Human Performance

and Error Reduction Tools

By
Parvaiz Shafi Khan
Visiting Faculty Member; PIEAS

Safety is an Overriding Priority

How Accident OCCURE
PURPOSE OF THE WORKSHOP

 Provides a set of practical methods and techniques for

anticipating, preventing, and catching active human errors.

 Improve human performance

 Goal – Prevent errors
CONTENT OF THE WORKSHOP
Why – do errors occur?

How – can we prevent errors?

What – will you do to prevent errors?

WHAT IS EXPECTED OF PARTICIPANT
 Actively participate!
 Ask for clarification if you do not understand.
 Capture actions you can take at your station
to improve performance.
ERROR
 WHAT IS HUMAN ERROR?

People action that unintentionally

departs from an expected behavior
causing harm to person,
Environment, Equipment
1. Over speed, Signal,
2. Airplane Crash
3. Chernobyl Disaster
NPP Severe Accidents on INES
TMI-2

Chernobyl

Fukushima

International Nuclear Event Scale

HUMAN ERRORs
WHAT IS HUMAN PERFORMANCE
 A series of behaviors executed to
accomplish specific task objectives
or results.
 Behaviors are what people do and
say.
 Results, good or bad, are achieved
by behaviors, the mental and
physical efforts to perform a task.
 Human performance is behavior
plus results
(P = B + R)
 HUMAN PERFORMANCE

Principle 1:
People are fallible,
and even the best
people make
mistakes.
Neither manager
nor worker is
immune.
 HUMAN PERFORMANCE

Principle 2:
Error-likely situations are
predictable, manageable,
and preventable.

Recognizing the likelihood

of such an error permits us
to manage the situation
proactively and prevent its
occurrence.
 HUMAN PERFORMANCE

Principle 3 :
Individual behavior is
influenced by the
group’s work practices
and values.
 HUMAN PERFORMANCE

Principle 4: -
People achieve
high levels of
success by
encouragement
from leaders, and
co-workers.
 HUMAN PERFORMANCE

Principle 5:
Events can be avoided
through an understanding Chernobyl – Unit 4
of the reasons mistakes
occur and application of
the lessons learned from
past events.
HUMAN PERFORMANCE TOOLS
Goal:
 Basic purpose of human performance tools
is to help the individual worker maintain
positive control of a work situation.
 Positive Control ensures What is intended
to happen - Is what happens - and that is
all that happens.
 Positive control is critical at steps where
error-free performance is essential.
HUMAN PERFORMANCE TOOLS
Defined
 Set of discrete behaviors that help
workers anticipate or prevent active
errors before they cause harm.
 Two tool types: *Fundamental and
Conditional

 * Focus of this session

PROCEDURE USE AND ADHERENCE
CLEAR COMMUNICATION
 Human Error Prevention Tools

Situation Verbal Operational

Awareness Procedure Communication Checks Verification Care
Barriers

Questioning Procedure Effective Independen Care

First Flagging
Attitude use Verbal t Enough to
Check
Communicati Verification Act
STOP on
Phonetic Concurre
Procedure Blocking
When Alphabets Self nt
Adherenc
Unsure Check Verificatio
e
Task Procedure 3-Way n Fundamental
Peer Check Tool
Preview Deviation Communicatio
n Conditional Tool OOPS
Pre-Job Place
Brief Keeping Out Of Procedure, Parameter, Process –
Job site
Review
Summarize AnticipateSTOP
Foresee Evaluate Review STA
Stop Think Act

RRreceiver
Questioning Attitude: To identify gaps between actual and desired situation Verbal Comm.: To ensure understanding between sender and eview
Post-Job Stop When Unsure: To eliminate doubt, uncertainty and confusion Phonetic Alphabets: To eliminate confusion regarding letter of referred alphabet

Review Task Preview: To prepare worker to perform a job right first time 3-Way Comm.: To ensure reliable transfer of information & understanding
Pre-Job Brief: To understand what to accomplish and what to avoid First Check: To ensure proper equipment is to be manipulated
Job Site Review: To improve situation awareness when first arriving at site Self Check : To focus attention on the task, keeping in mind STAR

