Whole Brain Thinking For Future Leaders

6. Whole Brain ThinkingFor the Future of Leadership

7. Leaders Challenge: Identifying what factors affect people performance

8. A Simple Model Performance outcome Y is a function of factors X.

9. Are People a Critical X?

10. Tangible vs. Intangible Assets

12. �In order to identify the elusive recipe for outstanding leadership, we have reviewed data ranging from leaders neurology to measures of the emotional climate that a leader creates.� Outstanding leaders seem to have one common characteristic trait��.. Daniel Goleman, Ph.D Richard Boyatzis, Ph.D Annie McKee, Ph.D

14. Emotional Intelligence

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16. Most of the material on successful leaders seem to capture three reoccurring principles on what to lead�

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26. Human Performance ImprovementA New Way of Thinking! Leaders are challenged to �detect the undetected�. Traditional walkabouts and assessments will not detect Latent Conditions.

29. Why a Human Performance Improvement Approach?

30. This model is one of the key aspects of human performance that describes the overall context of the initiative. (Briefly explain it. Note that precursors to error can be internal or external to the individual. It�s simply meant to provide a basic concept of the kinds of things that can lead to human error.. Everyone has an impact. We�re really talking Organizational Performance.) This model isn�t only applicable to the nuclear industry. It comes from research which examined many businesses that focus on human performance. Work Through a traffic accident to point out the pieces of the model. Discuss visions, values and beliefs. . Ask what an event is. an undesirable consequence to the plant generally in terms of reduced safety margin. . Ask what initiates a human performance event. initiating action Emphasize the aspect of human involvement. Action may be exactly what procedure calls for, yet it is inappropriate because of plant conditions. Define error precursors and flawed defenses. Emphasize that precursors provoke error while flawed defenses allow the consequences of the act to propagate. ERROR PRECURSORS Unfavorable factors embedded in the job site that increase the chances of error during the performance of a specific task by a particular individual. (See also human nature, individual capabilities, task demands, and work environment) FLAWED DEFENSES Defects with administrative or physical defensive measures that, under the right circumstances, may fail to: �������� Protect plant equipment or people against hazards �������� Prevent the occurrence of active errors �������� Mitigate the consequences of error . Ask what causes or creates these precursors and flawed defenses? latent organizational weaknesses NOTE: The values of the individual need to match the values of the organization. This model is one of the key aspects of human performance that describes the overall context of the initiative. (Briefly explain it. Note that precursors to error can be internal or external to the individual. It�s simply meant to provide a basic concept of the kinds of things that can lead to human error.. Everyone has an impact. We�re really talking Organizational Performance.) This model isn�t only applicable to the nuclear industry. It comes from research which examined many businesses that focus on human performance. Work Through a traffic accident to point out the pieces of the model. Discuss visions, values and beliefs. . Ask what an event is. an undesirable consequence to the plant generally in terms of reduced safety margin. . Ask what initiates a human performance event. initiating action Emphasize the aspect of human involvement. Action may be exactly what procedure calls for, yet it is inappropriate because of plant conditions. Define error precursors and flawed defenses. Emphasize that precursors provoke error while flawed defenses allow the consequences of the act to propagate. ERROR PRECURSORS Unfavorable factors embedded in the job site that increase the chances of error during the performance of a specific task by a particular individual. (See also human nature, individual capabilities, task demands, and work environment) FLAWED DEFENSES Defects with administrative or physical defensive measures that, under the right circumstances, may fail to: �������� Protect plant equipment or people against hazards �������� Prevent the occurrence of active errors �������� Mitigate the consequences of error . Ask what causes or creates these precursors and flawed defenses? latent organizational weaknesses NOTE: The values of the individual need to match the values of the organization.

