Session No.

540

Reducing Frequency and Lowering Severity of Human Error:

Optimize Performance

Tom Harvey, CSP

Optimize Performance
West Columbia, SC

What are the effects of human error? How would it feel to significantly reduce the frequency and
lower the severity of the errors you make? What are the benefits of teaching your children,
grandchildren, friends, and others close to you how to live safer and more productive lives? How
strong is the connection between safe lifestyles off-the-job and injury avoidance on-the-job?

When evaluating these issues, it is insightful to remember that people are not perfect, and
even the best make mistakes. Embracing this truism allows for real safety improvement strategies
that are designed with the understanding that human error is inevitable, and caused by complex
factors such as decision making and perception of risk. We can positively affect decision-making
factors, but we cannot control all the choices people make, or the actions they take. We can help
people develop clearer perceptions of risk, but great disparities still exist. At a recent human
performance conference for utilities, in a room of 100 attendees, a picture was shown of a person
standing on a rock precipice approximately eight-feet across, and 2000-feet high. When the
question was asked, How many attendees would consider walking out onto the precipice an
acceptable risk? one-third of the attendees raised their hands. This is a simple illustration of how
everybody views risks differently.

Accepting that we cannot fully control the human condition, other means must be used to
raise awareness levels that error-traps exist and risks are elevated. Learning how error-traps can
be recognized and avoided will reduce the chance of errors that result in events.

Somewhere in the world, two technicians have a work plan to solve a time-sensitive
problem. Several critical tasks within the job have not worked, so the frustrated senior technician
informally changes the plan and barks out an imprecise directive to a junior technician. The
junior tech is not clear on the instructions, but thinks she understands well enough to proceed.
Shortly thereafter, she skips a critical precautionary step, resulting in a serious injury.

Failure to recognize and control these error-traps scope change, vague guidance,
overconfidence, mental stress, and time pressure forms a toxic mix that dramatically drives up
the likelihood of error. This elevated risk can be controlled by knowing and using Tools in this
case, questioning attitude, effective communication, pre-task review, and coaching.
Seeing the Big Picture

Failure to accept the inevitability of human error will result in continual frustration over adverse
events, poor performance, and reactionary measures that focus too heavily on the last person(s)
involved in the error. A typical knee-jerk recommendation is retraining. What should be said is,
Why do we need to retrain everyone on this same bad procedure that didnt work the first time,
even though they could do it right if they wanted to, but chose not to?

The focus should be on the cumulative effects of organizational breakdowns, flawed

defenses, and system failures that allowed the event to occur. Otherwise, improvement
opportunities are lost. This undue attention on symptoms instead of causes will yield only small
gains, whereas accurate analysis and correction of system failures will return great benefits.
Human performance will improve once organizational factors are redesigned to promote success
and avoid failure. And, as individuals learn and use a set of well defined, proven tools, common
error-traps are mitigated. Thus, a comprehensive, holistic approach is needed that addresses all
components of performance error-traps, organizational factors, and performance tools.

The North American Electrical Reliability Corporation (NERC) cites an event report where
an employee was tasked to enter 83 pieces of data into a controller that was designed to only
accept 80 pieces of data. When the 81st data-point was entered, the system failed, and the cause
was attributed to human error by the data-entry person. There was human error, but it was at the
design/engineering/planning stage, not at the point of the event!
 Similarly, a video used in Optimize Performance training shows a woman falling into a
basement trap door in the floor opened by another employee unbeknownst to her. Watching the
video, its easy to understand other safety-systems factors that contributed to the event. However,
if one were to only read a narrative of the event, it would be easy to jump to the incomplete
conclusion that it is all her fault. The video shows the trap door in the middle of a congested work
floor, opened by a co-worker who did not communicate with the woman who is facing away, and
there are no barricades or warning devices.