Turn Post Job Review: To perform self assessment after work for feedback Peer Check: To prevent an error by the performer during critical steps

over Turn Over: To orderly transfer work related information to others Independent Ver.: To detect an error by the performer involving equipment
Procedure Use: To aware and link directly to procedure classification Concurrent Ver.: To prevent an error by the performer when doing action
Procedure Adherence: To ensure that procedure is understood and followed Flagging: To ensure that correct equipment is being manipulated
Procedure Deviation: To ensure approvals prior to deviating procedure Blocking: To ensure that incorrect equipment not being manipulated
Place Keeping: To mark steps to avoid repetition and omission Care Enough to Act: To take action to improve situation or to prevent harm
 HUMAN ERROR PREVENTION Tools
Prevent Detect Fund. Cond.
Tool When to Use
Errors Errors Tools Tools
CARE 1 - Tool
1. Care Enough to Act Used take action that will improve a situation or prevent harm   
SITUATION AWARENESS 7 - Tools

2. Questioning Attitude Used to identify gaps between the actuel situation and the   
desired situation.
3. Stop When Unsure Used to resolve uncertainty.  
4. Task Preview Used to prepare the worker to perform a job right the first time.  
Used to engage workers prior to a task so that they clearly
5. Pre-job Briefing  
understand what to accomplish and what to avoid.
Used to improve a person’s situation awareness, when first
6. Job Site Review  
arriving at the job site.
Self-assessment conducted after a work activity to solicit and
7. Post-job Review  
record feedback from the workers.
Orderly transfer of work-related information, tasks, and
8. Turnover responsibilities between individuals, one off-going and the   
other on-coming.
PROCEDURES 4 - Tools
Linked directly to the procedure classification and specifies the
9. Procedure Use
extent to which the performer is required to rely on the  
procedure versus their own memory.
10. Procedure Adherence Used to ensure that a procedure is understood and followed.  
Used to ensure that appropriate approvals are obtained prior to
11. Procedure Deviation deviating from a procedure.  
Used to mark the steps in a procedure that have been
12. Place keeping completed or that are not applicable, so that steps are not  
accidentally omitted or repeated.
 HUMAN ERROR PREVENTION Tools
Prevent Detect Fund. Cond.
Tool When to Use
Errors Errors Tools Tools

COMMUNICATION 3 - Tools

1. Effective Verbal Used to ensure a common understanding between a Sender

and a Receiver.  
Communication
Used to eliminate confusion regarding which letter of the
2. Phonetic Alphabet  
alphabet is being referred to.
3. Three Way Used to ensure a reliable transfer of information and
Communication
 
understanding.
CHECKS 3 - Tools
Used to ensure the first manipulation of in-plant equipment is
4. First Check performed on the proper unit / channel / component.  
Used to focus attention on the appropriate component, think
5. Self-Check about the intended action, understand the expected outcome   
before acting, and verify the expected outcome after the action.
6. Peer-Check Used to prevent an error by the Performer.   
VERIFICATION 2 - Tools

7. Independent Used to DETECT an error by the Performer involving the

Verification condition or status of a component.  

Used to PREVENT an error by the Performer when changing

8. Concurrent Verification the condition or status of a component.  

OPEARTIONAL 2 - Tools
BARRIERS
Used to ensure that the correct component is being  
9. Flagging
manipulated or worked on.
Used to ensure that the incorrect component is not manipulated or  
10. Blocking
worked on.
 TOP TEN CAUSES
OF HUMAN PERFORMANCE ERRORS

Time Pressure Fatigue/ Low

Alertness Level/ First
½ hour after meal or
wake-up (Diet/Sleep)
Distractions in the Over-Confidence
Workplace

High Work Load Vague or Incorrect

Guidance
First Time for the Task Imprecise
Communication

First Day Back After Stress

Days Off