I mproving Human Performance: Building a Culture of High Reliability Building a Culture of High Reliability James Merlo, PhD, Associate Director of Human Performance James Merlo, PhD, Associate Director of Human Performance March 26, 2013
RELI ABI LI TY | ACCOUNTABI LI TY Which Direction? 2
RRM Direction • Reliability – addressing real problems to improve the reliability of the grid reliability of the grid. • Assurance – being accountable to customers, the industry and government for the performance of the grid. • Learning – enabling the industry to learn from experience to improve future reliability performance. • Risk ‐ based model – focusing actions and programs on issues i k b d d l f i i d i most important to grid reliability. 3 RELI ABI LI TY | ACCOUNTABI LI TY
Challenge www.airlines.org/PublicPolicy/Testimony/Pages/testimony_5-13-09Senate.aspx&docid=qnHU9MAraY_WIM&w=550&h=403&ei=mdRbTvkrhLm3B8nyibgM&zoom=1&iact=rc&dur=62&page=2&tbnh=167&tbnw=216&start=50&ndsp=31&ved=1t:429,r:4,s:50&tx=110&ty=85 4 RELI ABI LI TY | ACCOUNTABI LI TY
Too Hard? “Complicated Industry” “Come along way” Come along way “Can’t get to zero” “Automate, technology reduces the need for human operator” d f h t ” 5 RELI ABI LI TY | ACCOUNTABI LI TY
Too Hard? “Complicated Industry” “Come along way” “C “Can’t get to zero” ’t t t ” “Automate, technology reduces the need for human operator” 6 RELI ABI LI TY | ACCOUNTABI LI TY
Challenge www.airlines.org/PublicPolicy/Testimony/Pages/testimony_5-13-09Senate.aspx&docid=qnHU9MAraY_WIM&w=550&h=403&ei=mdRbTvkrhLm3B8nyibgM&zoom=1&iact=rc&dur=62&page=2&tbnh=167&tbnw=216&start=50&ndsp=31&ved=1t:429,r:4,s:50&tx=110&ty=85 7 RELI ABI LI TY | ACCOUNTABI LI TY
Five Questions • Know thy user Know thy user • Elegant simplicity • Actions not words A i d • The rat is never wrong • You can’t afford not to know the truth 8 RELI ABI LI TY | ACCOUNTABI LI TY
Five Questions • Know thy user Know thy user • Elegant simplicity • Actions not words A i d • The rat is never wrong • You can’t afford not to know the truth 9 RELI ABI LI TY | ACCOUNTABI LI TY
Know thy user • Know thy user Context Matters Human Ingenuity Human Ingenuity Only two hands, two eyes, see the pattern? If you only have a minute, it only takes a If l h i t it l t k minute… Set me up for success…please… f l Human nature 10 RELI ABI LI TY | ACCOUNTABI LI TY
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Signs Darnell, M. J. (2006). Bad Human Factors Designs. Baddesigns.Com 17 RELI ABI LI TY | ACCOUNTABI LI TY
Human Performance Tenets • People are fallible, and all people make mistakes • Error likely situations are predictable manageable and • Error ‐ likely situations are predictable, manageable, and preventable • Individual behavior is influenced by organizational y g processes and values • People achieve high levels of performance largely because of the encouragement and reinforcement received from leaders, peers, and subordinates • Events can be avoided through an understanding of the • Events can be avoided through an understanding of the reasons mistakes occur and application of the lessons learned from past events or near misses learned from past events or near misses 18 RELI ABI LI TY | ACCOUNTABI LI TY
Sometimes it is a Human 19 RELI ABI LI TY | ACCOUNTABI LI TY
Five Questions • Know thy user Know thy user • Elegant simplicity • Actions not words A i d • The rat is never wrong • You can’t afford not to know the truth 20 RELI ABI LI TY | ACCOUNTABI LI TY
Elegant simplicity • Elegant simplicity Elegant simplicity Russians and the US Space Program How many tools in the box? How many tools in the box? The tool shouldn’t be harder than the task. Surround the truth it is out there somewhere Surround the truth…it is out there somewhere… 21 RELI ABI LI TY | ACCOUNTABI LI TY
Flowchart for Human Performance 22 RELI ABI LI TY | ACCOUNTABI LI TY
Human Performance Tools 23 RELI ABI LI TY | ACCOUNTABI LI TY
