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Human Error

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Definition: An action that unintentionally departs from an expected behavior ' ... The strategic approach to improving human performance embraces two primary changes: ... – PowerPoint PPT presentation

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Title: Human Error


1
Human Error
  • Brian Harkins

2
Error
  • Definition An action that unintentionally
    departs from an expected behavior
  • 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, peoples work
    is subject to and constrained by multiple
    factors.
  • --Sidney Dekker

3
Violation
  • Deliberate, intentional acts to evade a known
    policy or procedure requirement for personal
    advantage usually adopted for fun, comfort,
    expedience, or convenience
  • Violation is a motivational issue

4
Error Or Violation?
  • People do not make mistakes intentionally.
  • Error is behavior, without malice of forethought.
  • Violation involves the deliberate deviation from
    expected behavior.
  • Errors are for the most part unintentional.
    It is very hard for management to control what
    people did not intend to do in the first place.
  • Dr. James Reason

5
Can we punish errors away?
  • You did not intend to make that mistake and did
    not understand the consequences, so I am going to
    punish you so the next time you dont intend to
    do something, you wont do it

6
Strategic Approach
  • The strategic approach to improving human
    performance embraces two primary changes
  • Anticipate, prevent, catch, and recover from
    active errors at the job site.
  • Identify and eliminate latent organizational
    weakness that provoke human error and degrade
    defenses against error and the consequences of
    error.
  • Reduce errors Manage defenses No Events
  • Re Md ?E

7
  • Events are not so much the result of error-prone
    workers as they are the outcome of error-prone
    tasks and error-prone work environments, which
    are controlled by the Organization.
  • James Reason, Managing the Risks of
    Organizational Accidents
  • ---------------------------------------
  • A review of 35 events in nuclear power plants
    that had the potential to do core damage
    identified 270 errors of which 81 were latent
    and 19 were active errors.
  • Nuclear Regulatory Commission, NUREG/CR-6753,
    March 2002

8
Job-Site Conditions
The link between organization and the job-site
Source Dean Ripley. Performance Improvement
Pathfinders, Models for Organizational Learning.
1997, p54.
9
JENGA
10
Terminology
  • Active Errors Error that results in immediate
    unfavorable result to the plant or personnel.
  • Latent Errors Errors that result in hidden
    organization related weaknesses or equipment
    flaws that lie dormant.
  • Latent Organizational Weaknesses Hidden
    deficiencies in management control processes or
    values creating workplace conditions that provoke
    error.
  • Error Precursors Unfavorable conditions at the
    work site that increase the probability of errors

11
Common Traps of Human Nature
  • Stress
  • Mental Strain Avoidance
  • Inaccurate Mental Models
  • Limited Working Memory
  • Limited Attention Resources
  • Mind-Set

12
Common Traps of Human Nature
  • Difficulty Seeing Ones Own Error
  • Limited Perspective
  • Susceptibility to Emotional/Social Factors
  • Motivated toward Goal Accomplishment
  • Fatigue

13
Unsafe Attitudes
  • Risk Perception Human beings are poor judges of
    risk. People are less afraid of risks or
    situations
  • They feel they have control
  • Risk provides wanted benefits
  • Know about and live with the hazard
  • Risks are routine - not new or novel
  • Risks come from people or organizations they
    trust
  • Unaware of the hazard(s)

14
Hazardous Attitudes
  • Pride - Dont insult my intelligence.
  • Heroic - Ill get it done, hook or by crook.
  • Invulnerable - That cant happen to me.
  • Fatalistic - Whats the use?
  • Bald Tire I have 60K miles and havent had
    a flat yet.
  • Summit Fever - Were almost done.
  • Pollyanna - Nothing bad will happen.

15
Uneasiness and Intolerance
  • People should possess a keen sense of uneasiness
    toward any activity
  • Uneasiness prompts a person to expect success
    but anticipate failure.
  • Strategic foundation for improving performance
    Personnel recognizing error-likely situations and
    degraded or missing defenses.