33. Two Kinds of Error Definition of human error: an action (behavior) that unintentionally departs from an expected behavior (see Glossary) Write on flip chart Error = Delta Behavior/standard or expectation. A violation involves a deliberate deviation from specified behavior (management expectations). This course does not deal with violations. However, we need to ask if the observed behavior was a violation? What is the true expectation? What we always do and has been accepted maybe the true expectation, not what we say. Or what is specified in administrative or other procedure. .Fact: Error is defined by the behavior (B) not the result (R). NOTE: The same behavior can have little or no consequences or have great consequences. Error is classified based upon result. .Two kinds of error (based upon the kinds of results they obtain) .Active errors � errors(delta behavior/standard) that change equipment, system, plant state, or peoples state triggering immediate undesired consequences. Latent errors (typically by management and staff) - errors resulting in undetected organization-related weaknesses or equipment flaws that lie dormant. Latent errors create latent conditions, for example �. .Compare and contrast the who, what, when, and visibility for these two types of error. Have chart made up on flip chart. Leave answers blank. Facilitate responses from participants. Characteristics Active Latent Who? front-line workers management & staff What? change plant state change paper, policies, values When? Immediate dormant Visible? yes no .Error classification sprint - HANDOUT .Instructions: Take one minute to check the appropriate column on the exercise sheet Move quickly. Identify whether the action is an active or a latent error. .Review the results of a few with the participants. Make sure to review 4 and 10 closely. They are related. ASK: did the I&C technician in 10 make an active error. If he did what is it? Note: It depends on the expectations of the station. Strict Procedure/schedule compliance or know the system. .Direct attention the the definition of an error. Delta behavior/standard of expectation Definition of human error: an action (behavior) that unintentionally departs from an expected behavior (see Glossary) Write on flip chart Error = Delta Behavior/standard or expectation. A violation involves a deliberate deviation from specified behavior (management expectations). This course does not deal with violations. However, we need to ask if the observed behavior was a violation? What is the true expectation? What we always do and has been accepted maybe the true expectation, not what we say. Or what is specified in administrative or other procedure. .Fact: Error is defined by the behavior (B) not the result (R). NOTE: The same behavior can have little or no consequences or have great consequences. Error is classified based upon result. .Two kinds of error (based upon the kinds of results they obtain) .Active errors � errors(delta behavior/standard) that change equipment, system, plant state, or peoples state triggering immediate undesired consequences. Latent errors (typically by management and staff) - errors resulting in undetected organization-related weaknesses or equipment flaws that lie dormant. Latent errors create latent conditions, for example �. .Compare and contrast the who, what, when, and visibility for these two types of error. Have chart made up on flip chart. Leave answers blank. Facilitate responses from participants. Characteristics Active Latent Who? front-line workers management & staff What? change plant state change paper, policies, values When? Immediate dormant Visible? yes no .Error classification sprint - HANDOUT .Instructions: Take one minute to check the appropriate column on the exercise sheet Move quickly. Identify whether the action is an active or a latent error. .Review the results of a few with the participants. Make sure to review 4 and 10 closely. They are related. ASK: did the I&C technician in 10 make an active error. If he did what is it? Note: It depends on the expectations of the station. Strict Procedure/schedule compliance or know the system. .Direct attention the the definition of an error. Delta behavior/standard of expectation

35. Strategic Approach These statements represent the goals we are headed for in this industry and with this training. These statements represent the goals we are headed for in this industry and with this training.

36. Stuff You Need to Know

37. Two Views of Human Error The Field Guide will encourage you to build a picture of How a process and other circumstances unfolded around people How peoples assessments and actions evolved in parralel with their changing situations How features of peoples tools and tasks and organizational and operational environment influenced their assessments and actions The Field Guide will encourage you to build a picture of How a process and other circumstances unfolded around people How peoples assessments and actions evolved in parralel with their changing situations How features of peoples tools and tasks and organizational and operational environment influenced their assessments and actions

39. Latent Conditions: 

40. Human Performance

42. Limitations of Human Nature Avoidance of mental strain Inaccurate mental models Limited working memory Limited attention resources Pollyanna effect Mind set Difficulty seeing own errors Limited perspective Susceptible to emotion Focus on goal These characteristics of human nature, among many others, are encountered whenever people perform complex tasks in a complex work environment. Consequently, there is always the chance for error. See the quotation in the desk reference Page _______ �Safety is a continuous fight with human nature.� Dr. E. Scott Geller Author: The Psychology of Safety These characteristics of human nature, among many others, are encountered whenever people perform complex tasks in a complex work environment. Consequently, there is always the chance for error. See the quotation in the desk reference Page _______ �Safety is a continuous fight with human nature.� Dr. E. Scott Geller Author: The Psychology of Safety

43. Error Precursors Error Precursor - unfavorable prior conditions that reduce the opportunity for successful behavior at the jobsite; creates (exacerbates) the mismatch associated with task demands and the individual (error-likely situation/ELS). List derived from INPO event data base and several credible references associated with human performance. Handout � �Lifted Leads� Newsletter Have students read �ME- Out of Sync� Identify error precursors (use yellow cards) Facilitate a discussion. Multiple error precursors - increase chances of error; change the situation How do the above conditions change from normal on-line to outage How many error precursors are necessary to cause error? None. Why? Human performance is not rocket science, i.e., black and white. Individual differences Some people respond differently, or to a different degree, to error precursors. You may have error prone people Error Precursor - unfavorable prior conditions that reduce the opportunity for successful behavior at the jobsite; creates (exacerbates) the mismatch associated with task demands and the individual (error-likely situation/ELS). List derived from INPO event data base and several credible references associated with human performance. Handout � �Lifted Leads� Newsletter Have students read �ME- Out of Sync� Identify error precursors (use yellow cards) Facilitate a discussion. Multiple error precursors - increase chances of error; change the situation How do the above conditions change from normal on-line to outage How many error precursors are necessary to cause error? None. Why? Human performance is not rocket science, i.e., black and white. Individual differences Some people respond differently, or to a different degree, to error precursors. You may have error prone people

