How do we know that work is being performed to set standards? If there is a difference, how do we measure it?

This begins an important conversation about drift, or, more scientifically, normalized deviation. At a high level, drift is nothing more than performing a task either below or above a set standard. In practical terms, drift is performing below standards. But there are times when performing above a set standard can be a problem as well.

Oftentimes, drift is written off as complacence. However, there is generally more going on. As a quick aside, complacency is not a legitimate root cause – hopefully this can be discussed later. When we learn a new task, our view of risk is in line with the actual level of risk involved. Whether we know it or not, by using a procedure (or rule-base) to complete a task, we are accounting for the actual risk in the task assuming the procedure is written correctly. After completing this task many times, we tend to begin our drift.

When the same task or step is completed successfully many times, we tend to start cutting corners – not out of malicious intent, rather because we can be more efficient. By cutting corners, we have now reintroduced risk back into the task that the procedure was designed to remove. We now have a flawed barrier, a piece of Swiss cheese with a hole in it.

Most people do this with a task performed every day – driving a car. During the learning process, rules are followed to a T. Turn signals are used, speed is kept within limits and complete stops are performed at red lights and stop signs. Within a short amount of time, all three of these rules are bent or broken. Turn signals are only used “when required,” speed limits are viewed as minimums, and rolling stops become the norm. We have reintroduced risk back into this task that the rules are meant to manage.

But remember, this reintroduction of risk is unintentional. If we saw the risk, we wouldn’t cut corners. If we knew that a car was in our blind spot, we would use the tools available at our disposal to prevent a collision. But since our perception of risk has become lower than it actually is, we inadvertently cause an error-likely situation. Eventually, unless measures are in place to reign drift back in, our mental model and perception of risk will result in an event.

So how do we rein in the expansion of drift?

First, we need robust processes for our critical tasks. This isn’t to say that we need a checklist for everything, but we do need processes in place to ensure our employees are made aware of when they need to either focus more or take a step back. Tools to assist here will be introduced later.

Secondly, we need oversight from front-line supervisors and managers. You can’t coach from your office. Be visible where your employees are located. When deviations from standards are seen, use that as a coaching moment. Stay positive and suppress the surge to penalize, especially for small things. Obviously, safety or major reliability concerns need to be evaluated differently.

And remember, Human Performance isn’t a big stick, rather, it’s a tool used to make our organizations safer and more reliable.

For more information on barriers or to see how we can help, please contact us.

What Are Barriers?

Barriers are a foundational tool used in HPI programs and processes, but they can also be misunderstood…

Barriers are a foundational tool used in HPI programs and processes, but they can also be misunderstood. Today, we will look at what barriers are, what they aren’t, and how they should be used most effectively. This is an important concept to understand prior to learning the various tools and applying the various techniques available to us as Human Performance Improvement practitioners.

So what are barriers? Barriers are essentially safe-guards to prevent something from happening. In a safety program, barriers can be designed to prevent workers from contacting electrically energized equipment or falling from a height. In a Human Performance Improvement program, barriers are designed to prevent errors from escalating.

If barriers are used to prevent errors from escalating, then what isn’t a barrier designed to do? For one, a barrier will not prevent an error from occurring. This is a common misconception. We can use guard rails to prevent someone from falling (the consequence), but the guard rails won’t prevent the person from losing their balance (the error). Terminal barriers will not prevent someone from inadvertently contacting a terminal block (the error), but they will prevent that inadvertent contact from making an electrical connection when used correctly (the consequence). Using caution tape will not prevent an employee from mistakenly walking up to the wrong equipment (the error), but that caution tape should prevent an employee from working on the wrong equipment when used correctly (the consequence).

Knowing this, how can we effectively apply barriers in our Human Performance Improvement programs to get the most help without excessive burdens on our workers? The trick is to know how to layer barriers in a method that gives us “Defense in Depth.”

Referring to the figure, Defense in Depth attempts to prevent errors from escalating by layering barriers in a methodical way. By viewing this layering of barriers as slices of Swiss cheese, it can be easily seen that the various barriers used must complement each other. No single barrier can prevent everything, but at the same time, no combination of barriers can be allowed to have the same weakness. A hole in one barrier should be stopped at the next level.

Barriers (or defenses) can be broadly grouped into four groups: Administrative, Physical, Oversight and Behavioral. Barriers should be used from all four categories (when possible) to be most effective.

Administrative barriers are processes and procedures. These can be written (preferably), but aren’t always. These barriers lay down the groundwork of how employees are supposed to interact with equipment. Wearing PPE, such as hearing protection, or mandating a lock out/tag out program are examples of an administrative barrier.

Physical Barriers are engineered barriers designed to prevent employees from interacting with equipment in certain ways. Guard rails, mufflers and interlocks are examples of physical barriers.

Oversight Barriers include managerial oversight. These barriers typically include coaching and observation to ensure employees are behaving in a manner that is expected. Often times, after an incident, supervisors find out after the fact that employees were doing things in a way that wasn’t up to expectations.

Behavioral Barriers are the defenses we put in place at the point of contact. When we typically think about HP tools, behavioral barriers are the tools that come to mind first. These are the self-checks, communication tools and checklists that are all designed to improve an employee’s self-awareness and situational awareness. These tool also account for an employees perceived level of risk, which can be different than actual risk (future post).

Note that, over time, our defenses can break down due to drift (future posting) – this is essentially allowing the holes in the cheese to get bigger, which allow the gaps in our barriers to overlap. The behavioral barriers prevent errors from escalating while the administrative and managerial defenses counteract drift to ensure adherence to the behavioral barriers. Purposely defeating a physical barrier should only be done according to procedures under certain circumstances. Defeating a physical barrier just to make a job easier is a violation.

