Managing Human Risk

A Risk-Based Approach to Managing the Human Risk
an unclear and present danger

Tony Muschara, CPT

The Certified Performance Technologist (CPT) designation is awarded by the
International Society for Performance Improvement (ISPI) to experienced
practitioners in the field of organizational performance improvement whose work
meets both the performance-based Standards of Performance Technology and
application requirements. For more information, visit www.certifiedpt.org

Copyright 2010 by Muschara Error Management Consulting, LLC

Managing the Human Element

―You cannot manage
what you do not understand.‖
-- Elliot Jacques,
The Requisite Organization

Human element logo adapted from Dow Chemical: http://www.dow.com/hu/.
2

What’s the Common Cause?
 Challenger (7) / Columbia (7)
 Texas City (15)

 Chernobyl (>56)

 Kansas City Hyatt (114)

 Piper Alpha (167)

 Herald of Free Enterprise (186)

 Tenerife (583)

 Bhopal (>2200)

3

The Real Hazard to Safety & Quality
“An unclear and present danger!”

Threats to
Safety and Quality “We have met
the enemy …
and he is us.”
-- Walt Kelly

Errors
happen!
4

Touching = Risk
 Assets
 Equipment, services, deliverables, time,
information, people, knowledge, money, etc.
 Hazard
 Human Fallibility – Human Error
 Exposure
 ―Touching‖ assets
 Risk
 Likelihood (frequency of occurrence)
 Consequences (severity of occurrence)
 Event
 Accident, Incident, Mishap, ‗D‘ Words 5
5

Purpose of Hu Management

To protect
products, servi
ces, assets, an
d people from
human error

6

Types of Error
 Active Errors
 Physical, observable actions that change
equipment, system or facility state, resulting
in immediate unwanted outcomes (harm)
 Latent (sleeping) Errors
 an action, inaction or decision that creates an
unwanted condition (weakness) but goes
unnoticed at the time, causing no
immediate, apparent harm to the
work, facility, or personnel

Latent weaknesses accumulate!
7
7

Latent System Weaknesses (LSW)
Undetected deficiencies in facilities,
processes, or values that create job-site
conditions that provoke error and/or degrade
the integrity of defenses.

Latent Error – An act or decision
inconspicuous to the individual that
establishes a latent condition.

8

Be Aggressive!

The causes of
tomorrow‘s events exist
today!

Latent System
Weaknesses
Accumulate!

9

Severity of Hu Events in Nuclear*

Number of Number of
Population Latent Errors Active Errors

Operations 31 41
Maintenance 54 4
Engineering 67 3
Management 68 2
Totals 220 50
*U.S. NRC, NUREG/CR-6753, Review of Findings for Human Error Contribution to Risk in Operating Events, August 2001.
10

Latent System Weaknesses in Events*
 Not correcting known problems; accepting degraded
equipment
 Inadequate involvement in risk-significant activities
 Structure / processes impede proper practices
 Increase in volatility of operations
 Reduction in reserves and options for technicians
 Ineffective self-assessment and corrective action
processes
 Strained resources
 Design-related deficiencies
 Inadequate pre-job briefings
 Procedures incomplete, unclear, or incorrect
*U.S. NRC, NUREG/CR-6753, Review of Findings for Human Error Contribution to Risk in Operating Events, August 2001.
11

Risk Management Strategy for Hu
1. Minimize the frequency of occurrences:
 Reduce active errors at critical touch points
 Reduce drift in standards with safe practices
 Operationally oriented (touching)
2. Minimize the severity of occurrences:
 Reduce effects of latent errors (conditions)
 Minimize the accumulation of latent system
weaknesses (faulty defenses)
 Organizationally oriented (managing system
health)
12

Managing Hu Risk*

The application of managerial and
technical skills in a systematic,
forward-looking manner to identify
and control the human hazard to
key assets throughout the life
cycle of a project, product,
service, program, or work activity.

* Source: System Safety Course, FAA Academy
13

Hu Event Chain*
Learning

1 2 3
Organization / Local
Management Factors B RL RM

Latent Weaknesses

Flawed Defenses

Event - An unwanted outcome, triggered by human
error, that results in the serious impairment or
B – Behavior termination of an asset’s ability to perform its
RL – Results (local: individual) desired function, damage to the environment, or
RM – Results (mission: many) serious injury to people
*Reason, J. (2003), Managing Maintenance Error, p.90.
14

Reducing Error at Critical Steps

15

Integrating Hu
Work Execution Process into Operations

Asset &
Hazard
Positive control
Touching
needed here!