44. Performance Modes Begin Note to Facilitators: 1. The material on this slide is complex; difficult to understand and difficult to explain. Before presenting this slide as part of the Human Performance Course, please read Source: James Reason. Managing the Risks of Organizational Accidents, 1998. The information in the book is very helpful in teaching Human Performance, as is this slide. 2. Consider drawing the diagram piece-by-piece on a flip chart rather than trying to explain all sections at once from the Ppt. Slide. End Note to Facilitators. If I know how to perform a task, and I possess the ability to perform the task, then why do I sometimes err with simple tasks? Human Nature - not an excuse, but characteristic of human beings to be imprecise (expected reliability: .995 to .997 typically or .9999 ideally). What if task must have reliability of 1? Transitions: From SB: Delta - change in task/environment; Into KB: ? - uncertainty & doubt Definitions of each performance mode (see Generic Error Model in HPF course reference). Include examples from both every day life and plant activities. Recall example events for each mode. (Human Error, p61) Mental States: Auto, If-Then, Patterns Reliability or Chances for error: SB - 1:10K (ideal conditions); RB - 1:1K (nominal); KB - 1:2 (urgent) (chances for success improve in KB performance mode as time to make a decision increases) Distribution of error industry wide: SB: 25%, RB: 60%, KB: 15% (Source: PII); Describe event in each mode. Time spent in each mode: SB: 88-90%, RB/KB: 10-12% (Source: Hypnotherapy, Atlanta Constitution, 11/22/98) RB/KB involve conscious decision making; roughly 75% of errors made during activities that take roughly 10% of time (supposition - no empirical data to support) Error Modes: SB � Inattention; RB � Misinterpretation; KB � Inaccurate mental model/picture KB: unfamiliarity �, anxiety �, stress �, search for patterns, �, assumptions �, trial & error (Easter egging) �, panic (vagabonding or tunneling) �, event or value-added progress. Conscious, directed thinking can exclude outside sensory information - could miss important information. (Restak, Brainscapes, p30) Time Effects: As time to respond increases, the chance for error diminishes. Chance for error is highest when the unfamiliar situation (especially involving danger) strikes suddenly without warning and requires quick reaction. (Man Made Disasters, p33-34) WANT TO AVOID THIS!!! Workers - SB and RB most often (prescriptive in nature); Managers - RB and KB (discretionary) SB - Unconscious competence; RB - Conscious competence; KB - Conscious incompetence PB - Unconscious incompetence (panic-based) To improve importance - stimulate interest in the task; why job is critical to plant success; WIIFM Biases take over in KB, e.g., pattern matching, frequency and confirmation biases Review error precursors that are particularly potent for each error mode (SB - distractions, illness & fatigue, simultaneous tasks; RB - mind set, confusing procedure; KB - hidden system response, assumptions, lack of fundamental knowledge) (see more information in Man-Made Disasters, p113-115) Error-Prevention Techniques: SB � self-checking, peer checking, slow down; RB � critical parameter, peer-checking, If2Then2; KB � team problem-solving, devil�s advocate, �buy time,� Purpose of Task Preview - to identify method of best control; not to question competence Note: After illustrating each performance mode on the flip chart, refer to the Generic Error Modeling System (GEMS) model in the student notebook to reinforce student understanding of each performance mode. � Begin Note to Facilitators: 1. The material on this slide is complex; difficult to understand and difficult to explain. Before presenting this slide as part of the Human Performance Course, please read Source: James Reason. Managing the Risks of Organizational Accidents, 1998. The information in the book is very helpful in teaching Human Performance, as is this slide. 2. Consider drawing the diagram piece-by-piece on a flip chart rather than trying to explain all sections at once from the Ppt. Slide. End Note to Facilitators. If I know how to perform a task, and I possess the ability to perform the task, then why do I sometimes err with simple tasks? Human Nature - not an excuse, but characteristic of human beings to be imprecise (expected reliability: .995 to .997 typically or .9999 ideally). What if task must have reliability of 1? Transitions: From SB: Delta - change in task/environment; Into KB: ? - uncertainty & doubt Definitions of each performance mode (see Generic Error Model in HPF course reference). Include examples from both every day life and plant activities. Recall example events for each mode. (Human Error, p61) Mental States: Auto, If-Then, Patterns Reliability or Chances for error: SB - 1:10K (ideal conditions); RB - 1:1K (nominal); KB - 1:2 (urgent) (chances for success improve in KB performance mode as time to make a decision increases) Distribution of error industry wide: SB: 25%, RB: 60%, KB: 15% (Source: PII); Describe event in each mode. Time spent in each mode: SB: 88-90%, RB/KB: 10-12% (Source: Hypnotherapy, Atlanta Constitution, 11/22/98) RB/KB involve conscious decision making; roughly 75% of errors made during activities that take roughly 10% of time (supposition - no empirical data to support) Error Modes: SB � Inattention; RB � Misinterpretation; KB � Inaccurate mental model/picture KB: unfamiliarity �, anxiety �, stress �, search for patterns, �, assumptions �, trial & error (Easter egging) �, panic (vagabonding or tunneling) �, event or value-added progress. Conscious, directed thinking can exclude outside sensory information - could miss important information. (Restak, Brainscapes, p30) Time Effects: As time to respond increases, the chance for error diminishes. Chance for error is highest when the unfamiliar situation (especially involving danger) strikes suddenly without warning and requires quick reaction. (Man Made Disasters, p33-34) WANT TO AVOID THIS!!! Workers - SB and RB most often (prescriptive in nature); Managers - RB and KB (discretionary) SB - Unconscious competence; RB - Conscious competence; KB - Conscious incompetence PB - Unconscious incompetence (panic-based) To improve importance - stimulate interest in the task; why job is critical to plant success; WIIFM Biases take over in KB, e.g., pattern matching, frequency and confirmation biases Review error precursors that are particularly potent for each error mode (SB - distractions, illness & fatigue, simultaneous tasks; RB - mind set, confusing procedure; KB - hidden system response, assumptions, lack of fundamental knowledge) (see more information in Man-Made Disasters, p113-115) Error-Prevention Techniques: SB � self-checking, peer checking, slow down; RB � critical parameter, peer-checking, If2Then2; KB � team problem-solving, devil�s advocate, �buy time,� Purpose of Task Preview - to identify method of best control; not to question competence Note: After illustrating each performance mode on the flip chart, refer to the Generic Error Modeling System (GEMS) model in the student notebook to reinforce student understanding of each performance mode. �

