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HUMAN PERFORMANCE IMPROVEMENT Interview Support Documents Interview Questions · Bush List · Klein List How they are used: The Bush List is useful as a starting point to gain a general understanding of the event. The Klein List is useful for a second interview where you are trying to gain a better understanding of the context of decisions made at each critical juncture. Interview Handout How it is used: The Swiss Cheese graphic is a useful analogy to describe to employees your desire to understand the defenses / barriers to prevent this type of event. The Tunnel graphic is a useful analogy to describe to employees your desire to understand their mindset at critical junctures. Error Precursors (Expanded List) How it is used: This list is provided to the employee with the request to highlight those errors they felt influenced their behavior leading up to the event. Once complete, they are asked to identify the top few that played the largest role in the event. Performance Model (with Defenses) How it is used: This figure is provided to the employee with the request to highlight those defenses they believe prevent this kind of event. Once complete, they are asked to identify those defenses that were weak in this event (i.e. The holes in the Swiss cheese). Culpability Decision Tree How it is used: Interview others of the same discipline, work team etc. once the context of the event is understood to determine if the substitution test is passed (e.g. Would other employees have made the same error(s))? 72 Hour Profile How it is used: There are times when details of the past 72 hours of specific employees is needed to gain a better understanding of the human condition leading up to the event. The employee is asked to provide their response to the 10 or 11 questions as appropriate. This process generates some very sensitive data that will need to be appropriately protected.

File: OS&H/Activities & Projects/HPI/HPI Interview ­ Fluor Hanford blanks.doc

HUMAN PERFORMANCE IMPROVEMENT Example Interview Questions NOTE: The purpose is to understand the CONTEXT in which the employee made their decisions leading up to the event. Here are questions that Shane Bush typically asks when interviewing The Bush List 1. Introduce yourself and the purpose for the interview; explain that we are going to take notes to ensure accuracy. 2. Ask interviewee to introduce him/her self and title. 3. Ask what they know about human performance and educate if necessary. 4. Ask them to explain their involvement in the incident. 5. When they are done explaining, or if they seem to pause, ask "and then what happened?" Repeat this process until they have no more to say. 6. During the interview identify key words or remarks that you will want to follow up on (pull the thread). 7. When following up on key words or remarks, ask "how did that make you feel?" (You may not want to ask some thread pulling questions until a 2nd interview.) 8. When interviewee voice perceptions or feelings make sure to capture exact quotes as evidence as why they feel that way. 9. When interview use words like "stressed, in a hurry, production oriented, etc" ask them what evidence makes you think they were stressed or in a hurry. Make sure to capture their replies. 10. When interviewees are explaining tasks that they were involved in or observing, ask "What else was going on?" 11. Ask the interviewee how this particular event could have been prevented or how it could be prevented from happening again. 12. Ask the interviewee if they were king or queen for thee day how they would have performed the task. 13. When appropriate ask "why do we do it that way?" 14. Ask what they talked about in the pre-job. 15. At the end of the interview, ask if there is anything else you should have asked them.

Source: BushCo/University of Idaho, Human Performance Fundamentals Certificate Course, Handout, 3/20-24/06.

HUMAN PERFORMANCE IMPROVEMENT Example Interview Questions Here are some questions that HPI researchers typically ask to find out how the situation looked to the people from the inside of the tunnel at each critical juncture: The Klein List Cues What were you seeing? What were you focusing on? What were you expecting to happen? Interpretation If you had to describe the situation to your fellow crewmember at that point, what would have told? Errors What mistakes were likely at this point? Previous Experience / Knowledge Were you reminded of any previous experience? Did this situation fit in a standard scenario? Were you trained to deal with this situation? Were there any rules that applied clearly here? Did you rely on other sources of knowledge tot tell you what to do? Goals What goals governed your actions at this time? Were there conflicts or trade-offs to make between goals? Was there time pressure? Taking Action How did you judge you could influence the course of events? Did you discuss or mentally imagine a number of options or did you know straight away what to do? Did the outcome fit your expectation? Did you have to update your assessment of the situation?

Source: Dekker, Sidney; The Field Guide to Human Error Investigations, 2002, Pg 71-72. Course book for Human Performance Fundamentals Certificate Course, 3/20-24/06.

Outcome

HUMAN PERFORMANCE IMPROVEMENT

Interview Handout Reason's Swiss Cheese (Defenses / Barriers to prevent this type of event)

Source: Reason, James, Managing the Risk of Organizational Accidents, Page 9, 1997.

