Welcome to the third blog in our Human Performance series, writes Teresa Mullen, and thank you for the feedback to the second blog in this series (if you missed the blogs, you can read them here and here).
People are fallible and even the best people make mistakes, but error-likely situations are predictable, manageable and preventable (Zachary Blanton/123rf)
As promised, in this article we will be discovering the principles of human performance.
Why are the principles important?
The reason for looking at the five principles of human performance so early on in our series is because they provide a foundation on which a human performance improvement (HPI) programme can be built. The principles challenge our traditional ‘Bad apple’ thinking and make us take stock of our perception of humans at work, the errors they make and the way an organisation can set people up for success or failure when these employees are sent out to work for them.
The five principles from the United States Department of Energy (DoE) have been universally adopted. They apply to every organisation and are the underlying truths of human performance. Embedding them and implementing the concepts and practices that support them is critical for a successful HPI programme and so everyone at every level of the organisation must accept and embrace them.
The five principles are:
- People are fallible, and even the best people make mistakes;
- Error-likely situations are predictable, manageable, and preventable;
- Individual behaviour is influenced by organisational processes and values;
- People achieve high levels of performance because of the encouragement and reinforcement received from leaders, peers, and subordinates; and
- Events can be avoided through an understanding of the reasons mistakes occur and application of the lessons learned from past events (or errors).
Let’s take a closer look at each one of these in turn.
People are fallible, and even the best people make mistakes
A study by the World Association of Nuclear Operators (WANO) published some years ago discovered that humans, on average, make five errors every hour. It’s quite a challenge to get your head around this fact, particularly when you start to consider the potential impact on your business of the cumulative effect! Fortunately for us, the majority of these errors are inconsequential, we often don’t even realise we’ve made an error at all. Unfortunately, as we are all too well aware, some of them can result in catastrophic consequences.
So, what are these human errors? And most importantly, how can we get rid of them? Here’s the rub – you cannot eliminate human error; in fact, as our great friend and mentor T Shane Bush, of Bushco HPI will tell you: “Two things will happen to you if you try to eliminate human error – 1) You will go broke, and 2) You will go insane.”
Put simply, human error is something you didn’t intend to do. So, can we punish human error out of the system? No. Can we reward human error out of the system? No. It is pretty much like gravity, weather and the British love of queuing. You have to accept that it is there and work with or around it.
Dr James Reason, author of Human Error (1990) wrote: “It is crucial that personnel and particularly their managers become more aware of the human potential for errors, the task, workplace, and organisational factors that shape their likelihood and their consequences. Understanding how and why unsafe acts occur is the essential first step in effective error management.”
Error-likely situations are predictable, manageable, and preventable
A good thing about human error is that the conditions in which it thrives are predictable and therefore with some good analysis of our existing data, a little bit of forethought and sound planning, we can predict its likelihood, understand the consequences and do something to reduce its impact. A great example of this in practice is the humble USB stick. Every time we try to plug a USB stick into our computer, what happens? We try to put it in upside down. However, the great thing about the design of the USB is that you physically cannot insert it the wrong way up. It has a built in forcing function that prevents you from actually doing it. Interestingly, the USB design does not reduce our error rate, but it does reduce the consequences of error.
Just as the banks were able to predict that people withdrawing cash from a cashpoint machine might take their cash and leave their card, similar predictions can be made within the context of work. By changing the work situation to prevent, remove, or minimise the presence of error-likely situations, tasks and individual factors at the job site can be managed to prevent, or at least reduce, the consequences of error – ie we can fail-safe.
Individual behaviour is influenced by organisational processes and values
The culture of an organisation comprises the values, attitudes, beliefs and behaviours of the people who work in it, coupled with the rules, policies, processes and procedures which are developed to make sure that the work of the organisation is achieved in the desired way. Add to the mix the management style for the organisation and you can begin to see why culture in one organisation can differ so greatly to that of another. This established culture of the organisation then starts to drive the behaviours of the workers and managers; suddenly we can find ourselves in the type of organisational drift scenario that we covered in Blog 2.
This principle is the antithesis of the theory that bad attitudes, misaligned worker values and peer pressure are major influencing factors when undesired behaviours are displayed; there are almost always some underlying organisational weaknesses or latent conditions at play.
People achieve high levels of performance because of the encouragement and reinforcement received from leaders, peers, and subordinates
And this can be a double-edged sword. Notice that the principle does not say ‘good’ performance. All human behaviour, good and bad, is reinforced, whether by immediate consequences or by past experience. A type of behaviour is reinforced by the consequences the individual experiences when the behaviour occurs; where the consequences are positive the behaviour is repeated.
In my work I encounter many instances of leaders unwittingly reinforcing undesired behaviours, for example the pat on the back for a job well done, without asking whether or not all the rules were applied and the procedure followed. These are not bad leaders, they are people with good intent trying to do the right thing. We must ensure that we do celebrate and encourage the correct, desired behaviours and in doing so we must consistently observe, question and intervene to stop unsafe undesired behaviours even when they result in the desired outcome.
Events can be avoided through an understanding of the reasons mistakes occur and application of the lessons learned from past events (or errors)
The most traditional source of organisational learning and improvement comes from the analysis of events, non-conformities and problem reports. While this retrospective look-back is important for continuous improvement, the ability to anticipate mistakes and intervene to prevent them or reduce their consequences is clearly the preferred approach. Human performance improvement requires a combination of both proactive and reactive approaches.
We are very often contacted by new or prospective clients after the event – at the point when they are scratching their head wondering how this could possibly have happened (perhaps again) and looking for a solution to the problem of human error. Root cause analysis is typically poor, if done at all. Causal factors are rarely identified accurately, and identification of critical steps only starts to appear in investigation reports after we have introduced the concept to our clients.
Unless you have defined these things, there is a very real risk that the corrective actions put in place will not have the desired effect in preventing a repeat or similar outcome in the future. This principle directs us to focus attention on the people at the sharp end of our business to understand their map of the world. Human performance improvement shows us that people are the solution to be harnessed, not the problem to be solved.
This has been our whistle stop introduction to the principles of human error. What are your thoughts on these principles? Do you have the same or similar ones? Do you agree or disagree with any of them and if you are familiar with them, what has been your experience of them in practice? Would love to hear your thoughts. Please contact me at firstname.lastname@example.org you would like some more information about the principles or any other aspects of my work.