2018 HPRCT Conference

Some HPI experts tell us to reduce human errors. Others warn us to stop focusing on the “humans.” Still others, argue that “errors” don’t exist at all. If you’re confused, you’re not alone. Join us to cut through the confusion and learn pros and cons of each of these three core error management strategies:

• Apply Classic Defenses
• Improve Work Processes
• Build Organizational Resilience

Practical, real-world examples included as always.

All participants will receive a copy of the “Three Strategies” handout.

As a forward-thinking and responsible leader, your interest may be piqued by the promises of modern safety culture: theory that describes the daily sociotechnical complexities of your work, the potential to move beyond toxic blame culture, the hope offered by a more appreciative approach to process improvement. But when you are back at your job site or workstation, you may still witness a good worker being fired because “someone’s head had to roll,” or a disagreement escalating into a shouting match and rank being pulled to settle the outcome. Perhaps you even see yourself in those very real, very common situations. 
 
So what is it that makes traditional safety culture so easy and satisfying in the short term? What gives modern safety culture and an HRO-mindset a scientific likelihood to succeed in the long term and deliver more return on your investment? What actions can you count on to facilitate or destabilize worker motivation? The answers lie in our most basic, 300-million-year-old human biology. Modern research into brain activity utilizing functional MRI and classic behavioral interventions shed new light on otherwise elusive concepts. 
 
After this 25-minute interactive seminar, you will learn how to: 
1. Map positive and negative social stimuli to the activation of common neurotransmitters in specific regions of the brain.  
2. Predict how your leadership approach – even down to individual choices – may influence the workers and teams in your shop on a neurological level. 
3. Infuse your leadership decisions with evidence-based social and behavioral neuroscience. 
*No biology or medical knowledge required; all are encouraged to attend. 

The expected response to workplace ‘green and red lights’ rarely result in error or undesirable consequences, whereas the uncertainty produced by ‘yellow light’ moments eventually do. Though highly predictable and easily recognizable, managers, first line supervisors, work planners and front-line workers continue to speed through the workplace intersection when encountering a yellow light moment, regretting the decision in both the short and long run.  During this interactive session, participants will recognize their own yellow light issues, the cognitive biases that create unproductive and unsafe responses and actions and the five error reducing techniques High Reliability Organizations use to turn perilous yellow lights into reliable green and red-light decisions.  

 
Human Performance Improve Activities in JANSI  
JANSI assistances for Utility QA activities, such as assistance for the developing Japanese QA standards of JEAC4111 and JEAG4121, which are based on ISO9001 and customized for nuclear facilities according to IAEA GSR-part 2 recommendation. 
Committees are managed by JANSI; 

• QMS Committee 

   Resolution of common issues on QA by nuclear operators. Consider response policies to issues, share information on overseas QA activities and consider introduction into Japan in pursuit of excellence. 
   ■ Human Factor Committee 
     Reducing human errors and improving human performance. Consider measures for human error reduction, survey activities in other industries, and develop safety awareness posters. Made Human performance improving handbook and held a lecture for that. 
   ■ RCA Committee 
     Improving the effectiveness of Root Cause Analysis (RCA).             RCA training (introduction, skill improvement), case study meetings, create training videos for interviewers. 
 
Fukushima-Daiichi Accident Analysis from Good Practice Viewpoint  
Whereas the direction which discusses the safety from the accident analysis, a new trend of analytical methods such as resilience engineering, high-reliability organization, or risk literacy research, which analyze the various events by focusing on the good practices, are becoming popular. 
Various good cases of resilience response were observed in the individual base and also in the organizational base in Fukushima-Daiichi accident as below: 

• The effectiveness of insight and of the risk evaluation on accident cases, such as inundations in LeBlayais and Madras plants, and September 11 terrorism and B.5.b.order from US Nuclear Regulatory Commission to keep the plant in safe condition even natural disasters or acts of terrorism occurred, 
• The decision of continuation of seawater infusion (individual base). 
• Reflection of the experience on Chuetsu-Oki Earthquake, 
• Improvement of seismic base isolation building equipped emergency power system and air conditioning system, which was effectively used for emergency response facility (on-site of organizational base), 
• Deployment of fire engines, which was effectively used for water infusion (on-site of organizational base). 
• The effectiveness of command system in ordinal time due to training (on-site of organizational base), 

