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TRAIN 2007 Human Performance in Tourist Railroading

Objectives of Presentation. Learn what Human Performance IsDiscuss how it applies to our industryUnderstand the role of

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TRAIN 2007 Human Performance in Tourist Railroading

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    1. TRAIN 2007 Human Performance in Tourist Railroading G. Mark Ray Director: TVRM and ARM

    2. Objectives of Presentation Learn what Human Performance Is Discuss how it applies to our industry Understand the role of “barriers” Learn about Human Error Prevention Tools Know the importance of being “error-free”

    3. Why me? I am not an expert Frankie asked me to do a presentation My position with TVA The need for tourist railroading to be free of human performance related errors

    4. What causes Human Error? Overconfidence Complacency Time Pressure Distractive Work Environment Imprecise Communications Stress Return from Time Off First-time evolution Vague or incorrect guidance Our goal is ZERO human errors!

    5. What is Human Performance? “A series of behaviors performed to accomplish specific task objectives, controlled by the individual, regardless of the object of the behavior.”

    6. What’s that in English? Train departing the station – Conductor signals Engineer to depart Engineer gives Rule 14(b) and starts bell Engineer positions reverser Engineer releases brakes Engineer works throttle to accelerate train

    7. Performance Modes Starting the train required the engineer to be in one of three “performance modes”: Skill-Based Mode Rule-Based Mode Knowledge-Based Mode

    8. Skill – Based Mode Learned behaviors/actions, characterized by routine tasks performed in a familiar environment. Which tasks in starting the train are in the skill-based mode?

    9. Rule – Based Mode Decisions made by stored rules accumulated through the life experiences, training and written policies; characterized by ‘if/then’ statements. Which tasks in starting the train are in the rule-based mode?

    10. Knowledge – Based Mode Decisions made by analytical thinking and fundamental knowledge – no learned skills or rules exist to determine correct course of action; characterized by problem solving and decision making. Which tasks in starting the train are in the knowledge-based mode?

    11. Which Performance Mode? Train departing the station – Conductor signals Engineer to depart Engineer sounds Rule 14(b) and starts bell Engineer positions reverser Engineer releases brakes Engineer works throttle to accelerate train

    12. Why is the performance mode important? The probability of making an error is different with each mode. Which has the lowest probability? Skill-Based Which has the highest probability? Knowledge-Based Can we stay in just one performance mode?

    13. Another example TT Instruction says “Water in boiler must be at 2/3 Glass before proceeding past MP 32.4” Train approaches MP 32.4 with ˝ glass of water Fireman observes glass and starts injector Upon reaching MP 32.4, water is at correct level and Fireman secures injector Which performance modes apply here?

    14. The TT Instruction Why do you think that TT Instruction exists? The TT Instruction is an example of a “barrier”. Barriers are lines-of-defense used to prevent human error.

    15. Lines of Defense (Barriers) 1st Line – Equipment Performance 2nd Line – Administrative Controls 3rd Line – Culture 4th Line – Oversight

    16. 1st Line – Equipment Performance The integrity of this line of defense depends on how carefully we operate and maintain the following: Motive Power and Rolling Stock Safety Equipment Track Structure How can the condition of a locomotive, injector, whistle, bell, low-water alarm, or the track have an impact on human performance?

    17. 2nd Level – Administrative Controls The integrity of this line of defense depends how rigorously we follow these procedures: Rulebook Timetable Bulletins Special Instructions Blue Flag, 3 Step Protection, Locks, etc This type of barrier is probably the most familiar to all of you.

    18. 3rd Level – Culture The integrity of this line of defense depends on our sensitivity to the human capacity to err and how much concern we have for our fellow railroaders. Culture consists of the values, beliefs, and attitudes possessed by T & E personnel that either encourage high standards of performance or mediocrity.

    19. More on Culture A good culture is paramount to a safe operation. Key elements of a good culture include – Commitment to Safety from Management Teamwork Passion to do the right thing Observer/Coach (as opposed to Critic/Judge) Training Feedback

    20. 4th Line – Oversight The integrity of this line of defense depends on management’s commitment to high levels of human performance. Oversight tools include: Qualification and Testing Observations Efficiency Tests Check Rides

    21. Qualification and Testing Qualification to operate in T&E Service should be based upon three cornerstones: Skills Testing – Typically performed through a demonstration of skills to a company officer in order to achieve promotion. Rules Testing – A written test on the operating rules of your railroad. This would also cover bulletins, timetables, and special instructions. Knowledge Testing – A mechanical test that can be performed by either oral or written examination.

    22. “The HEAT is on” What does HEAT mean? H = Human E = Error A = Avoidance T = Techniques These are some tools that can be used to prevent human error.

    23. Human Error Avoidance Techniques Some effective tools include: Three-Way Communication Pre-Job Briefings Phonetic Alphabet STAR (Two-Minute Rule) QV&V (Questioning Attitude) Eyes on Path

    24. Three-Way Communication A key tool to ensure effective communication. Example: Sender states the message Receiver repeats the message back to the sender Sender acknowledges that the message was understood Remember the train leaving the station example? Ever copy a train order or a track warrant?

    25. Pre-Job Briefings The pre-job briefing is used to ensure that everyone involved in a task understands all the actions to be performed. Key questions to discuss are: What are we going to do? What is the worst thing that can happen? What are the critical steps? What are the error-likely situations? What are our safety concerns?

    26. Phonetic Alphabet Another tool for effective communication.

    27. Self-Checking (STAR) S – Stop T – Think A – Act R – Review “Don’t Get in a Hurry”

    28. Stop, Think, Act, and Review Stop – Pause before performing operation / manipulation, especially at critical steps, or decision points. Eliminate distractions if necessary. Think – Focus attention on the step to be performed. Verify the action to be taken is appropriate and understand the expected result. Know what actions to take should an unexpected result occur.

    29. Stop, Think, Act, and Review Act – Perform the intended action. Maintain eye and physical contact while performing the action. Review – Verify anticipated result obtained.

    30. STAR – Examples Yes or No? Aligning a Switch (Double Check) Making a Cut (passenger or freight cars) Operating an Injector Service Brake Application Emergency Brake Application Making a Cut (Steel or Wood) Others

    31. QV&V QV&V stands for Qualify, Validate, and Verify. This is also referred to as having a “questioning attitude”. Qualify – Is the source of information accurate, reliable, and relevant to the situation? Validate – Is the information expected and does it make sense? Verify - Confirm the information!

    32. Eyes on Path “Eyes on Path” literally means “watch where you’re going”. It’s broader meaning is to “Keep Your Focus” despite distractions like these: Radio Chatter Cell Phone ringing Railfan asking for a cab visit Balky injector Bad Fireman

    33. Why “Error Free”? We should all consider Human Performance to: Keep your members/employees safe Prevent harm to the Public Avoid increased scrutiny from our regulator Prevent higher insurance premiums Maintain trust by peers or class 1’s

    34. Summary Performance Modes Skill-Based Rule-Based Knowledge-Based Barriers or Lines of Defense Equipment Performance Administrative Controls Culture Oversight Human Error Avoidance Techniques

    35. Questions and Discussion How many of you are familiar with Human Performance tools? Does your railroad use of any of these tools? Does anyone have a practice or an example to share with others? Does anyone have a question? Did you find this seminar useful?

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