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Improving Human Performance: from Individual to Organization and Sustaining the Results

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Improving Human Performance: from Individual to Organization and Sustaining the Results Improving Human Performance: From Individual to Organization and Sustaining the Results March 27th 2012 RRM Direction • Reliability – addressing real problems to improve the reliability of the grid. • Accountability – being accountable to customers, the industry and government for the performance of the grid. • Learning – enabling the industry to learn from experience to improve future reliability performance. • Risk-based model – focusing actions and programs on issues most important to grid reliability. 2 RELIABILITY | ACCOUNTABILITY Top Priority Reliability Issues • Misoperations of relay protection and control systems • Human errors by field personnel • Ambiguous or incomplete voice communications • Right-of-way maintenance • Changing resource mix • Integration of new technologies • Preparedness for high impact, low frequency events • Non-traditional threats via cyber security vulnerabilities NERC President’s Top Priority Issues for Bulk Power System Reliability, http://www.nerc.com/news_pr.php?npr=723 at http://www.nerc.com/fileUploads/File/News/NERC%20President%20Top%20Priority%20BPS%20Reliability%20Issues%201 -7-11.pdf 3 RELIABILITY | ACCOUNTABILITY Top Priority Reliability Issues • Misoperations of relay protection and control systems • Human errors by field personnel • Ambiguous or incomplete voice communications • Right-of-way maintenance • Changing resource mix • Integration of new technologies • Preparedness for high impact, low frequency events • Non-traditional threats via cyber security vulnerabilities NERC President’s Top Priority Issues for Bulk Power System Reliability, http://www.nerc.com/news_pr.php?npr=723 at http://www.nerc.com/fileUploads/File/News/NERC%20President%20Top%20Priority%20BPS%20Reliability%20Issues%201 -7-11.pdf 4 RELIABILITY | ACCOUNTABILITY Reliability Risk Management Concept Severity Avoid Learn and Reduce Inverse Cost-Benefit Reporting Threshold 5 RELIABILITY | ACCOUNTABILITY Reliability Risk Management Concept Severity Avoid Learn and Reduce Inverse Cost-Benefit Reporting Threshold 6 RELIABILITY | ACCOUNTABILITY Drifting to Failure* Expectations: Desired approach to work (as imagined) Normal Practices: Work as actually performed (allowed by mgmt!) Hi Stated Expectations Drift “Normal” Practice Real Error Margin for Error Reliability Latent Error Inconspicuous and seemingly harmless buildup Hidden hazards, threats, unusual of “hidden” error and organizational weaknesses conditions, & system weaknesses Lo Time 7 * Adapted from Muschara Error Management Consulting, LLC RELIABILITY | ACCOUNTABILITY Safety Check Peer Check 8 RELIABILITY | ACCOUNTABILITY Too Hard? “Complicated Industry” “Come along way” “Can’t get to zero” “Automate, technology reduces the need for human operator” 9 RELIABILITY | ACCOUNTABILITY Too Hard? “Complicated Industry” “Come along way” “Can’t get to zero” “Automate, technology reduces the need for human operator” 10 RELIABILITY | ACCOUNTABILITY Challenge www.airlines.org/PublicPolicy/Testimony/Pages/testimony_5-13-09Senate.aspx&docid=qnHU9MAraY_WIM&w=550&h=403&ei=mdRbTvkrhLm3B8nyibgM&zoom=1&iact=rc&dur=62&page=2&tbnh=167&tbnw=216&start=50&ndsp=31&ved=1t:429,r:4,s:50&tx=110&ty=85 11 RELIABILITY | ACCOUNTABILITY Stuff Happens 12 RELIABILITY | ACCOUNTABILITY Human Performance Analysis • We have not fully understood an event if we don’t see the actors’ actions as reasonable. • The point of a human error investigation is to understand why people did what they did, not to judge them for what they did not do. • The difference between an accident and a serious incident lies only in the result. 13 RELIABILITY | ACCOUNTABILITY Human Performance It is not a matter of if the automation fails, it is a matter of when. 14 RELIABILITY | ACCOUNTABILITY Quick History of Human Performance • Anthropometry •Human Factors Psychology • Applied Psychology • Industrial Design • Cognitive Science • Industrial Engineering • Cognitive Psychology • Industrial and Organizational • Engineering Psychology Psychology • Aviation Psychology • Operations Research • Ergonomics • Physiological Psychology • Experimental Psychology • Psychology • Human Factors • Statistics • Human Systems Integration 15 RELIABILITY | ACCOUNTABILITY Quick History • Scientific understanding of the properties of human capability (Human Factors Science). • The application of this understanding to the design, development and deployment of systems and services (Human Factors Engineering). • Equipment design, Task design , Environmental Design, Training, Selection • The art of ensuring successful application of Human Factors Engineering to a program (sometimes referred to as Human Systems Integration) 16 RELIABILITY | ACCOUNTABILITY Human Factors • Human factors involves the study of all aspects of the way humans relate to the world around them, with the aim of improving operational performance, safety, through life costs and/or adoption through improvement in the experience of the end user. • The terms human factors and ergonomics have only been widely used in recent times; the field's origin is in the design and use of aircraft during WW II to improve aviation safety. 