This same rush to judgment happens with plane crashes and train collisions with vehicles.
Barring some obvious alternative cause, plane crashes are attributed to pilot error, and train
collisions are due to a vehicles driver trying to beat the train or go around crossing arms.
Whether true or not, its hard to imagine all four pilots in the recent Asiana Air crash in San
Francisco making the serious error of slow speed and undershooting the runway, but that was the
initial assumption broadcast. Even if it is pilot error, we need to learn that robust technology and
protective systems should not allow four pilots to make such grievous errors.

Consider another event where a truck and trailer was struck by a train at a private crossing.
A tempting conclusion is that they were going around flashing lights and cross arms, or trying to
out race the train to a crossing. How much would your opinion change if you were to learn that it
was a private crossing with no lights or cross arms, the train was being pushed backward -- thus
no light or horn was being used -- and was traveling at a high rate of speed? Focusing too much
attention on the last individuals involved in an event greatly limits a more complete
understanding of what contributed to the event, and how to prevent similar future events.

Optimize Performance (OP) looks at the big picture, giving a comprehensive understanding
of all the factors affecting human performance. The OP approach is brilliantly simple, yet
profoundly impactful: simple enough for everyone to learn and use, and impactful because it
works. The practical value of Optimize Performance is realized by individuals and organizations,
on and off the job.

Human Performance was first developed in the nuclear power industry and the nuclear
Navy, and extended into select segments within the military, aviation, utilities, and other
industries. Regulatory agencies are embracing human performance concepts and have
aggressively begun incorporating them into regulations. This rapidly emerging trend is definitely
going to continue. Optimize Performance is a much enhanced advancement of traditional human
performance.

Optimize Performance methods include:

A set of well defined Tools that act as mental PPE to prevent errors and adverse events.
Recognition of OP Traps that create error-likely situations. Both Situational-Factor Traps
and Normalized-Drift Traps are identified and mitigated with OP Tools.
Error and Event Root Cause Review that evaluates how OP Tools/Traps can be mined to
prevent recurrence and generate concrete and applicable lessons learned.
OP Principles

The core of OP is PEOPLE:

People are going to make mistakes.
Error-likely situations can be predicted and events can be eliminated.
Organizational values strongly influence performance.
Positive and negative reinforcement determine behavior.
Learning from the past will stop future events.
Everyone can benefit from OP!

OP addresses different types of errors, uses errors and mistakes interchangeably, and
differentiates between errors and violations. Errors are unintentional lapses, slips, or other
mistake. Violations are choosing to do the wrong thing. OP is designed to minimize the frequency
and severity of errors. However, as the use of OP Tools increases, and as Traps are recognized
and corrected, decisions to commit violations will decrease.

OP promotes a just culture within a learning organization where admission and

reporting of errors, mistakes, and violations are encouraged so that root causes can be corrected.
All too often, errors and violations are responded to with the same type of harsh punishment.
These negative outcomes discourage error reporting, driving this valuable information
underground, preventing learning from human error cause analysis.
 Even if the action is determined to be a violation, determination of what motivated the
employee(s) to commit the violation is essential. Many believe that meting out harsh
discipline/punishment will solve the problem it will not! The problem will not be solved until
the reasons for the offending action are determined and addressed -- and there can be many
reasons that motivate employees to commit violations, and not perform to desired standards.

OP Traps

OP recognizes a variety of 20 traps that place individuals and groups in error-likely situations.
The OP Traps are separated into two groups: Situational Factors and Normalized Drift.

Situational Factors affect individuals at a given point in time. Normalized Drift is a trap in
the form of weakness and breakdowns in organizational and personal defenses, which become
accepted over time. Both sets of OP Traps result in sub-standard performance and adverse events.

