The strategic approach to improving human performance within safety embraces two (2) primary challenges:
- Anticipate, Prevent, Catch, and Recover from ACTIVE errors
- Identify and Eliminate LATENT organizational weaknesses that provoke human error and degrade controls against error and the consequences of error
Preventable errors will not be eliminated if opportunities to err are not methodically identified. Even if opportunities to err are systematically identified and prevented, people may still err in unanticipated and creative ways. Consequently, additional means are necessary to protect against errors that are not prevented or anticipated. Reducing the error rate minimizes the FREQUENCY but NOT the SEVERITY of events.
Only controls can effectively reduce the SEVERITY of the error outcome. Defense-in-depth controls or safeguards arranged in a layered fashion – assure that if one fails, the remaining controls will function as needed to reduce the impact on the incident.
To improve human performance and facility performance, efforts should be made to
- REDUCE errors at all levels of the organization and
- ENHANCE THE INTEGRITY of controls/safeguards discovered to be weak or missing
Reducing errors (Re) and managing controls (Mc) will lead to zero significant events (ØE). The formula for achieving this goal is
Re + Mc = ØE
Eliminating significant facility events will result in performance improvement.
Reducing Error
An effective error-reduction strategy focuses on work execution because these occasions present workers with opportunities to harm key assets, reduce productivity, and adversely affect quality through human error. Work execution involves workers having direct contact with the facility when they touch the equipment and when knowledgeable workers touch the paper that influences the facility (procedures, instructions, drawings, specifications, etc.). During work execution, the human performance objective is to ANTICIPATE, PREVENT, or CATCH active errors, especially at critical steps, where error-free performance is absolutely necessary. While various work planning methods may be used, opportunities for reducing error are particularly prevalent in what is herein expressed as preparation, performance, and feedback.
Preparation — planning – identifying the scope of work, associated hazards, and what is to be avoided, including critical steps; job-site reviews and walk-downs – identifying potential job-site challenges to error-free performance; task assignment – putting the right people on the job in light of the job’s task demands; and task previews and pre-job briefings – identifying the scope of work including critical steps, associated hazards, and what has to be avoided by anticipating possible active errors and their consequences.
Performance — performing work with a sense of uneasiness; maintaining situational awareness; rigorous use of human performance tools for important human actions, avoiding unsafe or at-risk work practices; supported with quality supervision and teamwork.
Feedback — reporting – conveying information on the quality of work preparation, related resources, and workplace conditions to supervision and management; behavior observations – workers receiving coaching and reinforcement on their performance in the field through observations by managers and supervisors.
Managing Controls
Incidents involve breaches in hazard/risk controls or safeguards. As mentioned earlier, errors still occur when opportunities to err are systematically IDENTIFIED and ELIMINATED. Therefore, management must take an aggressive approach to ensure hazard/risk controls function as intended.
The top priority to ensure safety from human error is to IDENTIFY, ASSESS, and ELIMINATE hazards in the workplace. These hazards are most often closely related to vulnerabilities with controls. They have to be found and corrected. The most important aspect of this strategy is an assertive and ongoing verification and validation of the hazard/risk controls. Ongoing self-assessments are employed to scrutinize controls, and the vulnerabilities are mended using the corrective action program (CAP). A number of safety controls have been developed. Four (4) general control types are reviewed briefly for this discussion of the Human Performance Improvement (HPI) strategic approach.
- Control of Hazards by ELIMINATION or SUBSTITUTION – Organizations evaluate operations, procedures, and facilities to identify workplace hazards. Management implements a hazard prevention and elimination process. When hazards are identified in the workplace, they are prioritized, and actions are taken based on risks to the workers. Management puts in place protective measures until such time as the hazard(s) can be eliminated. An assessment of the hazard control(s) is carried out to verify that the actions taken to eliminate the hazard are effective and enduring.
- ENGINEERING CONTROLS – These provide the facility with the physical ability to protect from errors. To optimize this set of controls, equipment is reliable, is kept in a configuration resistant to simple human error, and allows systems and components to perform their intended functions when required. Facilities with high equipment reliability, effective configuration control, and minimum human-machine vulnerabilities tend to experience fewer and less severe facility events than those that struggle with these issues. How carefully facility equipment is DESIGNED, OPERATED, and maintained (using human-centered approaches) affects the level of integrity of this line of protection.
- ADMINISTRATIVE CONTROLS – Policies, procedures, training, work practices processes, and expectations direct people’s activities so that they are predictable and safe and limit their exposure to hazards, especially for work performed in and on the facility. Altogether, such controls help people anticipate and prepare for problems. Written instructions specify what, when, where, and how work is to be done and what personal protective equipment workers are to use. The rigor with which people follow and perform work activities according to correctly written procedures, expectations, and standards directly affects the integrity of this line of protection.
- Cultural norms – These are the assumptions, values, beliefs, and attitudes and the related leadership practices that encourage either high standards of performance or mediocrity, open or closed communication, or high or low standards of performance. Personnel in highly reliable organizations practice error-prevention rigorously, regardless of their perception of a task’s risk and simplicity, how routine it is, and how competent the performer is. The integrity of this line of defense depends on people’s appreciation of the human’s role in safety, the respect they have for each other, and their pride in the organization and the facility.
- Oversight – Accountability for personnel and facility safety, security, and ethical behavior in all facets of facility operations, maintenance, and support activities is achieved by a kind of “social contract” entered into willingly by workers and management where a “just culture” prevails. In a just culture, people who make honest errors and mistakes are not blamed, while those who willfully violate standards and expectations are censured. Workers willingly accept responsibility for the consequences of their actions, including the rewards or sanctions. They feel empowered to report errors and near misses. This accountability helps verify margins, controls and processes’ integrity, and performance quality. Performance improvement activities facilitate the accountability of line managers through structured and ongoing assessments of human performance, trending, field observations, and use of the corrective action program, among others. The integrity of this line of defense depends on management’s commitment to high levels of human performance and consistent follow-through to correct problems and vulnerabilities.