17 RELIABILITY | ACCOUNTABILITY Human Factors Science Human factors are sets of human-specific physical, cognitive, or social properties which either may interact in a critical or dangerous manner with technological systems, the human natural environment, or human organizations, or they can be taken under consideration in the design of ergonomic human-user oriented equipment. 18 RELIABILITY | ACCOUNTABILITY Human Performance Improvement (HPI) • Human Performance Technology (HPT), also known as Human Performance Improvement (HPI), "uses a wide range of interventions that are drawn from many other disciplines, including total quality management, process improvement, behavioral psychology, instructional systems design, organizational development, and human resources management" (ISPI, 2007). • HPT is a systematic approach to improving individual and organizational performance (Pershing, 2006). HPT stresses a rigorous analysis of the requirements of organization, process and HP for new design and/or identifying the causes for performance gaps, and attempts to provide new designs and/or solutions to improve and sustain performance and to evaluate the results against the requirements. 19 RELIABILITY | ACCOUNTABILITY Challenge www.airlines.org/PublicPolicy/Testimony/Pages/testimony_5-13-09Senate.aspx&docid=qnHU9MAraY_WIM&w=550&h=403&ei=mdRbTvkrhLm3B8nyibgM&zoom=1&iact=rc&dur=62&page=2&tbnh=167&tbnw=216&start=50&ndsp=31&ved=1t:429,r:4,s:50&tx=110&ty=85 20 RELIABILITY | ACCOUNTABILITY Human Factors Analysis and Classification 21 RELIABILITY | ACCOUNTABILITY Flowchart for Human Performance 22 RELIABILITY | ACCOUNTABILITY Sometimes it is a Human 23 RELIABILITY | ACCOUNTABILITY Human Performance Tenets • People are fallible, and all people make mistakes • Error-likely situations are predictable, manageable, and preventable • Individual behavior is influenced by organizational processes and values • People achieve high levels of performance largely because of the encouragement and reinforcement received from leaders, peers, and subordinates • Events can be avoided through an understanding of the reasons mistakes occur and application of the lessons learned from past events or near misses 24 RELIABILITY | ACCOUNTABILITY Human Performance Tools 25 RELIABILITY | ACCOUNTABILITY Human Performance Tools • Two Minute rule • Stop when unsure • Self checking (also called STAR and touch STAR) • Procedure use and adherence • Three way communication • Phonetic alphabet • Pre-job brief • Peer check • Concurrent verification • Independent verification • Flagging operational barriers • Place keeping • Post job interview • First Check 26 RELIABILITY | ACCOUNTABILITY Read All About It 27 RELIABILITY | ACCOUNTABILITY Five Questions • Elegant simplicity • Know thy user • The rat is never wrong • Actions not words • You can’t afford not to know the truth 28 RELIABILITY | ACCOUNTABILITY Five Questions • Elegant simplicity • Know thy user • The rat is never wrong • Actions not words • You can’t afford not to know the truth 29 RELIABILITY | ACCOUNTABILITY Elegant simplicity • Elegant simplicity . Russians and the US Space Program . How many tools in the box? . The tool shouldn’t be harder than the task. Surround the truth…it is out there somewhere… 30 RELIABILITY | ACCOUNTABILITY Human Performance Tools • Two Minute rule • Stop when unsure • Self checking (also called STAR and touch STAR) • Procedure use and adherence • Three way communication • Phonetic alphabet • Pre-job brief • Peer check • Concurrent verification • Independent verification • Flagging operational barriers • Place keeping • Post job interview • First Check 31 RELIABILITY | ACCOUNTABILITY Five Questions • Elegant simplicity • Know thy user • The rat is never wrong • Actions not words • You can’t afford not to know the truth 32 RELIABILITY | ACCOUNTABILITY Know thy user • Know thy user . Human Ingenuity . Only two hands, two eyes, see the pattern? . If you only have a minute, it only takes a minute… . Set me up for success…please… . Human nature 33 RELIABILITY | ACCOUNTABILITY Signs Darnell, M. J. (2006). Bad Human Factors Designs. Baddesigns.Com 34 RELIABILITY | ACCOUNTABILITY Five Questions • Elegant simplicity • Know thy user • The rat is never wrong • Actions not words • You can’t afford not to know the truth 35 RELIABILITY | ACCOUNTABILITY The rat is never wrong • The rat is never wrong . Behaviorism . Not enforcing a policy
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