Situational Factors are traps that exist at a given point in time and affect individuals while
performing a task, which can increase the chance of making an error, and include the following:

1. Time Pressure: Pressure exerted, whether obvious or concealed, self-imposed or system-

imposed, to accomplish a task within a set period of time
2. Distractions/Interruptions: Being physically or mentally separated from the task
3. Multiple Tasks: Too many activities going on at the same time
4. Overconfidence: Overestimation of ones performance, ability, level of control, or rate of
work
5. Vague Guidance: Unclear instructions, whether written, demonstrated, or spoken
6. First Shift/Late Shift: Early/late in ones work schedule, or the first day before or after a
holiday, vacation, or other time away
7. Peer Pressure: Influence exerted by a peer, or peer group, in encouraging a person to change
their attitudes, values, or behavior
8. Scope Change: Abnormal or unplanned situation, or conditions outside of routines or
expectations
9. Physical Environment: Conditions within the work space where one will be performing a
task
10. Mental Stress: A compromised state of mind that limits a persons ability to focus and make
correct decisions

Normalized drift is traps in the form of weakness and breakdowns in organizational and
personal defenses that become accepted over time, resulting in sub-standard performance and
adverse events.

1. Conflicting Values: When stated, organizational principles and values do not match actual
performance
2. Condoning: Silent approval of unacceptable deviations
3. Bad Habits: Short cuts, complacency, wrong perceptions of risk, thrill seeking
4. Vague Policies: Misunderstood and inconsistently applied standards
5. Ineffective Training: Improved job performance not realized
6. Flawed Procedures: Needed but missing, incorrect, unclear
7. Faulty Equipment: Broken, out of date, inaccurate
8. Technology: Failure to take advantage of technology
9. Design/Engineering: Inaccurate drawings, component labeling, unapproved modifications
10. Lack of Accountability: Focus is on results rather than how achieved; expectations not clear

NORMALIZED DRIFT

Recognizing that these OP Traps exist and realizing that they are increasing the risk of an error
demands a heightened level of awareness. But risks are often not recognized, or they are
misperceived. Far more important than recognizing risk is understanding and using the OP Tools
that will protect people, property, and the environment against errors and events.

OP TOOLS

Drift and Risk grow proportionately

The most critical component of the OP process is understanding and using the 10 OP
Tools. While these tools may seem intuitive and like common sense, they are quite difficult to
perfect in practical use. Ask yourself, What am I good at doing, and how did I get good? And
the answer is practice. Whether its learning to play a musical instrument or become advanced in
an athletic sport or improving your aerobic dancing skills, practice is required. Proficiency will
not be attained by reading about the subject, watching training videos, or using buzzwords in
speech. There is no short cut; practice is the only way to realize the powerful benefits of OP.
However, because of the brilliant simplicity of OP, some well-meaning individuals will attempt
to use the traps and tools like buzz words, but not really know what they mean or how to properly
use them.

OP Tools are a set of thought-provoking defenses that will prevent, predict, or reduce the
likelihood of errors and events, only after the methods and techniques are fully embraced, learned
and practiced.
 The 10 OP tools are:

1. Questioning Attitude: A constant state of mind that: knows that it can happen to me; asks
what if? before acting; and, is not overconfident and resists a false sense of being right.
2. Job Plan Analysis: Used to analyze the big-picture risks of a job.
3. Pre-Task Review: Used just prior to performing the task to acknowledge the OP Traps that
create error-likely situations, and how to apply OP tools to prevent error.
4. Self-Check: The last line of defense performed on the immediate task at hand in real time.
5. Procedure Usage: Written forms of communication detailing step-by-step how to perform a
task.
6. Place-keeping: A preferred method using circle and slash to keep track of the proper
sequence of performing work tasks.
7. Peer Check: In-process, second check of intent and actions.
8. Effective Communication: A set of verbal messaging principles and specific techniques
called closed-loop communications.
9. Post-Job Review: An opportunity to collaborate on ways to improve a task after it has been
performed.
10. OP Coaching: Employees being ready, willing and able to give and accept constructive
feedback is one of the most powerful and effective ways to improve workplace safety and
reliability.

The understanding and use of these tools has been proven to reduce the frequency and
lower the severity of human error. Significant effort is needed to develop proficiency in the
techniques and methods that allow the tools to work on an individual and group/organizational
level.