16
Error-likely - Is this a setup?
17
Error-likely Situation
An error aboutto happen due toerror precursors
18
Error Precursors Short List
Task Demands
Individual Capabilities
Work Environment
Human Nature
19
Formosa Plastic Plant Explosion Fire Video
  • What are the Error Precursors that you see?
  • What was the Active Error?
  • What was the Passive Errors?
  • What was the Human Error?

20
Human Information Processing
Thinking
Sensing
Acting
When people err, there is typically a fault with
one or more of the stages of information
processing, not with one's motivation.
Source Wickens, 1992
21
Performance Modes
Source James Reason. Managing the Risks of
Organizational Accidents, 1998.
1/2
15 of errors
KB
1/1,000
Inaccurate Mental Picture
60 of errors
RB
Misinterpretation
1/10,000
25 of Errors
SB
88 - 90 of our time!! ---
Inattention
22
Skill Based (SB) Performance
  • Very familiar situations executed from memory
    without significant conscious thought or with
    little attention.
  • Test - can the person carry on a conversation
    while performing the task.
  • Error mode - Inattention. Primarily execution
    errors, involving slips and lapses in attention
    or concentration. Errors involve inadvertent
    slips and unintentional omissions triggered by
    simple human variability or by not recognizing
    changes in task requirements, system response, or
    plant conditions related to the task.
  • Error Rate - less than 1 in 10,000.
  • 90 of a persons daily activities are spent in
    the skill-based performance mode.
  • 25 of all errors.

23
Rule Based (RB) Performance
  • Based on the selection of stored rules derived
    from one's experience or from a procedure it
    follows an IF (symptom X), THEN (situation Y)
    logic.
  • Test Is the worker using IF (symptom X), THEN
    (situation Y) logic either using a procedure or
    by conscious mental thought.
  • Error mode is misinterpretation. Errors involve
    deviating from an approved procedure, applying
    the wrong response to a work situation, or
    applying the correct procedure to the wrong
    situation.
  • Error Rate - 1 in 1,000.
  • Roughly 60 of all errors.

24
Knowledge Based (KB) Performance
  • The person relies on his or her understanding and
    knowledge of the system (mental model), the
    system's present state, and the scientific
    principles and fundamental theory related to the
    system to develop an appropriate response.
  • Test Is this a unfamiliar situation (no skill
    or rule recognizable by the individual).
  • Error mode is an inaccurate mental model of the
    system, process, or situation. Knowledge-based
    activities require diagnosis and problem-solving.
    Decision-making is erroneous if problem-solving
    is based on inaccurate information.
  • Error Rate - 1 in 2.
  • 15 of all errors.

25
Error Precursors Effect on Performance Modes
  • Some error precursors are particularly powerful,
    depending on the performance mode of the
    individual performing the action. For instance
  • Skill-based performance strongly influenced by
    distractions, simultaneous tasks, and fatigue
  • Rule-based performance - strongly influenced by
    mindset confusing displays, and confusing
    procedures
  • Knowledge-based performance - strongly influenced
    by assumptions, first-time performance of the
    task, time pressure, lack of knowledge, and
    inexperience

26
Helicopter Landing Video
  • What were the performance modes of the pilot?

27
Error Prevention at the Jobsite
  • Machines Equipment can be designed to catch
    errors
  • Other People Co-workers and Supervisors are
    resources to help prevent or catch errors
  • Individuals The individual can catch his or her
    own error before it results in an event.

28
PROACTIVE MENTAL FRAMEWORK
29
Proactive Mental Framework - Plan
  • TWIN Analysis Reducing error precursors

30
Proactive Mental Framework - Prepare
  • SAFER Dialogue
  • Summarize Critical Steps
  • Anticipate Error Traps
  • Foresee Potential Consequences
  • Evaluate Defenses
  • Review Experience
  • Task Preview Before During Pre-job

31
Critical Process Step Concept
32
Critical Steps
  • Draining Waste Water from Reactor Vessel at
    Formosa Plastics
  • Ensure hazardous gasses have been purged from the
    reactor.
  • Open the manway door.
  • Power wash residue from walls.
  • Open the bottom valve and drain valve and drain
    flush water to the floor drains.
  • Close bottom valve and drain valve.
  • Notify the Poly Operator that the reactor is
    ready for a new batch.
  • Warning
  • Worker could be exposed to hazardous gasses if
    reactor has not been purged before the manway
    door is opened.
  • Do not over ride the bottom valve interlock
    without Shift Supervisor approval.

