The purpose of this presentation is to discuss a relatively new safety performance improvement strategy, which is "Human Performance Improvement." The following specific topics will be addressed:

  • The state of organizational safety maturity necessary for the implementation of human performance improvement strategies;

  • Human performance improvement principles and some elements of implementation oriented management systems; and

  • A discussion on the nature of mental processes, human error, error precursors and steps to minimize error.

Much of what is covered here is based on the work of Dr. James Reason and published in his books, Human Error and Managing the Risks of Organizational Accidents. It would appear that this topic has received relatively little discussion in mainstream safety circles. One purpose of this presentation is to build awareness and perhaps create more discussion on the topic in the safety community.

"Human Performance Improvement" (HPI), as discussed here, refers to an element of a safety management strategy and safety management systems aimed at preventing undesirable occurrences or events in occupational endeavors. Some human performance principles are offered, as are some comments on error prevention strategies and several important and relevant management systems.

HPI is most appropriate for and, indeed, is necessary in high reliability organizations. The definition of a high reliability organization used here is one in which the hazards and risks innate in operations are so significant, or the effects of incidents so catastrophic, that the organization's systems, procedures, standards and human performance, at all levels, must truly minimize the potential for an event or occurrence. Or put another way, an organization in which the safety management systems, procedures, standards and individual performance are sufficiently well developed and high that the probability of a serious organizational accident is de minimis. Examples of high hazard industries might include airlines, nuclear weapons research, nuclear power, some chemical processing industries, etc.

Successful implementation of HPI requires the prior achievement of a significant level of maturity in safety culture and safety management systems and technology in an organization. Consider maturity in safety systems from two viewpoints.

There are three elements which must be in place to achieve safety excellence:

The first is management commitment. This is the level of maturity in leadership, culture and management systems. It is well known that the single most important criteria for achieving safety excellence is true senior management commitment, vision and drive. From this commitment stems the strength of safety leadership, safety culture and safety management systems that an organization puts in place. Investigations of major incidents, like Chernobyl, Bhopal, Three Mile Island and the Columbia Disaster have all clearly demonstrated that management and management system failures are among the primary causes of these catastrophes.

The second is technology. If there isn't safe technology, facilities and equipment, the best management systems and behaviors are not enough. While there is always room for improvement, in many industries, available science, engineering and/or process technology has matured to the point that significant further improvement in safety will have to come from other areas.

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