Dekker's Tunnel (Reconstruct the unfolding mindset at critical junctures)

Source: Dekker, Sidney, The Field Guide to Human Error Investigations, Page 26, 2002.

The purpose is to understand the CONTEXT for the decisions leading up to the event.

ERROR PRECURSORS Highlight which error precursors you believe may have played a role in your actions related to the event being discussed. Then mark the top few that you think may have had the most impact.

Driver 1 ­ TASK DEMANDS Code 1A - Time Pressure (in a hurry) 1B - High Workload (Memory Requirements) 1C - Simultaneous, Multiple Tasks 1D - Repetitive actions/Monotony 1E - Irreversible acts 1F - Interpretation requirements 1G - Unclear goals, roles, or responsibilities 1H - Lack of or unclear standards 1I - Confusing procedure/Vague Guidance 1J - Excessive communication requirements 1K - Delays; idle time 1L - Complexity/High information flow 1M - Excessive time on task 1N - Long-term monitoring Driver 3 - INDIVIDUAL CAPABILITIES Code 3A - Unfamiliarity with task/First time 3B - Lack of knowledge (faulty mental model) 3C - New technique not used before 3D - Imprecise communication habits 3E - Lack of proficiency/Inexperience 3F - Indistinct problem-solving skills 3G - `Unsafe' attitudes for critical task 3H - Illness/fatigue (general health) 3I - Unawareness of critical parameters 3J - Inappropriate values 3K - Major life event: medical, financial, and emotional 3L - Poor manual dexterity 3M - Low self-esteem; moody 3N - Questionable ethics (bends the rules) 3O - Sense of control/Learned helplessness 3P - Personality type Driver 4 ­ NATURAL TENDANCIES / Code HUMAN NATURE 4A - Stress (limits attention) 4B - Habit patterns 4C - Assumptions (inaccurate mental picture) 4D - Complacency/Overconfidence 4E - Mind-set 4F - Inaccurate risk perception (Pollyanna) 4G - Mental shortcuts (biases) 4H - Limited short-term memory 4I - Pollyanna effect 4J - Limited perspective (bounded rationality) 4K - Avoidance of mental strain 4L - Tunnel vision (lack of big picture) 4M - "Something is not right" (gut feeling) 4N - Pattern-matching bias 4O - Social deference (excessive professional courtesy) 4P - Easily bored 4R - Close-in-time cause-effect correlation 4S - Difficulty seeing own errors 4T - Frequency and similarity biases 4U - Availability bias 4V - Imprecise physical actions 4W - Limited attention span 4X - Spatial disorientation 4Y - Physical reflex 4Z - Anxiety (involving uncertainty) 4AA - First day back from vacation/days off 4BB - Sugar cycle (after a meal) 4CC - Fatigue (sleep deprivation, circadian rhythms)

Driver 2 ­ WORK ENVIRONMENT Code 2A - Distractions/Interruptions 2B - Changes/Departure from routine 2C - Confusing displays/controls 2D - Work-arounds / Out-of-service instrumentation 2E - Hidden system response 2F - Unexpected equipment conditions 2G - Lack of alternative indication 2H - Personality conflicts 2I - Back shift or recent shift change 2J - Excessive group cohesiveness/peer pressure 2K - Production overemphasis 2L - Adverse physical climate (habitability) 2M - No accounting of performance 2N - Conflicting conventions; stereotypes 2O - Poor equipment layout; poor access 2P - Fear of consequences of error 2Q - Mistrust among work groups 2R - Meaningless rules 2S - Unavailable parts or tools 2T - Acceptability of "cook booking" practices 2U - "Rule book" culture 2V - Equipment sensitivity (inadvertent actions) 2W - Lack of clear strategic vision or goals 2X - Identical or adjacent displays or controls 2Y - Out-of-service warning systems 2Z - Nuisance alarms 2AA - Lack of procedure place-keeping

Performance Model with Defenses3 Action: Highlight items that are defenses that prevent this kind of event and mark those that were weak in this event)

Equipment Ergonomics & Human Factors; Environmental Conditions; Work-arounds & inconveniences; Housekeeping; RWPs; Worker knowledge, Skill, & Proficiency; Procedure/Work Package Quality; Equipment Labeling & Condition Personal Motives; Morale; Lockout/Tagout, Tool Quality & Availability; Intolerance for Error Traps; Foreign Material Exclusion; Values & Beliefs; Fitness for Duty, Uneasy Attitude; Roles & Responsibilities Walkdowns; HP Surveys; Task Qualification, Task Assignment; Performance Feedback

Turnover; Clearance Walkdown; Prejob planning; Just-in-time Operating Experience; Task Preview

Job-Site Conditions

Flagging; Challenge; Questioning Attitude; Process Critical Parameters; 3-Part Communication; Use & Adherence; Conservative Decision Making; Management Monitoring; Self-Checking; Placekeeping; Problem Solving Methodology; Double (dual) Verification; Supervision; Peer Checking; Rigor of Execution; Recognizing Error Traps; Team Skills; and Stop When Uncertain.

