Here we were in 2015, and still, we have far too many businesses still focusing on active failures and ignoring the latent failures impacting their significant incidents. This approach is the LAZY approach to incident investigation. It also misses the mark on corrective action plans, which almost ensure the organization will not learn from the incident and certainly will not achieve much risk reduction. The nuclear industry has done much work to improve human performance. Their research found three (3) critical areas that must be addressed if an organization wishes to improve human performance to reduce incidents.
Concerning human performance, consideration has to be given to the different influences that can impact the desired results at each level of performance. These include:
- Job or Individual Level:
- The influences at this level focus on the performance of individuals or groups performing job tasks. Employees in any position in the organization or a group of employees working together towards a common goal (e.g., the mechanical maintenance technician or a maintenance team) are considered. Leaders’ and managers’ performance is also considered an important influence at this level. Performance improvement tools at this level focus on improving individual or team performance on a task or set of tasks and minimizing surrounding conditions that can lead to increased human error rates.
- Process Level:
- This influence on performance focuses on how tasks are accomplished within the organization — the process by which work is done. Processes may include core processes (e.g., operation and maintenance), management processes (e.g., assessment and improvement of the performance of work), and support processes (e.g., training). Performance at all organizational levels can influence, and be influenced by, the processes in the organization.
- Organizational Level:
- This influence on performance deals with the overall organizational strategy, design and structure, and how resources are allocated throughout the organization. It is visible in the shared values and performance expectations that are seen in the organization (e.g., the expectation to follow procedures while performing work). Communication and organizational culture are central elements of the influence of the organizational level on performance. Individuals across the organization can influence and will be influenced by organizational elements. 70% of human errors (or 56% of all events) resulted from organizational and process weaknesses, NOT individual behavior.
To achieve excellence and consistency in human performance, there must be a work environment in which the appropriate processes (e.g., performance management or training) are in place to encourage and reinforce the desired behaviors that will, in turn, lead to the desired results. For those appropriate processes to be effective, the values and performance expectations identified and communicated at the organizational level must support those processes. The individual behaviors and processes will be only as good as the organizational structure that supports them. Events can occur even with individuals capable of performing work and the appropriate processes. Events may occur because the processes and correct individual behaviors are not appropriately valued within the organization (e.g., the culture of the organization does not support the right behaviors). for example, appropriate individual behaviors (e.g., following procedures) must occur in conjunction with appropriate processes (e.g., good maintenance processes) and organizational values (e.g., clear expectations to use and to follow procedures). The alignment of these three components in the right environment will go a long way to fostering excellent human performance.
The role of the individuals in human performance improvement of the collective behaviors of individuals across all areas and levels at a facility determines the overall performance outcome achieved. The work conducted by individuals is the product of mental processes influenced by diverse factors related to the work environment and the demands of the task, as well as the capabilities of each individual. In high-performing facilities, individuals at all levels take responsibility for their behaviors and are committed to improving themselves, the task, and the work environment. Individuals in high-performing facilities generally exhibit the following behaviors:
- communicate to create shared understanding;
- anticipate error-likely situations;
- confirm the integrity of defenses;
- improve personal capabilities;
- use and follow procedures and other work documents as intended;
- report deficiencies in processes, documents, or at the workplace;
- Demonstrate uneasiness and wariness (expecting success while anticipating failure) towards activities that can affect equipment performance or personnel safety;
- Do not proceed in the face of uncertainty;
- use non-technical, mental skills (error prevention tools) to anticipate, prevent and recover from error;
- exhibit intolerance for error-likely situations and organizational weakness.
In discussing the role of individuals in HPI, consideration must be given to the leadership role. Leaders are individuals within the organization who exert a specific influence on other individuals’ performance. Leading is a set of behaviors practiced continuously to direct and focus individual effort toward accomplishing the organization’s goals. The ‘leader’ is any individual who influences the actions of others or organizational processes. Effective leaders understand the variables that influence both individual and organizational performance. It is important to align organizational processes and values. Leaders integrate appropriate positive reinforcements into the work environment to encourage the desired behaviors and results. In general, leaders in high-performing facilities exhibit the following behaviors:
- facilitate open communication;
- promote teamwork to eliminate error-likely situations and strengthen defenses;
- Search for and eliminate organizational weaknesses that create conditions for errors;
- reinforce desired work behaviors;
- value the prevention of errors;
- Serve as a role model for the right behaviors, where managers and supervisors routinely communicate and reinforce desired behaviors through observation, coaching, counseling, and performance feedback.
The role of processes in human performance improvement all of the processes that are in place within an organization have a strong influence on an individual’s ability to perform the job effectively and, therefore, to achieve successful outcomes. Processes standardize the work that is conducted in an organization by providing:
- Structure to how work is conducted through the formalized procedures and job practices in place;
- Structure to the knowledge of the workforce through training and qualifications;
- Structure to how decisions are made, problems are identified, work is coordinated, and corrective actions are implemented.
By ensuring effective processes are in place, the following can be accomplished:
- Processes are implemented as designed and are assessed to verify that appropriate barriers exist and will minimize the likelihood of errors occurring. Key processes include work planning and scheduling, clearance tagging, plant modification, work control, and operating experience.
- Procedures are developed, verified, validated, available, and user-friendly.
- Procedures are periodically reviewed and corrected when deficiencies are detected.
- Initial and continuing training ensures that a competent and qualified workforce is available, with the desired technical knowledge and skills, work practices, and human performance fundamentals. In addition, appropriately qualified individuals are selected for the performance of work activities.
- An effective corrective action program is in place, which incorporates root cause analyses as appropriate.
- Work preparation and execution activities use pre-job briefings commensurate with the risk and complexity of the tasks. Front-line managers facilitate identifying and avoiding situations that can result in events. Key elements of work preparation include identification of critical steps, potential human errors and effects on the plant, contingency plans, and operating experience. Any changes to planned work activities are critically reviewed to ensure that the likelihood of errors and potential facility consequences are minimized.
The organization’s role in human performance improvement includes an organization’s goals, policies, and priorities that directly influence individuals’ behaviors by generating a pattern of shared understandings, processes, and values. Managers are responsible and accountable for organizational support of worker performance. However, all individuals within an organization should take it upon themselves to improve organizational processes and promote values of excellence. The organizational elements important for successful performance include:
- fostering a culture that values the prevention of events. Senior managers establish expectations for excellence in human performance and safety culture. Both strategic and business planning provide goals, objectives, resources, and metrics to fulfill these expectations.
- Strengthening the integrity of barriers to prevent or mitigate the consequences of error.
- Precluding the development of situations in which errors are more likely to occur.
- Creating a learning environment that encourages continual improvement.
- Ensuring effective communication mechanisms are in place to promote timely and accurate dissemination of information throughout the organization. Communication of information that can affect human or equipment performance is highly valued.
- Designing an organizational structure that ensures appropriate responsibilities and authority in the organization.
- Establishing healthy relationships across the organization based on trust, respect, and fairness is supported by motivating reward and accountability practices. Rewards and discipline are linked to specific behaviors.
- Establishing and maintaining an organizational intolerance for process, document, and workplace deficiencies.
Adopted from sources @ International Atomic Energy Agency and the U.S. Nuclear Regulatory Commission