Human Performance Improvement Through a Just Culture Joel E. Heim Manager, Training & Development
Moving from a Reactive Safety Culture
Principles of Human Performance People are fallible, and even the best 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 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 errors 3
12 Most Common Causes of Human Error Lack of Communication Lack of Teamwork (No Peer Caring) Norms (Culture) Pressure (Shortcuts) Complacency Lack of Knowledge (Unconscious Incompetence) Lack of Awareness Lack of Resources Distraction Lack of Assertiveness (Courage to speak up) Fatigue Stress
Information Word Game Bed Rest Awake Snooze Nap Drowsy Pillow Wake Tired Blanket Slumber Peace Yawn Doze
Error Precursors (Error Traps) Task Demands Time pressure High workload Simultaneous tasks Repetitive tasks Monotony Unclear goals Unclear standards Individual Capabilities Unfamiliarity with task Lack of knowledge Poor communication Inexperience Illness / Fatigue Unsafe attitude Major life event
Error Precursors (Error Traps) Work Environment Distractions Interruptions Departure from routine Work-arounds Personality conflicts Shift changes Production overemphasis Physical climate Human Nature Stress / Mental strain Habits / Biases Assumptions / Mindset Complacency Overconfidence Inaccurate risk perception Limited memory Circadian rhythm
Unsafe Attitudes / At-Risk Behaviors Pride Don t tell me what to do Heroic Custer at Little Big Horn, Here I come to save the day Fatalistic Predetermined, Inevitable, Let the chips fall where they may Invulnerability Nothing will happen to me Pollyanna All is well, What can go wrong, It s routine Bald Tire We ve always done it this way 9
Team Errors Halo Effect Blind trust due to experience or education Pilot / Co-pilot Reluctance of subordinate to question senior person Free Riding Taking passive role Groupthink Reluctance to question group opinion Diffusion of Responsibility Spread the blame 10
Error Likely Situations
Moving to a Just Culture Manage your state and habits of mind Pay attention to what stories you tell yourself Be aware of your mental biases Invincibility / Invulnerability Fundamental Attribution Error Outcome Bias Hindsight Bias Confirmation Bias
Why We Do What We Do Antecedent Prompts a Behavior Behavior Specific muscle movement Consequence What happens to us 19
Behavioral Consequences R+ positive reinforcement R- negative reinforcement P+ Punishment P- Penalty 20
Behavioral Consequences Determine the probability of a behavior re-occurring Will be either: Positive or Negative Immediate or Future Certain or Uncertain 21
Establish and Maintain a Just Culture An open, honest, reporting culture Look at the intent, not just the consequence Get away from fault and blame Recognize the difference between errors and violations Errors are unintentional slips or lapses Violations are intentional Balanced accountability is the key Just Culture begins with Trust
Five Dysfunctions of a Team Inattention to Results Avoidance of Accountability Lack of Commitment Fear of Conflict Absence of Trust From The Five Dysfunctions of a Team Patrick Lencioni 23
Strategic Approach for Human Performance Anticipate, prevent, catch, and recover from active errors at the job site Preparation Performance Feedback Identify and eliminate latent organizational weaknesses that provoke human error and degrade controls against error and consequences of error Control hazards by elimination or substitution Engineered Features Administrative Provisions Cultural Norms Oversight 24
Human Performance Tools Task Preview Job-site Review Questioning Attitude Stop when Unsure Procedure Use and Adherence Three-way Communication Phonetic Alphabet Pre-job Briefing Post job Review Concurrent Verification Independent Verification Place-keeping Validating Assumptions 25
Principles of Human Performance People are fallible, and even the best 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 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 errors 26
Universal Sign of Commitment
References DOE Human Performance Improvement Handbook Vol. 1 DOE human Performance Improvement Handbook Vol. 2 Crucial Conversations Joseph Grenny, David Maxfield, Kerry Patterson The Five Dysfunctions of a Team Patrick Lencioni Bringing Out the Best in People Aubrey Daniels
29