Human Performance Tools: What’s Right … What’s Wrong
WHAT ARE HUMAN PERFORMANCE TOOLS?
Over the past decade, best practices and techniques have been developed “stop” or manage human error. They were developed mainly in the US nuclear industry and vary in content/name by the consultant/organization that offers them. Common tools include:
- Procedure Use*
- Place Keeping*
- Pre-Job Brief*
- Post-Job Brief
- Peer Checking*
- Time Out
- Rule of Three
- 3-Way Communication*
- Observation & Coaching*
- Questioning Attitude
- Attention to Detail
- Errors Traps/Precursors
Here are some links to learn more about the tools above:
Also, if you plan on attending the 2014 Global TapRooT® Summit, attend Mark Paradies’ talk on human performance tools to learn more about these tools.
The asterisk (*) techniques above have always been included on the Root Cause Tree® (part of the TapRooT® System) because they are supported by established human factors research. Post-Job Briefs are also a well-established best practice that isn’t included on the Root Cause Tree® because it would occur after an incident or as part of the normal performance improvement program.
WHAT’S WRONG WITH HUMAN PERFORMANCE TOOLS?
Some of the techniques seem like excellent best practices (paying attention, having a questioning attitude, STAR, and Time Out), but I haven’t been able to find scientific human factors research that supports their use. For example, the “Rule of Three” is supposedly supported by research in the aviation industry that three yellow lights (conditions that are worrisome but not enough to prevent a flight) are equal to one red light (a fight no-go indicator – for example weather that doesn’t meet the flight minimums).
Because they seem like good ideas, you may decide to adopt them, but they may not work as intended in all cases. After all, research hasn’t tested their limits.
The final technique, Error Traps/Precursors seems to violate a couple of human factors principles and therefore should only be used with caution.
ERROR TRAPS / PRECURSORS
The concept behind Error Traps/Precursors is that certain human conditions are indicators of impending human error. If a person can self-monitor to detect the “error likely” human condition, he/she can then apply an appro-priate human performance tool to avoid (stop) the impending error. For example, if you notice that you are rushing, you could apply STAR.
What are these human conditions? The selection varies depending on the consultant that presents the technique, but they commonly include:
- High Workload
- New Tasks
- First Time
- New Technique
A problem with this technique is that the person performing work must self-monitor to detect the human condition to self-trigger action. I’ve never seen research that people are particularly good at self-monitoring to detect any human condition. And even if they were, the list seems to indicate that people would be would be constantly self-triggering. By this list, people are always just about to make a mistake. (To err is human?)
Constantly monitoring points to another human factors limitation. The human brain automatically apportions a very limited resource – attention. Your brain continuously, subconsciously decides what to pay attention to and what to ignore. Your brain decides what sounds are important and which ones are noise. Your brain may decide that motion in the visual field deserves more attention than a stationary object. Or that a sharp pain is more important than a faint touch.
In times of crisis or when one is busy, your ability to pay attention is stressed. Imagine yourself driving on ice. You are so focused on the feel of the road and preventing sliding that you don’t have enough attention left over to even have a casual conversation.
Even when you are not stressed, if you self-monitor your state, you stealing attention from some other task. What faint signal might you miss?
All of the Human Performance Tools have a common limitation. They are weak corrective actions. They are 5’s or 6’s on the TapRooT® hierarchy of controls. Rules, procedures, training, are all attempts at improving human performance. And the human may be your weakest safeguard. If your human performance improvement program is based on the weakest safeguards, what should you expect?
This doesn’t mean that you should not try proven human performance tools. It means that you should try to adopt stronger safeguards and understand the limitations of human performance tools and, at a minimum, implement defense in depth to ensure adequate performance.