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Human Performance, the Event Free Clock & Breaking the Safety Cycle. Introducing Leading Indicators to Break The “Safety Cycle”. How To Measure Safety Performance?. Where to Focus Safety Efforts?. Injuries. The Safety Cycle. Upper Limit. Lower Limit. Time. Safety Initiatives. Rules.

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human performance the event free clock breaking the safety cycle
Human Performance, the Event Free Clock & Breaking the Safety Cycle

Introducing Leading Indicators to Break

The “Safety Cycle”

how to measure safety performance
How To Measure Safety Performance?

Where to Focus Safety Efforts?

the safety cycle

Injuries

The Safety Cycle

Upper Limit

Lower Limit

Time

slide4

Safety Initiatives

Rules

Discipline

Training

Fewer Accidents?

Regulations

Awards

Safety Meetings

Pre-Job Brief

five basic facts
Five Basic Facts
  • People are fallible and even the best will make mistakes.
  • All consequential errors that could lead to injuries are preventable.
  • No worker would intentionally injure themselves.
  • If there is a method that could free a worker from being injured without undue burden, they would adopt it.
  • Fast improvement can only be achieved in an open, non-punitive, and constant learning workplace.
human performance
Human Performance

Basic Human Performance concepts focus on identifying and improving:

  • Human Errors
    • Reduce the chances of errors occurring, and
    • Reduce the effects of errors resulting in injury and/or system disturbances
  • Failed or Insufficient Layers of Protection
  • Latent Organizational Weaknesses
unwanted outcomes events
Unwanted Outcomes (Events)

EquipmentFailure – 20%

Individual Errors – 30%

Human Errors - 80%

Latent Organizational Weaknesses – 70%

human performance1
Human Performance
  • What is Human Performance?
    • A series of behaviors executed to accomplish specific tasks.
human performance2
Human Performance

Improve Human Performance

&

YOU WILL

Improve Operational Performance

the three types of human errors are
THE THREE TYPES OF HUMAN ERRORS ARE:
  • Knowledge-based Errors
    • These tasks are new, unfamiliar or unique to the performer
    • They depend heavily upon the performer’s fundamental knowledge, diagnosis, and analysis skills
    • Best described as trial and error or literally “I don’t know”
the three types of behavior based errors are
THE THREE TYPES OF BEHAVIOR BASED ERRORS ARE:
  • Rule-based Errors
    • These tasks are familiar to the performer
    • Upon correct recognition of a situation or condition, the performer can apply a stored rule to steer towards a known end goal
    • Tasks in this domain tend to follow if-then logic
the three types of behavior based errors are1
THE THREE TYPES OF BEHAVIOR BASED ERRORS ARE:
  • Skill-based Errors
    • These tasks are comprised of very familiar actions
    • Performed in comfortable surroundings
    • The human being is, or is close to, being on autopilot
task error model

Error Mode:

Inaccurate Mental Model

Error Rate 1:10

Error Mode:

Misinterpretation

Error Rate 1:100

Error Mode:

Inattention

Error Rate 1:1,000

Task Error Model

Rules, Standards, Checklist,

Written Procedures

Memorization, Practice

High – Attention - Low

Knowledge based – Rule based – Skill based

Low - Familiarity - High

some human performance tools for individuals
Some Human Performance Tools for Individuals
  • Questioning attitude
  • Stop when unsure
  • Self-checking
  • Procedure use and adherence
  • Three-way communication
  • Phonetic alphabet
  • Place-keeping
  • Two Minute Drill
  • Conservative Decision Making
some human performance tools for teams
Some Human Performance Tools for Teams
  • Pre-job briefing (Tailboard)
  • Peer check
  • Flagging
  • Turnover
  • Post-job review
  • Concurrent Verification
some human performance tools for leaders and management
Some Human Performance Tools for Leaders and Management
  • Observations & Feedback
  • Self-Assessments
  • Operating experience
what is an event clock
What is an Event Clock?
  • A real time Human Performance tool to effectively communicate current human performance status relating to safety and reliability.
  • Qualifying Events reset the clock to zero
  • Helps improve safety and reliability by being a vehicle to share lessons learned following Qualifying Events so that we engrain the HP tools into how we do business.
2012 event clock criteria
2012 Event Clock Criteria
  • Fatalities
  • Amputations
  • Loss of Consciousness
  • Electrical Contacts with Injury
  • Arc Flashes with Injury
  • Fractures (non-dental)
  • Lost-time Injuries
  • Switching Order & Clearance Errors (resulting in an event)
  • Motor Vehicle Accidents greater than $5K damage
  • Unplanned Significant Outages (with feeder breaker trip)
  • OSHA Violations with an event
slide35

Presented by: Chuck Thomack, CSP

  • Section Leader, Safety
  • (602) 371-7873
  • Charles.Thomack@aps.com
  • Date: September 28, 2012