Human Performance Improvement Principles Facilities Division Lawrence Berkeley
Human Performance Improvement Principles Facilities Division Lawrence Berkeley National Laboratory Janice Sexson Humans rather than technical failures now
represent the greatest threat to complex and potentially hazardous systems James Reason, 1995 Why A Human Performance Improvement Approach? To proactively prevent occurrences triggered by human error Occurrence
A condition that adversely affects, or may adversely affect, DOE or contractor personnel, the public, property, environment or the DOE mission Occurrences 20% Equipment Failure 80 % Human
Error Human Factors 70% Latent Organization Weakness 30% Individual Facts About Human Error
It thrives in every industry It is a major contributor to events and occurrences It is costly, adverse to safety and hinders productivity The greatest cause of human error is weakness in the organization not the lack of skill or knowledge Hazardous Attitudes
Pride-Dont insult my intelligence Heroic-Ill get it done, hook or by crook Invulnerable-That cant happen to me Fatalistic-what's the use
Bald Tire-Got 60 K miles and havent had a flat tire yet Summit Fever-Were almost done Pollyanna-Nothing bad will happen Human Error Individual Error-reduction tools
3 way communication Principles People are fallible, and even the best make mistakes Error-likely situations are predictable, manageable, and preventable Individual behavior is
influenced by organization processes and values Principles People achieve high levels of performance based largely on the encouragement and reinforcement received from leaders, peers, and
subordinates An understanding of the reasons mistakes occur, and application of the lessons learned from past events can avoid future events Blame Cycle A Human Error Happens
Worker is counseled and/or disciplined Error likely workplace exists
Trust levels reduced because of managements actions Latent organization weakness persist
Management is less aware of working conditions Worker no longer feels safe to communicate
Human Performance Event are not so much the result of error-prone workers as they are the outcome of errorprone tasks and error-prone work environments, which are controlled by the organization. Human Beings
http://www.youtube.com/watch?feature=player_embedded&v=8V2hhtNw8vU Notable Organizational Behaviors Managers foster a culture that values prevention of events Managers strengthen the integrity of defenses to prevent or mitigate the consequences Managers preclude the development of errorlikely situations Managers create a learning environment that promotes continuous improvement
Leadership Behavior Facilitate open communication Promote teamwork to eliminate error-likely situations and strengthen defenses Search for and eliminate organizational weaknesses that create error-likely situations Reinforce jobsite behaviors
Value the prevention of errors Individual Tools Questioning attitude Clear communication techniques Stop when unsure Management Tools Solicit and act on
feedback from worker Determine fundamental causes Monitor trends Self-Assessment Process mapping Task Analysis Benchmarking Summary
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