Reducing the Frequency & Severity of Human Error: Optimizing Performance
By Tom Harvey
What are the effects of human error? How would it feel to significantly reduce the frequency and lower the severity of the errors you make? What are the benefits of teaching children, grandchildren, family and friends how to live safer, more productive lives? How strong is the connection between safe lifestyles off the job and injury avoidance on the job?
When evaluating these issues, it is insightful to remember that people are not perfect and even the most careful make mistakes. Embracing this truism allows for safety improvement strategies that are designed with the understanding that human error is inevitable and caused by complex factors such as decision making and risk perception. We cannot control all of people's choices or actions, but we can positively affect decision-making factors and help people develop clearer perceptions of risk.
We cannot fully control the human condition, so other means must be used to raise awareness that error traps exist and risks are elevated. Learning how error traps can be recognized and avoided will reduce the chance of errors that result in events.
Seeing the Big Picture
Failure to accept the inevitability of human error will result in continual frustration about adverse events, poor performance and reactionary measures that focus too heavily on the last person(s) involved in the error. A typical knee-jerk recommendation is retraining. What should be asked is, "Why do we need to retrain everyone on this bad procedure that didn't work the first time, even though they could do it right if they wanted to, but chose not to?"
The focus should be on the cumulative effects of organizational breakdowns, flawed defenses and system failures that allowed the event to occur. Otherwise, improvement opportunities are lost. This undue attention on symptoms instead of causes will yield only small gains, whereas accurate analysis and correction of system failures will return great benefits. Human performance will improve once organizational factors are redesigned to promote success and avoid failure. And, as individuals learn and use a set of well-defined, proven tools, common error traps are mitigated. Thus, a comprehensive, holistic approach is needed that addresses all components of performance: error traps, organizational factors and performance tools (see Figure 1).
North American Electrical Reliability Corp. (NERC) cites an event in which an employee was tasked to enter 83 pieces of data into a controller that was designed to accept only 80 pieces of data. When the 81st data point was entered, the system failed, and the cause was attributed to human error by the data-entry employee. There was human error, but it was at the design/engineering/planning stage, not at the point of the event.
Similarly, a video used in Optimize Performance (OP) training shows a woman falling into a basement trap door in the floor that was opened by another employee unbeknownst to her. Watching the video, it is easy to understand other factors that contributed to the event. However, if one were to only read a narrative of the event, one could easily jump to the incomplete conclusion that it was her fault. The video shows the trap door in the middle of a congested work floor, opened by a coworker who did not communicate with the woman who is facing away. Additionally, no barricades or warning devices are present.
This same rush to judgment happens in response to plane crashes and train collisions with vehicles. Barring some obvious alternative cause, plane crashes are attributed to pilot error, and train collisions are attributed to a vehicle's driver trying to beat the train or go around crossing arms. Whether true or not, it is hard to imagine all four pilots in the recent Asiana Air crash in San Francisco, CA, making the serious error of slow speed and undershooting the runway, but that was the initial assumption broadcast. Even if pilot error is the cause, robust technology and protective systems should not allow four pilots to make such grievous errors.
Consider another event in which a semitrailer was struck by a train at a private crossing. It is tempting to conclude that the driver was ignoring flashing lights and cross arms, or trying to race the train to a crossing. How much would your opinion change if you learned that it was a private crossing with no lights or cross arms, that the train was being pushed backward, thus no light or horn was being used, and that it was traveling at a high rate of speed? Focusing too much attention on the last individuals involved in an event limits a more complete understanding of what contributed to the event, and how to prevent similar future events.
OP is a risk-based process developed by the author that aims to prevent, detect and control human error before events occur. It looks at the big picture, giving a comprehensive understanding of all the factors affecting human performance. The approach is simple, yet impactful both on and off the job.
The human performance training concept was first developed in the nuclear power industry and the nuclear U.S. Navy, then extended into select segments within the military, aviation, utilities and other industries. Regulatory agencies are now embracing human performance concepts and have aggressively begun incorporating them into regulations. OP has taken these concepts and enhanced their value.
OP methods include:
•A set of well-defined tools that act as mental PPE to prevent errors and adverse events.
•Recognition of traps that create error-likely situations. OP tools identify and mitigate both situational-factor traps and normalized-drift traps.
