Harnessing the Power of Human Performance to Improve Safety Culture
By Josh Williams Ph.D
Organizational leaders are increasingly turning to Human Performance (HP) principles to improve safety culture and performance. Unlike the old “command and control” engineering approaches, HP emphasizes the importance of improving environmental contingencies to encourage safe work practices. In fact, HP philosophy holds that human error is inevitable and is a predictable outcome of human beings operating in flawed environments (Conklin, 2012).
Basic HP tenants include (Williams & Roberts, 2018):
- Error-likely situations are predictable, manageable, and preventable. Most incidents are influenced by system factors like confusing procedures, excessive production pressure, faulty tools/equipment, insufficient personnel, and ineffective training.
- When SIFs occur, workers trigger latent conditions that already exist in systems, processes, procedures, and expectations. These conditions lay dormant until all the wrong events align perfectly to create gaps in worker protection.
- High reliability organizations have effective engineering (e.g., safeguards on equipment), administrative (e.g., procedures), and cultural (e.g., organizational values for safety) defenses to mitigate the influence of human error and error precursors.
- Safety should not be viewed as the absence of events but rather the presence of solid, consistent defenses against human error.
The Normalization of Deviance
Normalized deviation has been used to explain the Challenger explosion and other catastrophic events (Vaughan, 2016). Essentially, employees operate below the highest standards of the job and fail to follow all prescribed procedures and expectations for the job. This includes both active and latent errors. Active errors are unsafe acts by employees like slips, lapses, mistakes, and procedural violations. Latent errors are hidden failures built into the system like faulty equipment, inaccurate procedures, insufficient training, excessive production pressure, and insufficient personnel for the job.
Over time, these errors are ignored or go unnoticed by fellow employees and supervision. They become “normalized” in the system. As a simple example, teenagers learning to drive get both education and training on following traffic laws and safe vehicle operations (e.g., turn signal use, maintaining proper following distance). These behaviors are normally performed safely when people learn how to drive. However, these standards often drop over time as people learn they can “get away with” operating less safely. This is further supported by the risky actions of other drivers on the road. Drifting from higher to lower standards is a natural process both individuals and organizations need to constantly guard against. HP offers numerous tools to combat normalized deviance and other types of human error. These tools have been successfully used to improve safety culture and prevent SIFs.
There are numerous HP tools used to improve safety performance. These tools are used in a pro-active, ongoing manner to engage stakeholders to prevent human error. A few quick examples include:
- Peer checks: With peer-checks, coworkers provide each other helpful safety feedback to ensure error-free work. Peer-checks can be done informally through normal conversations and more formally with HP peer-check forms. Designated personnel also do peer-checks when opportunities arise and during scheduled walk-throughs. Peer-check forms should be collected and analyzed to find error-likely trends and to make and advertise all necessary improvements. Peer-checks should be joint problem solving, collaborative interactions.
- The two-minute rule: The two-minute rule encourages employees to take time before starting a job to review the immediate work environment to identify: a) altered conditions due to changes in work planning, b) potential job hazards, and c) error-likely situations. This is completed after pre-job briefings but before starting the job. The two-minute rule raises situational awareness to keep employees from operating on autopilot and making unnecessary errors.
- Three-way communication: Three-way communication is used for dangerous situations (e.g., confined space entry) where errors may lead to SIFs. With this technique, a given employee: 1) provides a coworker specific feedback, 2) waits for the employee’s response, and then 3) verifies the receiver understands the original message as intended (e.g., using carabiners when mountain climbing). Three-way communication promotes the reliable transfer of information so correct actions will follow. This should be used when providing critical information in error likely situations, directing equipment operation with dangerous tasks, and directing others to perform a dangerous task.
Benefits of HP
A sample of case studies showing HP success across several industries is shown below:
- Findings from three case studies with Nordic Nuclear Facilities showed safety accident rates dropped significantly and human error rates dropped by 400% following HP implementation. Specific HP tools used included: peer checks, task observations, and three-way communication (Oedewald et. al., 2015).
- After implementing a human performance coaching program in a radiation department, close call reporting increased more than 4 times the rate prior to implementation. This feedback helped prevent more serious incidents from occurring. During this time, the mean number of days between serious safety incidents went from 200 to more than 1,000.Not surprisingly, employee responses on a safety culture survey after HP implementation improved for all 42 items (and results were statistically significant for 7 of the 10 main survey categories; Dickerson et. al., 2010).
- In a study from Johns Hopkins, the introduction of HP pre-job briefings with surgeons resulted in a 19% reduction in communication breakdowns and an 82% decrease in operating delays. Researchers concluded that this HP tool should also be applied to improve overall hospital profitability and safety (Nundy et. al., 2008).
- As part of the World Health Organization’s Safe Surgery Saves Lives Program, the use of HP checklists with surgeons were associated with a significant reduction in major postoperative complications after inpatient surgery and resulted in a 47% decrease in mortality and 36% drop in morbidity. Researchers concluded these checklists helped save lives by a) reminding operating room staff to check key details during operations, and b) encouraging increased teamwork and communication (Haynes et. al., 2009).
Error-likely situations are predictable, manageable, and preventable. Effective HP implementations help reduce human error, improve safety culture, and prevent serious injuries and fatalities.