33
Guidance for Level of Pre-job Briefing
Task
Simple or Repetitive
SAFER Dialogue
Preplanned Prejob Briefing Forms
 
 
 
Complex or Infrequent
Generic Prejob Briefing Checklist
Infrequently Performed Testor Evolution
 
 
 
34
Pre-job Brief Should Cover
  • Task (Scope, Sequence Critical Steps)
  • Expected Plant Responses
  • Responsibility of each individual
  • Specific method(s) of communications
  • Radiological and environmental concerns
  • Operating experiences and lesson learned
  • List of job hazards, special precautions and
    appropriate PPE
  • Appropriate procedures, drawings, and other
    references
  • Identification of energy source controls
  • Input, questions and concerns from those in
    attendance 

35
Five Key Pre-Job Questions
  • Have we done this job before? (Identify problems
    and operating experience)
  • What are the critical steps? (Irrecoverable
    actions)
  • What mistakes might be made? (Error likely
    situations)
  • What is the worst thing that can happen? (to the
    workers, plant or equipment) What kind of
    defenses should be considered? (what defenses are
    in place, are they adequate, how we know and what
    will we do if a defense fails)

36
Things to Avoid During Pre-job Briefs
  • Generalities no discussion of specific error
    traps
  • No adaptation of error-prevention tools
  • Monologue by one person
  • Principal participants not present for briefing
  • Supervisor responsible for conducting multiple
    pre-job briefings at the same time
  • No consideration of the scope of the task or when
    the original task becomes a new task
  • No planning for the conduct of the pre-job
    briefing
  • Using a checklist of over 270 items to cover
    during a pre-job briefing, especially low-risk
    activities
  • Conducted in a distracting location

37
Proactive Mental Framework - Perform
Error-Prevention Tools
  • Self-checking
  • Peer-checking
  • Three-way communication
  • Procedure Use and Adherence
  • Stop when Unsure
  • Interruption/Backup
  • Questioning Attitude
  • Place keeping
  • Stop Think Act Review (STAR)
  • Concurrent verification
  • Independent verification
  • Stating Intentions Before Acting
  • Flagging

38
Proactive Mental Framework Pursue Excellence
  • Post-job Critique
  • Management System Feedback
  • LEARN
  • Look Critically,
  • Engage to Improve,
  • Avoid Recurrence,
  • Report Honestly,
  • Nurture Learning in Others

39
Post-Job Critique
  • Purpose Organizational Improvement
  • Quick and easy
  • Production and Prevention
  • Management Acknowledgement
  • Follow-through

40
Top 10 Error Traps
  • Time pressure
  • Distracting environment
  • High workload
  • First time evolution
  • First working day after days off
  • One-half hour after wake-up or meal
  • Vague or incorrect guidance
  • Over-confidence
  • Imprecise communications
  • Work stress

41
Team Errors
  • Halo Effect Blind trust in specific individuals
    because of their experience or position in the
    organization
  • Pilot / Co-pilot Subordinate person reluctant
    to challenge senior person
  • Free Riding One person leads while others loaf
  • Groupthink Reluctance to share contradictory
    information because it might break harmony
  • Risky Shift Tendency to gamble more as a group
    because accountability is diffused

42
Antidotes to Team Errors
  • Train on team errors and their causes
  • Practice questioning attitude/situation awareness
  • Designate a devils advocate
  • Maintain independence in thought from other
    members
  • Challenge actions and decisions of others

43
Antidotes to Team Errors
  • Call time outs to help the team achieve a
    shared understanding of plant or product status
  • Perform a thorough and independent task preview
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