•Error and event root-cause review that evaluates how tools/traps can be mined to prevent recurrence and generate concrete and applicable lessons learned.
The core of the process is people:
•People are going to make mistakes.
•Error-likely situations can be predicted and events can be eliminated.
•Organizational values strongly influence performance.
•Positive and negative reinforcement determine behavior.
•Learning from the past will stop future events.
•Everyone can benefit.
The process addresses different types of errors, uses errors and mistakes interchangeably, and differentiates between errors and violations. Errors are unintentional lapses, slips or other mistakes, whereas violations are the result of choosing to do the wrong thing. OP is designed to minimize error frequency and severity. However, as the use of the tools increases, and as traps are recognized and corrected, decisions to commit violations will decrease.
The process promotes a just culture within a learning organization where admission and reporting of errors, mistakes and violations are encouraged so that root causes can be corrected. Errors and violations are often responded to with the same type of harsh punishment. These negative outcomes discourage error reporting, driving valuable information underground and preventing learning.
Even if the action is determined to be a violation, learning what motivated the employee(s) to commit the violation is essential. Many believe that meting out harsh discipline/punishment will solve the problem, but it will not. The problem will not be solved until the reasons for the offending action are determined and addressed; and many reasons may cause employees to choose to commit violations and not perform to desired standards (Figure 2).
OP recognizes 20 traps that put individuals and groups in error-likely situations. These traps are separated into two groups: situational factors and normalized drift.
Situational factors affect individuals at a given point in time. Normalized drift is a trap in the form of weakness and breakdowns in organizational and personal defenses that become accepted over time. Both sets of traps result in substandard performance and adverse events. The "OP Traps" sidebar provides examples of both types of traps.
Recognizing that these traps exist and realizing that they increase the risk of error demands a heightened awareness level. But risks are often unrecognized or misperceived. Far more important than recognizing risk is understanding and using the tools that will prevent errors and adverse events.
The most critical component of the OP process is understanding and using its 10 tools (see sidebar on p. 42). While these tools may seem intuitive, they are quite difficult to perfect in practical use. To improve performance in any venture, one must practice. Whether learning to play a musical instrument, advancing in an athletic sport or improving dancing skills, practice is required. Proficiency will not be attained by reading about the subject, watching training videos or using buzz words. There is no shortcut; practice is the only way to realize the powerful benefits of OP.
The program's tools are a set of thought-provoking defenses that will prevent, predict or reduce the likelihood of errors and events, only after the methods and techniques are fully embraced, learned and practiced.
The understanding and use of these tools has been proven to reduce the frequency and lower the severity of human error. Significant effort is needed to develop proficiency in the techniques and methods that allow the tools to work on an individual and group/organizational level.
A simple, but effective error review process offers a more complete understanding of adverse events and is a critical component of the root-cause analysis. This process helps identify traps that created error-likely situations, and tools that could have helped predict or mitigate the circumstances that resulted in the event. The error review process hones in on the key causal factors that influenced the event, and that led directly to root causes that must be fixed to prevent recurrence. The analysis tool can be used on any event, on or off the job.
Tuning In to WII-FM (What's In It for Me?)
OP training is highly successful because when trainees hear it is for their benefit, they want to learn. They are told to be selfish, and see if they can find value for themselves and their families. They are challenged to learn strategies that will work for them, and that they can teach to their kids. They are encouraged to focus on themselves and their families first, then think about how their employer will benefit.
The tools and strategies used to reduce errors and improve human performance on or off the job are inseparable. Experience has shown that the OP method and technique used at work is identically applicable away from work. Indeed, while it may sound counterintuitive, greater success is reached when OP is first learned and applied in personal, off-the-job contexts, then used at work. OP trainees buy in when they understand that humans are far more likely to be killed or seriously injured away from work. They learn that the most recent OSHA data show that 4,609 work-related deaths occurred in 2011, while CDC reports 120,859 unintentional deaths from activities such as hunting and other sporting activities, cleaning roof gutters from a ladder, crossing a busy parking lot with small children and motor vehicle crashes. During training, people become aware of how they and their families can reduce mistakes and live more productive lives. They commit to optimizing their performance by internalizing strategies that foster a 24/7/365 mind-set and lifestyle.