 

Prior to learning about the “new view” of safety, we had only introduced HPI tools within our organization.  Like many companies, we are also using Lean to drive our continuous improvement efforts and Open Book Management to help employees “think, act and feel” like owners.  As we began exploring more about HPI our company decided to actively shape our culture.  Initially, this was through Senn Delaney’s “unfreezing sessions” and then subsequently followed by Tim Kight’s “Lead Now” and “R-Factor”.  We found that the new view concepts were synergistic with all of these efforts.  Our delivery of human performance fundamentals provided the basis for connecting all of these efforts together allowing them to truly become part of our culture.  Frontline employees were able to see how all of the pieces fit together. 

Learning from events and near misses can be a matter of life or death yet the style of our messages has not changed significantly over the years.  We feel powerless when, after modifying procedures and implementing corrective actions, we have a repeat event: it’s a different person at a different plant but not much else is different.  This talk is a practical “how to” craft stories such that important, hard earned lessons are more memorable and more likely to be acted on.  The methods are based in what we can learn from cognitive and marketing sciences.  Specifically, I explore how knowledge of how memories are stored and retrieved and theories in overcoming resistance to persuasion can be used to improve event lessons learned and reporting programs.    

This presentation will discuss the development of a Safety Critical Task Analysis (SCTA) tool used to identify opportunities for human error and its benefits. It will also describe the successful collaboration between BP and BHGE in the development, testing, and implementation of the tool in different work processes.

In recent years, safety leaders have focused attention on systemic issues that can contribute to human error when completing tasks. Reduction of error traps and implementation of strong defenses play an important role in today’s view of on-the-job safety. Having strong barriers is especially important where there are safety-critical tasks. With that in mind, BP developed a tool to identify error traps and expose potential for barrier failure in collaboration with BHGE.  The team tested the tool across multiple activities including mud logging and directional drilling operations. The tool’s main objectives are to:

• Identify the possible human errors during the Critical Task
• Identify which of those errors can lead to the Critical Task failing, leading to a failure of the barrier based on safeguard and mitigations in place. 
• Assess the risk associated with the error.
• Identify ways to eliminate error traps and strengthen barriers.

Human performance holds great promise for improving safety and reducing SIFS (Serious Injuries & Fatalities).  In this session, we explore how easy it is for people to judge other people’s instinctive decisions, rather than exploring the context in which those decisions were made AND without using "the big stick approach".  Change how you view the world of behaviors, their contexts and how we interpret and learn from them.   
 
The purpose of analyzing the human behavioral component of any event is to understand why those involved did the things they did. Investigations attempt to understand the workplace conditions, worker attitudes, adequacy of staffing levels, and the effectiveness of leadership in order to explain what happened.  This presentation seeks to understand how worker’s decisions and the capacity of the organizational management system to influence of safe and at-risk behaviors make sense at the time, given the environment within which they were working.    
When we incorporate elements of Human and Organizational Performance (HOP) and Behavior-Based Safety (BBS) into the investigation it allows management to create an environment where workers can make good decisions by recognizing the role of the individual and human fallibility, identifying how organizational systems influence human behavior and embracing the role of the leader to manage organizational systems in order to positively influence human behavior.  Further, as worker behaviors are examined using the behavioral approach, the underlying & well-hidden management system at risk behaviors become apparent. When we reach these holistic conclusions, we can concentrate on improving the management system....instead of using the easy answer of the "big stick".  This blended approach allows us to become an advocate for the most precious resource we have – the worker. 
 
