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Human Performance Improvement. Principles for Managers. Course Objective. Management will be able to create an environment where workers can make good decisions by: Recognizing the role of the individual and human fallibility in human performance

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human performance improvement

Human Performance Improvement

Principles for Managers


course objective
Course Objective
  • Management will be able to create an environment where workers can make good decisions by:
    • Recognizing the role of the individual and human fallibility in human performance
    • Identifying how organizational systems influence human behavior
    • Embracing the role of the leader to manage organizational systems and positively influence human behavior


human performance
Human Performance

“People do not operate in a vacuum, where they can decide and act all-powerfully. To err or not to err is not a choice. Instead, people’s work is subject to and constrained by multiple factors”.

— Sidney Dekker


what is human performance
What is Human Performance?

An individual…

working within

organizational systems…

to meet expectations

set by leaders.


how to improve human performance
How to Improve Human Performance

Address limitations of human nature

Remove error traps

Create error-tolerant systems

Reinforce desired behaviors


Incentives to meet leader’s expectations



  • Operational Upset: A condition that adversely affects, or may adversely affect, DOE or contractor personnel, the public, property, environment or the DOE mission.
  • Error: An unintentional deviation from an expected behavior.
  • Violation: Deliberate, intentional acts to evade a known policy or procedure requirement for personal advantage usually adopted for fun, comfort, expedience, or convenience


hpi principles
HPI Principles
  • People are fallible
  • Error-likely situations are predictable
  • Individual behaviors are influenced
  • Operational upsets can be avoided
  • People achieve high levels of performancebased encouragement and reinforcement.


the individual
The Individual

HPI Principle #1:

People are fallible, and even

the best make mistakes.


origins of human error
Origins of Human Error

Human Errors

System Induced Error

Operational Upsets

Slip, trip or lapse

Human Error

Equipment Failures


  • Count the number of passes between white-shirted players
  • You MUST be accurate


limitations of human nature
Limitations of Human Nature

Mistakes arise directly from the way the mind handles information, not through stupidity or carelessness.

— Dr. Edward de Bono



Limitations of Human Nature

See page 4 in your Concepts Guide

  • Stress
  • Avoidance of mentalstrain
  • Inaccurate mentalmodels
  • Limited working memory
  • Limited attention resources
  • Mind set
  • Difficulty seeing own errors
  • Limited perspective
  • Susceptible to emotion
  • Focus on the goal
  • Fatigue


hazardous attitudes
Hazardous Attitudes

See page 6 in your Concepts Guide

  • Pride: “Don’t insult my intelligence.”
  • Heroic: “I’ll get it done, by hook or by crook.”
  • Invulnerable: “That can’t happen to me.”
  • Fatalistic: “What’s the use?”
  • Bald Tire: “Gone 60K miles without a flat yet.”
  • Summit Fever: “We’re almost done.”
  • Pollyanna: “Nothing bad will happen.”



“Risks that you can control are much less a source of outrage than risks you can NOT control.”

— PeterSandman

… in other words, the risks that scare people and the risks that actually kill people are very different


performance modes
Performance Modes

See page 7 in your Concepts Guide

When switching from one performance mode to another a worker is presented with a new situation but has only old information on which to base decisions.


error traps
Error Traps

HPI Principle #2:

Error-likely situations are predictable, manageable, and preventable.


saw stop tm
Saw StopTM


error precursors

Time pressure (in a hurry)

  • Unfamiliarity w/ task / First time
  • High Workload (memory requirements)
  • Lack of knowledge (mental model)
  • Simultaneous, multiple tasks
  • New technique not used before
  • Repetitive actions, monotonous
  • Imprecise communication habits
  • Irrecoverable acts
  • Lack of proficiency / Inexperience
  • Interpretation requirements
  • Indistinct problem-solving skills
  • Unclear goals, roles, & responsibilities
  • “Hazardous” attitude for critical task
  • Lack of or unclear standards
  • Illness / Fatigue
  • Distractions / Interruptions
  • Stress (limits attention)
  • Changes / Departures from routine
  • Habit patterns
  • Confusing displays or controls
  • Assumptions (inaccurate mental picture)
  • Workarounds / OOS instruments
  • Complacency / Overconfidence
  • Hidden system response
  • Mindset (“tuned” to see)
  • Unexpected equipment conditions
  • Inaccurate risk perception (Pollyanna)
  • Lack of alternative indication
  • Mental shortcuts (biases)
  • Personality conflicts
  • Limited short-term memory
Error Precursors

See page 18 in your Concepts Guide

Task Demands

Individual Capabilities

Work Environment

Human Nature


error prevention tools


Concurrent verification

Independent verification

Three-way communication


Pre-job briefing

Post-job briefing

Procedure use & adherence


Questioning attitude

Conservative decision making

Stop & collaborate

Error Prevention Tools


the organization
The Organization

HPI Principle #3:

Individual behavior is influenced by organizational processes and values.


new vs old view of human error
Human error is a cause of accidents

To explain failure, investigations must seek failure

They must find people’s inaccurate assessments, wrong decisions and bad judgments

Human error is a symptom of trouble deeper inside a system…

To explain failure, do not try to find where people went wrong.

