Reducing Errors and Improving Safety Through a Human-Performance Initiative
Behavior-based programs have proven effective in reducing workplace incidents because safety becomes a collective responsibility shared by all employees. In the complete paper, the authors describe a program known as Human Performance.
Human error can be defined as an action or behavior that unintentionally results in an undesirable or unwanted condition or leads a task or system outside of acceptable limits or established standards. An error-free workplace is not possible. The average worker will make anywhere from 10 to 12 errors per hour. These errors, however, will not necessarily lead to an injury or quality defect and are considered to be part of normal operations.
Employee Experience vs. Error. One might expect workers to become more competent and the quantity of errors to decrease with increased experience. However, that is not the case. Initially, the individual is within their learning phase, causing a higher chance of injuries. But once the worker obtains the experience and understanding to perform safe, quality work, the rate of accidents can increase because additional error traps come into play. The experienced worker may become overconfident in their ability, increasing the level of risks taken (cutting corners or multitasking) or working in the absence of an established procedure.
How Errors Lead to Accidents. Although it is impossible to have an error-free workplace, it is possible to have an incident-free workplace. Errors do not equal incidents or events. This is because multiple layers of physical and administrative defenses typically exist between errors and an incident. Physical defense layers can include engineered safety features or personal protective equipment. Administrative defenses include observers, training, briefings, procedures, instructions, and policies. In summary, events typically do not occur because of a single error.
The first step in error reduction is to understand various modes of operation and how errors can occur. The authors discuss three error modes: skill-, rule-, or performance-based.
- Skill-based performance involves completing tasks from memory and habit, for instance using a hand tool. Workers spend 90% of their time within this mode and it accounts for 25% of errors. The chances for these errors are lowest, however, at 1 in 10,000.
- Rule-based performance steps beyond memory and requires technical knowledge through procedures or instructions. The odds of generating an error while in rule-based mode increases to 1 in 1,000 and accounts for 60% of errors. Errors within rule-based performance include deviating from procedure, skipping a step or losing the place in a procedure, or misinterpretation.
- Knowledge-based performance accounts for 15% of errors. The worker relies on knowledge, perceptions, and previous circumstances to decide how to proceed. Because the worker has not encountered these situations before and humans are working with flawed systems or minds, the chances of error increase to 1 in 10 or as much as 1 in 2.
Overview of HuP
Employee behaviors can be affected by personal factors, external factors, or peer pressure and culture within an organization. The complete paper provides a summary of primary human-performance traps that increase the chances for errors, including pressure, stress, past behavioral patterns, and unfamiliarity with tasks.
The organization itself can create or amplify these traps based upon its culture. Two types of safety culture exist with regard to incidents: blame culture and reporting culture. In a blame culture, the organization stops investigating when the culprit (individual) is identified. Within a reporting culture, however, the investigation expands to identify all latent and active errors by including equipment design, procedure, and management as well. The aim is to fix as many weaknesses in the process as possible, as shown in Fig. 1.
HuP Error-Prevention Tools
HuP tools provide an effective means of reducing the potential for incidents by decreasing errors. By using the seven tools described in this section, the execution of which are described in the complete paper, organizations can minimize the potential for mistakes.
1. Prejob Briefing. Purpose. Ensure safe and efficient execution.
- Review critical elements.
- Define the role of team members.
- Define hazard potential of the task and steps to mitigate it.
- Discuss HuP tools designed to minimize errors.
Timing. The prejob brief is completed before initiation of any work processes to ensure that everyone has a clear understanding of the task to be performed. The briefing works best when a person is operating in knowledge- or rule-performance mode.
2. Self-Checking STAR (Stop, Think, Act, Review) Process. Purpose. This is a skill-based technique designed to focus an individual’s attention before performing an action. The steps include the following:
- Stop and pause: Focus your attention on the task at hand, one task at a time, and avoid distractions.
- Think: Understand what has to be completed before operating equipment.
- Act: Without losing eye contact, touch the component and say out loud the intended action, and then perform the action.
- Review: Were the intended results achieved? If not, perform the contingency plan from the prejob brief.
Timing. The self-checking STAR procedure is applicable during the following conditions:
- Tasks are interrupted.
- Task repetition is high.
- Time pressure exists.
- Fatigue may be experienced.
- Procedures are difficult.
- Before an irrevocable task
- Before manipulation of any plant equipment
3. Procedure Use and Adherence. Purpose. This tool is used to control the user’s behavior to perform consistently and reliably to high standards.
Timing. It is used any time a procedure governs work activity, such as is required when operating in rule-based performance modes. Procedure use and adherence would not be effective in knowledge-based operations because the worker is encountering a new situation in that scenario.
4. Questioning Attitude. Purpose.
- Challenge preconceptions and assumptions.
- Stimulate healthy critique regarding processes and procedure.
- Consider actions and assumptions from differing perspectives.
- Ensure everyone has all necessary information to perform the job safely the first time.
- Minimize the potential for mistakes.
Timing. A questioning attitude is a HuP tool effective in all modes of operation, but it is most effective during rule-based modes of operation. As described in the complete paper, execution of this step requires qualification, validation, and verification of all information one encounters in a task.
5. Peer Check. Purpose. This tool, used to verify that the task to be performed is the correct one, works well within an existing team by increasing situational awareness using collaboration and an independent verifier.
Timing. This tool is best used in the following scenarios:
- The task is high-risk.
- The worker may be uneasy or confused.
- Actions/steps/manipulations are required that, if not performed correctly, could result in significant consequences.
- Before the work is performed or after it has been performed but before it is “released” (before its potential impact can occur)
- If requested
6. Three-Way Communication. Purpose. Three-way communication, in which the sender and receiver use paraphrase and written symbology to make sure that a message is clearly understood, aids in reducing errors and encouraging good habits necessary to sustain effective communications during critical, abnormal, and emergency situations.
Timing. Three-way communication can be used in all phases of operation, but it is especially appropriate to use when:
- Instructions must be clear and concise.
- Critical information is verbally communicated (either the collaborative or the directed communication technique, as appropriate for the situation, may be used).
- The use of hand signals alone is not appropriate (this does not apply to crane operations and surveying).
- Telephone and or radio communication involving critical information is used.
7. Placekeeping. Purpose. Placekeeping is used to ensure that a facility or procedure is in good working order and that no unknown safety hazards are present.
Timing. Because a procedure is being used, this technique works well when operating within the rule-based mode, for example in the following scenarios:
- The procedure requires that an individual initials or signs steps (the signing or initialing of steps constitutes placekeeping).
- If no placekeeping techniques (aids) are provided, the method of circle-and-slash constitutes placekeeping.
The HuP program was piloted in the Middle East and demonstrated positive results within 2 years. Proactive safety improvements were achieved with an increase of 50% in safety and quality observation reporting, a 42% increase in safety engagements (safety walk-and-talks) by top management on site, and maintenance of a total recordable injury frequency rate of zero. Latin American facilities also experienced a reduction in lost-time injuries by 66%. A major advantage of the program is that contractors and employees are more willing to express concerns and stop work in unsafe situations.
This article, written by JPT Technology Editor Chris Carpenter, contains highlights of paper SPE 199450, “Human Factors and Performance: Reducing Errors and Improving Safety,” by Salman Khan, Leah Boyd, and Ferdinand Velez, Siemens Energy, prepared for the 2020 SPE International Conference and Exhibition on Health, Safety, Environment, and Sustainability, originally scheduled to be held in Bogota, Colombia, 28–30 July. The paper has not been peer reviewed.