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Human Performance
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What is Human Performance?
An individual…
working within
organizational systems…
to meet expectations
set by leaders.
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How to Improve Human
Performance
Address
Removeerror-
Create
Reinforce error
limitations
traps
tolerant
desired of
human
systemsnature
behaviors
Individual
Incentives to meet
leader’s expectations
Organization
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Definitions
• Operational Upset: A condition that adversely
affects, or may adversely affect, DOE or
contractor personnel, the public, property,
environment or the DOE mission.
• Error: An unintentional deviation from an
expected behavior.
• Violation: Deliberate, intentional acts to evade a
known policy or procedure requirement for
personal advantage usually adopted for fun,
comfort, expedience, or convenience
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HPI Principles
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The Individual
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Origins of Human Error
Human Errors
Operational Upsets
Slip, trip or
Human lapse
Error Equipment
Failures
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Basketball
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Limitations of Human Nature
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Limitations of Human Nature
See page 4 in your Concepts Guide
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Risk
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Error Traps
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Saw StopTM
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Error Precursors
See page 18 in your Concepts Guide
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Error Prevention Tools
• Self-checking • Pre-job briefing
• Peer-checking • Post-job briefing
• Concurrent • Procedure use &
verification adherence
• Independent • Problem-solving
verification • Questioning attitude
• Three-way • Conservative decision
communication making
• STAR • Stop & collaborate
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The Organization
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New vs. Old View of Human Error
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Types of Error
See page 12 in your Concepts Guide
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Understanding Events
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The Value of Error Tolerance
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Defenses in Depth
See page 14 in your Concepts Guide
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Traditional Heisenberg Model
See page 16 in your Concepts Guide
• Number of errors is
relative to the severity
of consequences
• For every major
accident there are
many errors
• Leads us to assume
that driving down errors
will eliminate major
accidents
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New View of Heisenberg Model
• The consequence of
error has no relationship
to the number of errors
• It is related to the
number and integrity of
defenses
• Any error can lead to a
major accident if
defenses fail
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Zero Operational Upsets
See page 20 in your Concepts Guide
Re + Md → OU
Reducing Error AND Managing
Defenses leads to Zero Operational
Upsets
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Medical Mistakes
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Organizational Values
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Blame Cycle
See page 23 in your Concepts Guide
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Culpability Decision Tree
Was the behavior
intended? See page 26 in your Concepts Guide
YES NO
Did the
employee have
Were the medical
consequences restrictions?
intended?
NO
NO
YES YES
Did the employee
knowingly violate
Intentional a requirement?
sabotage
YES NO
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Accountability vs. Culpability
See page 40 in your Concepts Guide
Accountability Culpability
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Performance Culture
See page 28 in your Concepts Guide
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Human to Systems Interface
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Fallacy of
Competing Resources
See page 31 in your Concepts Guide
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How Leaders Influence
Protection vs. Production
See page 33 in your Concepts Guide
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Implementing HPI