Instead, find how people’s assessments and actions made sense at the time, given the circumstances that surrounded them.

New vs. Old View of Human Error


the dryden event
The Dryden Event

Air Ontario Flight 363 Fokker F28Dryden, CanadaMarch 10, 1989


types of error
Types of Error

See page 12 in your Concepts Guide

  • Active Errors change equipment, system or processes that trigger immediate undesired consequences.
  • Latent Errors result in undetected organization-related weaknesses or equipment flaws that lie dormant.


understanding events
Understanding Events
  • Incentives are the cornerstone of human behavior
  • Dramatic events often have distant even subtle causes
  • Conventional wisdom is often wrong
  • Knowing what to measure and how to measure it makes a complex world much less complicated


organizational processes
Organizational Processes

Workplaces and organizations are easier to manage than the minds of individual workers. You cannot change the human condition, but you can change the conditions under which people work.

— Dr. James Reason


the value of error tolerance
The Value of Error Tolerance

Error without consequence is a good thing — it shows that our systems are error-tolerant and that they are working.


defenses in depth
Defenses in Depth

See page 14 in your Concepts Guide

  • Redundancy: many layers of protection.
  • Diversity: many different varieties of protection.
  • Independence: separate/autonomous layers of protection.


traditional heisenberg model
Traditional Heisenberg Model

See page 16 in your Concepts Guide

  • Number of errors is relative to the severity of consequences
  • For every major accident there are many errors
  • Leads us to assume that driving down errors will eliminate major accidents


new view of heisenberg model
New View of Heisenberg Model
  • The consequence of error has no relationship to the number of errors
  • It is related to the number and integrity of defenses
  • Any error can lead to a major accident if defenses fail


zero operational upsets
Zero Operational Upsets

See page 20 in your Concepts Guide

Re + Md → OU

Reducing Error AND Managing Defenses leads to Zero Operational Upsets


medical mistakes
Medical Mistakes


organizational values
Organizational Values

HPI Principle #4:

Operational upsets can be avoided by understanding the reasons mistakes occur and applying the lessons learned from past events.


blame cycle
Blame Cycle

See page 23 in your Concepts Guide


culpability decision tree
Culpability Decision Tree

See page 26 in your Concepts Guide


accountability vs culpability

The power to accomplish performance objectives


The blame for failure

A starting point for improvements

A dead end that discourages reporting


Is disempowering and divisive

Arises from empowerment and partnership


Accountability vs. Culpability

See page 40 in your Concepts Guide




performance culture
Performance Culture

See page 28 in your Concepts Guide

  • Encourage Reporting: Value errors as leading safety data
  • Create a Just Work Environment: Don’t try and punish errors out of the system
  • Flexibility: Prepare workers to adapt effectively to changing demands
  • Learning: Create opportunities for observation, reflection and feedback


barriers to a learning organization
Barriers to a Learning Organization
  • 20 years of experience = 1 year of learning repeated 20 times
  • Experts use their informational advantage to reinforce their biases


human to systems interface
Human to Systems Interface
  • People will never perform better than what the organization will allow
  • If a system relies on people doing the right thing every time, it will fail
  • No working system remains in stasis


the leader
The Leader

HPI Principle #5:

People achieve high levels of performance based largely on the encouragement and reinforcement received from peers, leaders, and subordinates.


fallacy of competing resources
Fallacy of Competing Resources

See page 31 in your Concepts Guide


how leaders influence protection vs production
How Leaders Influence Protection vs. Production

See page 33 in your Concepts Guide

  • What they pay attention to, measure, and control
  • Their reactions to critical incidents or crises
  • The allocation of resources
  • Their criteria for allocation of rewards and punishment
  • Their criteria for selection, advancement, and termination
  • Their deliberate attempts to coach or model behaviors.


reality check
Reality Check
  • Safety values express how you desire safety to be in your organization.
  • Safety systems are real defenses and actionable programs that provide measurable safety data sets.


implementing hpi
Implementing HPI
  • HPI is not just training
  • It is a way of doing business that includes:
    • Behavioral observation and walk-arounds
    • Conduct of operations and work management
    • Systems development and re-engineering
    • Issues reporting, management and corrective actions
    • Event investigation and lessons learned
    • Performance management and assurance
    • Simulations and training