Human Performance Tools Two Minute rule • • Stop when unsure • Self checking (also called STAR and touch STAR) • Procedure use and adherence • Three way communication Phonetic alphabet • • Pre ‐ job brief • Peer check Peer check • Concurrent verification • Independent verification Flagging operational barriers Fl i i l b i • • Place keeping • Post job interview • First Check 24 RELI ABI LI TY | ACCOUNTABI LI TY
Read All About I t 25 RELI ABI LI TY | ACCOUNTABI LI TY
Five Questions • Know thy user Know thy user • Elegant simplicity • Actions not words A i d • The rat is never wrong • You can’t afford not to know the truth 26 RELI ABI LI TY | ACCOUNTABI LI TY
Actions not words • Actions not words Actions not words It is not important unless it is checked. What is your story? h i ? Are you telling your story up or down? y g y y p 27 RELI ABI LI TY | ACCOUNTABI LI TY
RELI ABI LI TY | ACCOUNTABI LI TY Tell your story… 28
Five Questions • Know thy user Know thy user • Elegant simplicity • Actions not words A i d • The rat is never wrong • You can’t afford not to know the truth 29 RELI ABI LI TY | ACCOUNTABI LI TY
The rat is never wrong • The rat is never wrong Behaviorism Not enforcing a policy is like not having a policy at all policy at all Don’t have a rule that you aren’t going to enforce enforce 30 RELI ABI LI TY | ACCOUNTABI LI TY
The rat is never wrong Human behavior is shaped by interaction in the world… p y • Punishment stops behavior • Reinforcement shapes and sustains behavior Reinforcement shapes and sustains behavior 31 RELI ABI LI TY | ACCOUNTABI LI TY
Silence is Consent 32 RELI ABI LI TY | ACCOUNTABI LI TY
Five Questions • Know thy user Know thy user • Elegant simplicity • Actions not words A i d • The rat is never wrong • You can’t afford not to know the truth 33 RELI ABI LI TY | ACCOUNTABI LI TY
You can t afford not to know the truth • You can’t afford not to know the truth ’t afford not to kno the tr th Y Root cause Just Culture Near misses Near misses 34 RELI ABI LI TY | ACCOUNTABI LI TY
RELI ABI LI TY | ACCOUNTABI LI TY Stuff Happens 35
A Tale of Two Cylinders RELI ABI LI TY | ACCOUNTABI LI TY 36
Or…When Good Pistons go Bad! 37 RELI ABI LI TY | ACCOUNTABI LI TY
Why Root Cause Versus Apparent Cause? • Facts F Jeep had 107k miles Cylinders were fine…no abrasions (whew, got lucky) g y) Approx $2,500 to completely rebuild, same block just new pistons block just new pistons… Just MTBF for pistons…or maybe not… 38 RELI ABI LI TY | ACCOUNTABI LI TY
The rest of the story… • Mechanic noticed some scalding on other pistons • No history of ever over heating… • Jeep was hit on right side at 70k miles • Jeep was hit on right side, at 70k miles…. • Right fender was replaced, radiator and fan blade..no damage to engine block blade..no damage to engine block • New Fan blade was installed backwards!!!! • Jeep was running hotter than it should…just slightly…not enough to notice…and there was a new owner so there was no baseline owner so there was no baseline… 39 RELI ABI LI TY | ACCOUNTABI LI TY
Can Your Organization Handle the Truth? "Before you tell the "truth" to the Before you tell the truth to the patient, be sure you know the "truth,“ and that the patient wants to hear it." Journal of Chronic Diseases (1963) Journal of Chronic Diseases (1963) Dr. Richard Clarke Cabot (1868 ‐ 1939) 40 RELI ABI LI TY | ACCOUNTABI LI TY
Human Performance Analysis • We have not fully understood an event if we don’t see the actors’ actions as reasonable. • The point of a human error investigation is to understand why people did what they did, not to judge them for what they did not do. • The difference between an accident and a serious incident lies only in the result. 41 RELI ABI LI TY | ACCOUNTABI LI TY
Can Your Organization Handle the Truth? 42 RELI ABI LI TY | ACCOUNTABI LI TY
Five Questions • Know thy user Human Ingenuity Human Ingenuity • Elegant simplicity Russians and the Space Program • Actions not words It is not important unless it is checked • The rat is never wrong Behaviorism • You can’t afford not to know the truth • You can t afford not to know the truth Root Cause 43 RELI ABI LI TY | ACCOUNTABI LI TY
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