom of trouble deeper inside the system. Human error is systematically connected to features of people, tools, tasks and operating environment. Progress on safety comes from understanding and influencing these connections. Page 30

Human Error Discussion Errors happen frequently (every day, every shift); they are universal and inevitable Errors will always occur as long as humans are doing the work Humans, on average, make 10-12 errors per hour Errors are a part of human nature. You cannot change the human condition, but you can change the conditions in which humans work Most errors have minimal consequences Making an error is not always a bad thing Page 31

HuP Introduction Discussion? Because it is impossible to have an error-free workplace, does that mean it is impossible to have an incident-free workplace? Because it is impossible to conduct an error-free workplace, Siemens uses Human Performance tools to identify, manage, and control errors Page 32

Definition / Goal of Human Performance Human performance as it applies to the individual is a series of behaviors executed to accomplish specific task objectives Organizationally, human performance is the aggregate system of processes, influences, and behaviors that exist in the workplace Build management systems that intervene between cognitive error and an incident Learn to recognize error-likely situations Overall Goal Prevent all incidents related to human performance and achieve Zero Harm Page 33

An effective HuP Program Identifies Achieves Zero Harm Promotes Encourages Teaches Recognizes Identifies and prevents incidents due to errors both latent and active Promotes a culture where it is understood errors occur, and where value is placed in the reporting of errors Encourages performance by Setting Communicating Enforcing Standards Teaches techniques for Noticing Observing Assessing error-likely situations Recognizes violations and the intervention between violation and an incident Page 34

What we learned from Industry and Academia You can t stop Human Error (the cognitive act) You can intervene between error and incident You can learn to recognize error-likely situations Human Performance includes violation recognition and management as well Understanding these fundamentals opens opportunities Page 35

Where are the Human Error / Violation Events? Human Error / Violation Significant Events by Time with Company High potential for Human Error Incidents High potential for Human Violation Incidents Page 36

Moving beyond Hazards and Risks Error-Likely Situations Error-Likely Situations* Hazard and risk identification only covers part of the prevention-related activities to achieve an incident-free workplace Incident Prevention Tools identify error-likely situations *3W (Work, Worker, Workplace) HuP tool helps identify error likely situations Page 37

Definition: Error Precursors & Error-Likely Situations Error Precursors Unfavorable prior conditions that reduce the opportunity for successful behavior and performance of a task Error-Likely Situations A work-related situation in which there is a greater opportunity for error when performing a specific action or task due to the existence of error precursors Page 38

Anatomy of an Incident Flawed Defenses Latent Organizational Weaknesses Incident ONE WAY Error Precursors Initiating Actions 80% 20% Page 39

Incident Causation Model Successive Layers of Defenses awareness of hazards Hazards (errors, equipment failures, etc.) drawings & procedures alarms support systems containment Losses (events) Some holes are due to Active Failures; some are due to Latent Conditions Events don t typically occur because of one single error... Page 40

Types of Defenses Physical Defenses Engineered safety features Personal Protective Equipment (PPE) *Personal Protective Equipment (PPE) Administrative Defenses Observers Training, briefings Procedures, instructions, policies, standards Page 41

Latent Weaknesses in Organizations Latent Organizational Weaknesses Flawed Defenses Incident ONE WAY Error Precursors Training Possible Areas of Latent Conditions Contracts with Customer Communications Planning and Scheduling Maintenance processes Initiating Actions Procedure development Goals and priorities Roles and responsibilities Page 42

A shift in focus from human error to organizational processes (Nuclear Industry) 2014 International Atomic Energy Agency Report, USDOE http://enformable.com/2014/02/iaea-safety-report-shifts-focus-human-error-organizational-processes-cultural-values/ Page 43

How do we prevent events? Human Performance Employs tools to help identify error-likely situations and Allows for the placement of adequate defenses to either: prevent the error or violation reduce the magnitude of the error or consequences and / or correct the error Page 44

Human Performance Tools Page 45

HuP Tools Job Hazard Analysis Page 46

The 4 Ages of Safety Maturity HuP Action Compliance Management Systems Training Observation & Coaching Ensure Consistency Influence Actions Behavior Culture Page 47

Just Culture... A shift in thinking from a Blame and No Blame Culture Blame Culture An unwillingness to report ANY type of incident for fear of criticism or prosecution Safety Accountability Just Culture A Just Culture can satisfy demands for accountability while contributing to learning and improvement No Blame Culture Minimal or no accountability for incidents A reporting and blame culture can t co-exist Page 48

Our Zero Harm Management Stand Procedure will Reduce Loss and Create Value The Management Stand educates management in their role in meeting high safety standards and creating a safe workplace Provides guidelines on how to observe and assess types of acceptable vs. unacceptable behavior and standard gaps that can lead to loss Helps you understand incident causation and what management must do to create a Just Culture Page 49

A Management Stand Effectively Manages Risks through Processes and Procedures Benefits Creates a Just Culture with clear reporting and learning objectives Helps identify unsatisfactory situations establishes actions, not outcomes Provides opportunities for management to focus (or refocus) on establishing ultimate goals or culture Builds relevance within an HuP Culture and reduces loss by: Adding value Improving EBIT Reducing incidents Building consistent and expected behaviors Page 50

A Management Stand Effectively Manages Risks through Processes and Procedures A Management Stand will aid management in communicating their expectations more clearly, and manage more effectively Closes the gap between work as imagined vs. as performed Page 51

Recommended Readings Managing Maintenance Error James Reason The Human Contribution James Reason The Field Guide to Understanding Human Error Sidney Dekker Just Culture Balancing Safety & Accountability Sidney Dekker Behind Human Error David D. Woods Resilience Engineering Erik Hollnagel Safety I and Safety II The Past and Future of Safety Management Release Date: May 2014 Erik Hollnagel Page 52

Questions...Comments Page 53

Contact Global Manager HuP and Zero Harm 4400 Alafaya Trail Orlando, FL Phone: 1-727-510-8863 Fax: 1-727 826-3511 E-mail: tom.mcdaniel@siemens.com Page 54