 

A number of companies have had a lot of success in managing human fallibility through the philosophy of Human Performance Improvement (HPI).  Some of these same companies are realizing there is another level of success that can be achieved by enhancing the ingenuity of human beings.
Join us is studying how these companies are removing barriers that stand in the way of humans achieving their best performance while still managing human fallibility.  How did a Department of Energy (DOE) laboratory design, 3-D print, and deliver a running Shelby in less than 6 weeks?  How did “Psychology Safety” play a role in a major project coming in one year ahead of schedule and $10 million dollars under budget?

The purpose of this breakout is to provide a case study on how a field organization including production operations and Drilling and Completions can make a cultural shift to a learning organization that embraces Human Performance principles

The Eagle Ford team has been an early adopter of Human Performance and Learning Teams within COP. Since 2014, there has been an on-going effort to become a Learning Organization that embraces Human Performance principles.  Although the organization will not claim it has become a learning organization, it does have many characteristics suggesting a significant cultural and organizational change has occurred.  Below is a draft agenda
Agenda

• Background – How do we define a learning organization?
• What are the key focus areas to support the transformation?
• What specifically have you done to drive the cultural shift? (examples of learning teams, crucial conversations with leadership and management)
• What challenges and pitfalls have been overcome?
• What is next on the journey?

One of the loudest conversations currently taking place in Leadership and Performance Improvement space is- how to deal with different generations in the workforce, especially Millennials.  
Thirteen years of PPI experience working with tens of thousands of workers and their leaders around the globe have validated that all human beings have a core set of intrinsic characteristics- whether born in 1925 or 2001 (or anywhere in between).
The Millennial Generation has received a great deal of ‘press’ because (1) it is the largest generation ever, and (2) the ‘worldview’ of the members of this generation can be quite different from the Traditionalists, Boomers, and Xers.
Taking what in many organizations is four generations of workers and attempting to achieve a “one team” approach has proven a great challenge to many.  This is because of an acute focus on differences and the “sticking points” they create.
When the focus is placed on the intrinsic elements of what makes us “human”, these differences can be a blessing rather than a curse.
In this breakout session, participants will:

• Understand the results of their personal IQ (Influencer Quotient™), and how to leverage their individual preferences/biases to maximize their personal ability to influence
• Be introduced to a simple model of INFLUENCE
• Understand that the intrinsic needs and desires of all generations are essentially the same
• Recognize that out of ten core values, eight are the same across all generations
• Learn how to positively leverage the two values where Millennials differ from the three earlier generations
• Be given tangible “how to” insight into how influence across all generations, melding personal IQ with the simple model of INFLUENCE

The purpose of this session is to introduce attendees to the concept of organizational drift, its causes, and opportunities to manage organizational drift, based on the presenter’s research.

Summary:
Organizational drift, sometimes called “drift into failure,” “practical drift,” or “normalization of deviance, has been implicated in numerous accidents and disasters in the past two decades, from the NASA shuttle disasters to Deepwater Horizon, to even aspects of the recent financial meltdown. But what is drift and what can organizations do about it? This presentation will discuss the processes that enable organizational drift and provide attendees with the latest research on how to identify and manage drift to not only avoid accidents but also to enable successful performance.
Learning objectives:

• Define organizational drift.
• Review case studies where organizational drift has been identified.
• Identify the challenges and opportunities in identifying organizational drift in attendees’ workplaces.
• List methods to avoid drift into failure and enable a drift into success.

This presentation will introduce People Based Quality (PBQ) as it is being used on our various projects.

The Bechtel Quality department has developed an approach to address quality “error likely situations”.  We have a two-pronged approach to account for both manual and non-manual work situations.  The program is based on our 5 Quality Absolutes and proactively affects quality outcomes using a foundation of HU (HPI) tools and approaches. We believe that re-work includes re-hazards and directly affects our safety outcomes. Our experience has been that this approach definitely reduces rework and that it is well received by both supervision and line workers. Where we usually have to “push” our programs, this approach is actually creating “pulls” from the various organizations because it identifies knowledge and performance gaps prior to the work and closes those gaps before work begins. The presentation will include an audience participation portion to show PBQ in action.