Preparation Execution Feedback
Local
Factors
Operational
Organizational

Organization
(system)

16

Local Factors: Performance Drivers
Requirements,
Expectations,
& Feedback

Tools, Resources, &
Job-site Environment

Incentives &
Organization / Disincentives Worker
Management
System Behavior
Knowledge
& Skills

Capacity
& Readiness

Personal Motives,
Expectations,
& Preferences

17

Local Factors*
1. 2. 3.
Task &
Environmental
Requirements, Tools, Resources, Incentives
Factors Expectations, and and
and Feedback Job-Site Disincentives
job-specific requirements,
an environment of rewards and

35% 29% 11%
standards, guidance,
job-related external conditions sanctions explicitly or implicitly
reinforcement, coaching, or
affecting performance of the job associated with the job
correction on what one is
supposed to do and how well
4. 5. 6.
Human & Knowledge Capacity Personal
Individual and And Expectations,
Factors
Skills Readiness Motives, and
Preferences
individual‘s basic/specialized
individual‘s personal motivation,
understanding of technical individual‘s physical, mental,

11%
concepts, theories, systems,
construction, fundamentals,
including skills, proficiency,
and experience
8%
and emotional factors
influencing individual‘s ability /
capacity to perform a job 6%
anticipations, and preferences
related to needs for security,
achievement, affiliation, and
control

*INPO 06-003, Human Performance Reference Manual, p.91.
18

Positive Control*

What is intended
to happen

is what happens

and that is all that
happens.

* Source: Institute of Nuclear Power Operations (2006), Human Performance Reference Manual (INPO 06-003).
19

Probability of Success for 100 Actions

P (success) = .99100

20

Nuclear Explosive Operations*
“Critical Step” “Hazardous Step”
―Procedure step, if ―Procedure step that, if
skipped or performed performed incorrectly,
incorrectly, will increase has a potential to
the likelihood of a high- immediately result in a
energy detonation …, at dominant high-energy
some later step in the detonation, …‖
procedure.‖

* Fischer, S. et al (1998), ―Identification of Process Controls for Nuclear Explosive Operations. ―
21

Critical Step*

Any step, action or previous
actions that, if performed
improperly,
will trigger
immediate,
irreversible
harm.
* Source: Institute of Nuclear Power Operations (2006), Human Performance Reference Manual (INPO 06-003).
22

Excellence is NOT Good Enough!

ex⋅cel⋅lence
–noun
1. the fact or state of excelling; superiority;
eminence in a particular domain
2. condition of excelling
3. something in which one excels

Is “best in class” good enough?

23
23

Mental Skills (Hu Tools)*
Definition Skill Domains

Cognitive skills that  Situation Awareness
complement worker‘s  Communication
technical skills; a  Decision Making
discrete set of
cognitive behaviors to  Teamwork
act with less chance of  Stress / Fatigue
error—promoting safe Management
and efficient  Leadership
performance

24
* Flin, R., et al, (2008), Safety at the Sharp End, A Guide to Non-Technical Skills, p. 1.
24

Adaptive Strategies: Mental Skills
Performance Modes: Mental Skills (Hu Tools)
 Skill-based
provide people a discrete
set of cognitive behaviors to
 Rule-based help them perform their
 Knowledge-based actions more reliably—less
chance of error.
Current
Knowledge
They help focus attention by
slowing down the cognitive
cycle (shown at left).

Unfolding
Actions
Situation

Changes
25

Worker Contribution to Safety*
Worker Contribution to Safety

Safety
Barriers

Hu Tools

Improvisation
Lo Hi
Organization’s Anticipation of Risk
* Source: Svensen, O., et al. (Eds.) (2006), Nordic Perspectives on Safety Management in High Reliability Organizations: Theory and
Applications (NKS-131), Stockholm University, Sweden; p.154.
26

Means Workers Contribute to Safety*
 Barriers – preventing a set of predefined unwanted events
from occurring and/or means to reduce the consequences
of such events, e.g., procedures, pre-job briefing, placekeeping
 Mental Skills (Hu tools) – protecting against dangers not
explicitly predefined but likely to occur; subjective, real-time
evaluation of the danger associated with the situation at
hand, e.g., chronic uneasiness, self-checking, questioning attitude,
situation awareness

 Improvisation – fabricating a plan to address a danger
using what is conveniently on hand, especially when the
danger deviates radically from what has been anticipated,
e.g., conservative decision-making, stop when unsure
* Source: Svensen, O., et al. (Eds.) (2006), Nordic Perspectives on Safety Management in High Reliability Organizations: Theory and
Applications (NKS-131), Stockholm University, Sweden; p.154.
27