The benefits of the OP process can be realized by individuals and organizations on and off the job. OP traps increase the risk of error-likely situations. Situational factors affect individuals at a given point in time, whereas normalized drift is defined as traps in the form of weakness and breakdowns in organizational and personal defenses that become accepted over time. Both sets of traps result in substandard performance and adverse events.
OP tools are a set of thought-provoking defenses that will prevent, predict or reduce the likelihood of errors and events only after the methods and techniques are fully embraced, learned and practiced.
A simple, but highly effective error review process is a critical component of root-cause analysis because it helps determine traps that created error-likely situations, and aids in the evaluation of tools that could have predicted or mitigated the circumstances that resulted in the event.
Regulatory agencies embrace human performance concepts and have actively begun incorporating them into regulations. On many fronts, human performance is emerging as an effective and valuable performance-improvement process.
Once learned, these strategies improve all aspects of operational performance. When applied, OP changes culture. Improvements will be widespread and widely recognized. The frequency of human error will be reduced, and the severity of the effects of human error will be lowered. Safety will improve, reliability will increase, productivity will rise and people's lives will be enriched.
The author acknowledges several contributors to this article: Earl Carnes, James Merlo, Tony Muschara, David Bowman and the thousands of individuals who have embraced OP.
Tom Harvey, CSP, is the founder of Allied Safety Associates, the predecessor to Optimize Performance (www.optimizeperformance.net). Harvey is a past president of the South Carolina and Greater Baton Rouge chapters, and has developed four best-selling safety videos, including "Safety Decision Making: Overcoming Human Nature." He can be reached at email@example.com.
Situational factors are traps that exist at a given point in time and affect individuals while performing a task, which can increase the chance of making an error, and include the following:
- Time pressure. Pressure exerted, whether obvious or concealed, self-imposed or system-imposed, to accomplish a task within a set period.
- Distractions/interruptions. Being physically or mentally separated from the task.
- Multiple tasks. Too many activities going on at the same time.
- Overconfidence. Overestimating one's performance, ability, level of control or rate of work.
- Vague guidance. Unclear instructions, whether written, demonstrated or spoken.
- First shift/late shift. Early/late in one's work schedule, or the first day before or after a holiday, vacation or other time away.
- Peer pressure. Influence exerted by a peer, or peer group, that encourages a person to change his/her attitudes, values or behavior.
- Scope change. Abnormal or unplanned situation, or conditions outside of routines or expectations.
- Physical environment. Conditions within the work space where one will be performing a task.
- Mental stress. A compromised state of mind that limits a person's ability to focus and make correct decisions.
Normalized drift encompasses traps in the form of weakneses and breakdowns in organizational and personal defenses that become accepted over time, resulting in substandard performance and adverse events.
- Conflicting values. When stated organizational principles and values do not match actual performance.
- Condoning. Silent approval of unacceptable deviations.
- Bad habits. Short cuts, complacency, wrong perceptions of risk, thrill seeking.
- Vague policies. Misunderstood and inconsistently applied standards.
- Ineffective training. Improved job performance not realized.
- Flawed procedures. Needed but missing, incorrect, unclear.
- Faulty equipment. Broken, out of date, inaccurate.
- Technology. Failure to take advantage of technology.
- Design/engineering. Inaccurate drawings, component labeling, unapproved modifications
- Lack of accountability. Focus is on results rather than on how achieved; unclear expectations.
The 10 OP Tools
- Questioning attitude. A constant state of mind that: knows that "it can happen to me;" asks "what if?" before acting; and is not overconfident and resists a false sense of being right.
- Job plan analysis. Used to analyze the big-picture risks of a job.
- Pretask review. Used just prior to performing the task to acknowledge the traps that create error-likely situations, and how to apply tools to prevent error.
- Self-check. The last line of defense performed on the immediate task at hand in real time.
- Procedure usage. Written forms of communication detailing step-by-step procedures for performing a task.
- Place-keeping. A preferred method using circle and slash to keep track of the proper sequence of performing work tasks.
- Peer check. In-process, second check of intent and actions.
- Effective communication. A set of verbal messaging principles and specific techniques called closed-loop communications.
- Postjob review. An opportunity to collaborate on ways to improve a task after it has been performed.
- OP coaching. Employees being ready, willing and able to give and accept constructive feedback is one of the most powerful and effective ways to improve workplace safety and reliability.