Questioning Attitude Respect for Others

Worker Behavior

Handoffs; Training; Revisions; Rewards & Reinforcement; Meetings Change Mgmt; Procedure Compatible Goals & Priorities; Reviews and Approvals; Role Models; Safety Philosophy; Strategic HPI Plans; Design & Configuration Control; Staffing; Operating Experience; Work Planning; Simple/Effective Processes; Problem Solving; Task Allocation; Clear Expectations; Self-Assessment; Accountability; Scheduling / Sequencing; Change Mgmt; Socialization; Labor Relations; Corrective Action Program; Communication Practices & Plan; Management Practices; Trend Analysis

3

Organization Processes & Values

High Coaching Standards Motivation Healthy Compelling Relationships Vision Sets Example Open & Honest Communication

Leadership

Reinforcement Courage & Integrity Proper Reactions

QC Hold Points; Independent Verification; Forcing Function; Personal Protective Equipment; Failure Mode & Effects Analysis; Alarms

Plant Results

Safety Significant Systems; Equipment Reliability; Safeguards Equipment; Safety Envelop

Post-job Critiques; Root Cause Analysis; Problem Reporting; Independent Oversight; Performance Indicators

Source: INPO, Human Performance Fundamentals Course Reference, Revision 6, December 2002, Page 8

HUMAN PERFORMANCE IMPROVEMENT Culpability Decision Tree Analysis3

Culpability Evaluation Flowchart

Were actions as intended?

No

Knowingly violate expectation?

No

Pass substitution test? (see note)

Yes

History of human performance problems?

Yes

No

Yes

No

No

Were the consequences intended?

Were expectations reasonable, available, workable, intelligible, and correct?

Deficiencies in training and selection or inexperience?

SelfReported

Yes

Yes

No

No

Yes

Yes No

Yes

Organization induced violation Intentional act (not an error) Possible reckless violation Possible negligent error

System induced error Corrective training or other intervention may be warranted

Blameless error

Evaluate organizational processes and management/supervisory methods Note: Would other employees have made the same error? Source: Draft HNF-GD-xxxx, Human Performance Culpability Evaluation. Rev 1.

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Event Date: _____________ Event: _______________________________________________________________________ _______________________________________________________________________ Results: It was determined that other employees (would have) (would not have) made the same error.

HUMAN PERFORMANCE IMPROVEMENT 72 Hour Profile A 72-hour profile may be used for analyzing Human Performance Improvement factors. The profile traces the chronological actions and activities of each individual involved in the event for the 72 hours preceding the event. The responses must be treated with appropriate confidence. The following examples may be important in the development of the pre-event profile(s): (1) Travel completed. (2) Type of work performed and work schedule (hours). (3) Periods of rest and sleep. (4) Medications prescribed. (5) Alcohol and other drugs (prescription, nonprescription, and illegal). (6) General physical condition, including illnesses, viral infections, physical anomalies, recent chronic fatigue, hypertension, diabetes, elevated cholesterol, or other medical problems. (7) Individual's mental, emotional, and physical state including perceived stress and behavior changes based on supervisor, next-of-kin (if available), co-workers, and friends. (8) Other comments the supervisor, next-of-kin, co-workers, and friends wish to make related to the individual's condition or event activities. (9) Other factors prior to the event that could have affected the event occurrence or its outcome. (10) Adverse administrative or punitive action or any other behavior infractions for the past three years. (11) Include the following for personnel involved in Personal Fitness Test related events: (a) Height, weight and percent body fat. (b) Time from start or end of activity to onset of first symptom(s). (c) Physical condition and physical conditioning program prior to event. (d) Meal times, food and liquids, type of and quantity consumed, two hours prior to the event. (e) Smoking or drinking habits (alcohol) if any. (f) Weather conditions. (g) Wet Bulb Globe Temperature (WBGT) readings for heat related events.

Adapted from: MCO P5102.1A, Marine Corps Ground Mishap Investigation & Reporting Manual Section 4807.3, 72-Hour Profile, 12/29/00. (Referenced in Human Performance Fundamentals Certificate Course, 3/20-24/06.)

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