45. Human Performance Fundamentals Defenses Hard - Soft - Most defensive functions are achieved through a combination of hard and soft defenses. Hard defenses are Engineered safety functions, barriers, alarms, interlocks, etc. Soft defenses are usually a combination of paper and people:Legislation, procedures, licensing, oversight, In the early days workers involvement was mainly productive � they made or did things, that led directly to commercial profit. And thus were directly in contact with hazards. Now computers and technology have changed the workers involvement to that of planners, managers, maintainers of systems and processes. Ie operators, pilots, and removed them in a lot of cases from being directly involved with the hazards. This results in defense in depth which is a mixed blessing. This makes the system more complex and Opaque. This results in the build up of latent conditions. Most defensive functions are achieved through a combination of hard and soft defenses. Hard defenses are Engineered safety functions, barriers, alarms, interlocks, etc. Soft defenses are usually a combination of paper and people:Legislation, procedures, licensing, oversight, In the early days workers involvement was mainly productive � they made or did things, that led directly to commercial profit. And thus were directly in contact with hazards. Now computers and technology have changed the workers involvement to that of planners, managers, maintainers of systems and processes. Ie operators, pilots, and removed them in a lot of cases from being directly involved with the hazards. This results in defense in depth which is a mixed blessing. This makes the system more complex and Opaque. This results in the build up of latent conditions.

46. Human Performance Fundamentals Chapter III Dangerous Defenses Can you have too many defenses? What does it mean for them to become Opaque? What is the number one thing to be cautious of when contemplating a defense? Pose a case to the class. Can you have too many defenses? What does it mean for them to become Opaque? What is the number one thing to be cautious of when contemplating a defense? Pose a case to the class.

47. Human Performance Fundamentals Regulators Damned if they do and Damned if they Don�t Workload increased, resources slashed Accused of being to close to the client, while the client see�s them as intrusive and obstructive Accused of not being familiar with the operations, but depend upon the client for this information Usually technical specialists, while most accidents are due to the interaction between human and organizational factors