Mental Skills (Hu Tools)
1. Pre-job & Post-job briefings
2. Take a Minute
3. Self-checking (STAR) & Peer-checking
4. Questioning Attitude & Stop When Unsure
5. Rule of Three (conservative decision-making)
6. Assertive Statement
7. Three-part communication
8. Placekeeping (procedure use)
9. Flagging & Blocking
10. Concurrent & Independent Verification

28

Managing Defenses

29

Error Rate Error Rate Reduction

Before

Mental Skills

After
Random
Causes

Time

30

Severity Pyramid*

Fatality
1
First-aid
Cases 10
Equipment
Damage 30
Near Misses
& Errors 600
* Source: Frank Bird, Jr., Practical Loss Control Leadership, Det Norske Veritas, 1969.
31

Error Management Hierarchy

1. Eliminate the activity.
2. Prevent error.
3. Catch error.
4. Detect defect.
5. Mitigate the harm.
Prevention – Detection – Correction
--Dr. Chong Chiu,
Performance Improvement International, Inc.

32

Defenses
 Engineered Controls
 Do not depend on people to perform function
 Design – eliminate / substitute the task (task allocation)
 Safety Devices – passive and active controls or barriers
 Administrative Controls
 Warning Devices – detect and warn, labels
 Procedures, job aids, Hu tools, training, PPE
 Oversight Controls
 Supervisory practices
 Inspection and monitoring
 Audits and assessments
 Cultural Controls
 Leadership
 Values, beliefs, assumptions 33
33

Defenses and Error Management
Type Engineered Admin Oversight Cultural
Purpose Defenses Defenses Defenses Defenses
Eliminate
(substitute)
Prevent
Catch
Detect
Mitigate

Purpose – what you want to do in Hu
Type – how you want to do it
34

Defenses: Controls and Barriers
Controls: Barriers:
Measures that Measures that protect
guide, coordinate, or against harm by limiting
regulate or impeding the free
performance movement or flow of
information, objects,
substances, or energy

Engineered  Administrative  Oversight  Cultural

35

JHA – HuRM Contrasted
Job Hazard Analysis Hu Risk Management
(JHA) (HuRM)

1. Identify job steps 1. Identify key assets
2. Identify hazards and hazards
3. Define control measures 2. Identify risk-important
touchpoints
3. Assess risk at critical steps
4. Determine controls and
barriers for each critical step
5. Identify required
organizational factors to
sustain defenses

36

Hu Risk Management Process*

Pinpoint Assets

Identify TouchPoints

Assess the Risk

Identify Controls and Barriers
Prepare  Execute  Feedback
Anticipate – Monitor – Respond – Learn
Implement Defenses

* Adapted from INPO, Human Performance Tools for Managers and Supervisors, 2007.
37

Organizational Design
―It is impossible to manage any organization
solely by means of mindless control systems
that depend on rules, plans, routines, …for
correct performance. No one knows enough to
design such a system so that it can cope with a
dynamic environment.‖
-- Karl Weick
Authors: Managing the Unexpected

38

High Reliability Organization (HRO)
HROs are: ―Organizations [that] operate
under trying conditions yet perform relatively
event-free over a long period of time,
making consistently good decisions that
result in high quality and reliable
operations.‖
-- Karlene Roberts
U.C. Berkeley

Roberts, K. (2003), ―HRO has Prominent History,‖ Anesthesia Patient Safety Foundation Newsletter, Vol. 18, No. 1, pp.1-16.
39

Properties of Resilient Organizations*
 Anticipate – assess risk
 Monitor – asset‘s exposure to human

 Respond – positive control at critical touch
points
 Learn – report, assess,
analyze, trend, correct,
and improve (change
behavior)
Chronic Unease
* Source: Hollnagel, et al., Resilience Engineering, (2006), p.350, and Resilience Engineering Perspectives, Vol. 2, (2009), pp.117-133.
40

Organizational & Management System
Risk Factors*
 Communication  Housekeeping
Practices  Management and
 Continuous Leadership Practices
Improvement  Organizational Goals
 Culture and Priorities
 Expectations and  Policy & Strategy
Standards  Procedures
 Hardware and and Processes
Design  Training
 Hazard Controls  Work Management
 Human Resources
* Source: Greoneweg, J., Controlling the Controllable
41

Example Latent System Weaknesses
Work Management Training

 Lack of coordination  No task qualification
between work groups program
working in same physical  Ineffective OJT/TPE
space.  Lack of management
 Insufficient staffing for involvement
scheduled activity  Not adapting training to
 No hazard analysis done changes in equipment
during planning  Not incorporating lessons
 No review of schedule by learned into training
affected organizations materials