Error Review
A very simple, but highly effective OP Error-Review (OPER) process offers a more complete
understanding of adverse events and is a critical component of the Root Cause Analysis. The
OPER helps determine OP Traps that created error-likely situations, and OP Tools that could
have helped predict or mitigate the circumstances that resulted in the event. The error review
process is extremely accurate in focusing on the key causal factors that greatly influenced the
event, and that lead directly to root causes that must be fixed to prevent recurrence. The OPER
process is a one-size-fits-all analysis tool that can be used on any event, on or off the job.

Tuning in to WII-FM
OP training is highly successful because trainees want to learn once they are told what they will
learn is for their benefit. They are told to be selfish, and see if they can find value for themselves
and their families. They are challenged to learn strategies that will work for them, and that they
can teach to their 12-year-old son. They are encouraged to focus on, Whats in it for me and my
family? first, and then think about how their employer will benefit.

The tools and strategies used to reduce errors and improve human performance off or on
the job are inseparable. Deep experience has proven that every OP method and technique used at
work is identically applicable away from work. Indeed, while it may sound counter-intuitive,
greater success is reached when OP is first learned and applied within personal, off-the-job
contexts, and then used at work. OP trainees buy in when they understand that humans are far
more likely to be killed or seriously injured away from work. They learn that the most recent
OSHA data shows there were 4,609 work-related deaths in 2011, and that the CDC FastStats
reports a total of 120,859 unintentional deaths from activities such as watersports, hunting and
other sporting activities, cleaning roof gutters from a ladder, crossing a busy parking lot with
small children, and the bane of our civilized society: motor vehicle wrecks. During training,
people become convinced how they, and their families, can reduce mistakes and live more
productive lives. They commit to optimize their performance by internalizing OP strategies that
foster a 24-7-365 mindset and lifestyle.

Conclusion
The benefits of Optimize Performance can be realized by individuals and organizations on and off
the job. OP Traps increase the risk of error-likely situations. Situational Factors affect individuals
at a given point in time, whereas Normalized Drift is traps in the form of weakness and
breakdowns in organizational and personal defenses that become accepted over time. Both sets of
OP Traps result in sub-standard performance and adverse events.

OP Tools are a set of thought-provoking defenses that will prevent, predict, or reduce the
likelihood of errors and events only after the methods and techniques are fully embraced, learned
and practiced.

A simple, but highly effective OP Error-Review (OPER) process is a critical component of

root-cause analyses because the it helps determine OP Traps that created error-likely situations,
and aids in the evaluation of OP Tools that could have predicted or mitigated the circumstances
that resulted in the event.

Regulatory agencies are embracing human performance concepts and have aggressively
begun incorporating them into regulations. On many fronts, human performance is emerging as a
very effective and valuable performance-improvement process.

Once learned, these strategies improve all aspects of operational performance. When
applied, Optimize Performance changes culture. Improvements will be widespread and widely
recognized. The frequency of human error will be reduced, and the severity of the effects of
human error will be lowered. Safety will improve, reliability will be increased, productivity will
rise, and peoples lives will be enriched.

Your Assignment
Around noon on a Saturday, a family of four is planning to run errands and do some shopping.
The father is driving, and they have completed most of the errands and have just entered a very
crowded shopping center parking lot. The plan is to drop the mother off at one store, and she will
walk to meet the others at another store. There is some tension between the parents because Dad
thinks he is getting stuck with the kids again, and he cant talk to his wife because she is having a
fight with her pill-popping sister on the phone. The mother gets dropped off, and the father safely
parks the vehicle and now must plan the task of safely getting his 4-year-old son and 1-year-old
daughter out of the vehicle, across the busy parking lot, and into the store.

Assignment: Think about all the OP Traps that he must consider, and what OP Tools he should
use to safely accomplish the task.
Hint: Among all the many factors to consider, which child should Dad take out of the car seat
first?