42

Challenges to Managing Hu Risk
 Can’t afford to learn only from
operational events
 Fewer events
 Too costly
 Too late
 Must learn more from small events
 Trend analysis
 Historical data
 Near Hits
 And non-events (real-time operations)
 Human performance (local factors & behavior)
 Assessments (self and independent)
 System health – improve resistance to accidents and events

43

Improving System Health
Internal Methods External Methods

 Field observations  Industry operating
 Post-job reviews experience reports
 Reporting  Benchmarking
 Self-assessments  Independent oversight
 Metrics and trending
 Common Cause Analysis
 Surveys
 Root cause analysis
 Effectiveness Reviews

44

5-Tier Approach – Finding LSWs
1. Reporting
2. Observation and Coaching
3. Self-Assessment and Trending
4. Operating Experience and Benchmarking
5. Causal Analyses

“Eliminating latent [system weaknesses] is the most
effective way to manage human error.”
--Jop Groeneweg
Author: Controlling the Controllable

45

Management’s Role in Hu

46

Dr. Ignaz Semmelweis
 Vienna General Hospital‘s
obstetrical clinic
 Maternal mortality rate in midwifery unit
three times lower than doctor‘s unit
 Doctors often moved directly from
autopsies in morgue to maternity ward
 Maternal death rates dropped from 18.3%
to 1.3% with new measure
 Current compliance around 60%

 What was the new defense measure?

47
47

Drift and Accumulation*
Hi
Expectations
Safety

Drift Current
Practice
Real Safety
Margin
Danger

Accumulation
Hazards/Threats

Lo

* Adapted from Dekker, S. (2007), The Field Guide to Understanding Human Error.
Time
48

Chronic Sense of Uneasiness*
An attitude of
Q u e s tio n in g A ttitu d e M e te r
mindfulness
regarding one‘s H e a lth y U n e a s in e s s /
W a rin e s s /A le rtn e s s
To
capacity to err and in
ta e
er r
/ o
To C
o e rt
nc nsu Su ai
re n /
the presence of U U

hidden threats;
preoccupation
with failure

“When you stop being scared, you start making mistakes.”
-- unknown

* Source: Questioning Attitude Meter was developed by my friend John Summers.
49

Mindfulness
A rich awareness of the context of one‘s
situation characterized by the following:
1. Understand the ―big picture‖ of ongoing operations
2. Know what is important to safety, quality, and reliability
3. Know how to respond before or after losing control
4. Sensitive to emerging threats and dangers
5. Questioning attitude toward everything; nothing is
always as it seems

50

Work as Imagined
How managers IMAGINE
work is being done

∆
51

How work IS done

51

Management’s Role
 Integrate ―Anticipate, Monitor,
Respond, and Learn‖ properties into
risk-important processes and activities
 Leadership – ―chronic uneasiness‖

 Oversight – observation: eliminate gap between
work as imagined and work as done; aware of
current Hu threats to safety and product quality
 Organizational – optimize system health (minimize
accumulation of latent system weaknesses)
 Operational – counteract drift especially at critical
steps; coaching
52

Oversight of Hu – Operational

3 Questions to Ask Line Managers
1. What are your Hu vulnerabilities (Drift)?
2. What are you doing about them?
3. Are you successful controlling the
vulnerabilities?

1
Local 3
2

Factors
4 5 6 B
53

Management Disengaged – Effects
 People no longer fear error; complacency grows
 Mindlessness grows; the effectiveness of
anticipation, monitoring, and responding declines.
 Accepted practices drift from expectations;
production and efficiency eclipse safety and
reliability in importance.
 Latent system weaknesses accumulate
unhampered; threats and hazards proliferate and
defenses erode.
 Communication and learning diminish.

 Incidents grow in frequency and severity.
54

Effort vs. Importance*

Latent System Weaknesses

Human Error

Equipment Failure

Effort Expended Importance
(currently) (actual)

* Adapted from Kletz, T. (2001), An Engineer’s View of Human Error (3rd ed.); p.127..
55

Risk Management Strategy for Hu
1. Minimize the frequency of occurrences:
 Reduce active errors at critical touch points
 Reduce drift in standards with safe practices
 Operationally oriented (touching)
2. Minimize the severity of occurrences:
 Reduce effects of latent errors (conditions)
 Minimize the accumulation of latent system
weaknesses (faulty defenses)
 Organizationally oriented (managing system
health)
56

Questions and Comments

4724 Outlook Way
Marietta, Georgia 30066
678-665-2095
tmuschara@muschara.com
http://www.muschara.com

57

Managing Human Risk

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