For more information on barriers or to see how we can help, please contact us.

Mental Models

Recently, I went on a double date to an Escape Room-type establishment…

Recently, I went on a double date to an Escape Room-type establishment.  We had a good time, but ended up not escaping.  The last thing we had to do was to disarm a bomb by entering a code.  There were no constraints other than that.  We had the numbers, we tried every combination of those numbers, but none of them worked.

After our debrief, I conducted an after action review of what happened (because that’s just the kind of thing I like to do), and it got me thinking about my mental models of the task and my own situational awareness.

I had two sets of four numbers – I was arranging them, and someone else was entering them into the number pad.  Each set of four numbers were arranged based on a method I probably shouldn’t discuss, but let’s just say that it makes sense.  Each of the four numbers were arranged via the same method.  Two other people were watching the person entering the codes (peer check), but no one was watching me arrange the code.

These sets of numbers fit nicely into my mental model that codes are sets of three or four numbers.  Every combination that we entered up to that point fit exactly this mental model.  Not to mention that every real-life combination lock or keypad I have ever used fit this model as well.  They led us down this path, and we developed a confirmation bias.  No one told us that the codes were all like this.  But it was the demonstrated model, and we fell right into the trap.

Needless to say, the final code was eight digits.

Luckily for me, this was just a game.  However, for employees in the field or workers back in the office, what are the possible outcomes for falling into the trap of a false mental model – Latent errors, an inadvertent operation, or an injury?  The consequences of a wrong mental model was minimal for us.  For others, it may be substantially higher.  Bad mental models have a way of luring people into under-estimating their actual level of risk.

What Human Performance tools might have helped us?  For one, having someone peer check me could be more beneficial than watching someone enter numbers into a keypad.  Since we had four people, we could have divided up any way other than the way we did it and possibly seen improvement.  I could have taken a step back and tried to get myself to re-evaluate my model, but we only had a minute or two, so I succumbed to a time pressure (remember error precursors).  If I cannot put myself in a place to correctly use my Human Performance toolbox in a situation like this, how can we expect our employees to use theirs – especially when their mental model is wrong?

The trick is to build checks and balances into our work so we can routinely evaluate the situation.  Stay tuned for more on this topic.

For more information on mental models or to see how we can help, please contact us.

What is a Root Cause?

Cause Analysis is an extremely important Tool to include in your Human Performance “Toolbox.”  Unfortunately, Cause Analysis can be a vague term.

Cause Analysis is an extremely important Tool to include in your Human Performance “Toolbox.”  Unfortunately, Cause Analysis can be a vague term.  Cause Analysis can have different meanings depending on the severity of an incident and on the complexity of an incident.

To begin, let’s start with some definitions:

Cause Analysis can be broken up into two forms – Root Cause Analysis (RCA) and Apparent Cause Analysis (ACA).  Root Causes are ideally the lowest level at which an incident starts.  For simple incidents, these are extremely easy to find and correct.  If I trip over a step while reading a text on my iPhone, the root cause is my inattention to a task.  For complicated incidents, an investigator might have to dive several layers to find a root cause.

Apparent Causes, on the other hand, are those events or conditions that appear to be the cause of an incident, but they are often symptoms themselves of a deeper issue.  Apparent Causes are generally the result of using a tool such as the “5 Why’s.”  These investigations, while not as deep as a true root cause analysis, can be beneficial when a root cause isn’t necessary.  If the consequences of an event aren’t serious and time is critical, looking for Apparent Causes might be satisfactory.  It is situational dependent and up to the investigative team.

Now that we know what root causes and apparent causes are and the difference between the two, we need to clarify one thing.  Many times when conducting an RCA, we fail to take the investigation far enough – especially when investigating cases of Human Error.

Though many people won’t admit it, we tend to stop when we find the person that made a mistake.  We slap a Human Error label on the Root Cause line and nobody questions it because it makes sense.  We found “the problem,’ and the corrective action is easy.  Joe made a mistake – Send him home for a few days send him to training.  There is no culpability up the chain of command or on the Organization.  What we fail to realize is that mistakes made by employees can be symptoms themselves.

What if the employee didn’t have a procedure, or worse, a procedure with mistakes, for a complex task?

What if the employee did have a procedure, but it was common practice to cut a step (something we call Drift, and we’ll cover in a subsequent post)?  How do you hold one employee responsible for something everyone does?

What if the employee was specifically told by his supervisor to complete a task a certain way that introduced risk into the procedure?

Finally, the term Root Cause is bad in my opinion because it implies that there is only one root cause.  While this may be true in simple situations, it is never the case during complicated situations.  Read any investigative report for a major incident, and you’ll generally see many root causes – each a breakdown of a separate system that was intended to prevent such an accident.

This is not intended to be a cause analysis training, but this is an offering of Understanding Human Performance.  This post is geared more to bring some attention and focus on what cause analysis really is traps investigators can fall into.

To request more information on Cause Analysis or to see how we can help, please contact us.

The Importance of Intuition

How many times throughout our lives do we enter a new situation – either something we have never seen before, something familiar with a twist, or even something we haven’t encountered in a while.

How many times throughout our lives do we enter a new situation – either something we have never seen before, something familiar with a twist, or even something we haven’t encountered in a while.  Even without the ability to properly diagnose, we sometimes get an uneasy feeling that can’t be explained.

Intuition is our ability to understand something without being able to put our finger on exactly what that something is.  It can also be thought of as an instinct or a gut feeling, and humans have an uncanny ability, on a subconscious level, to understand when something might not be going quite right.

Our brains are essentially two systems running in parallel.  The primitive brain, or System 1, handles all of our instinctual and  “fight or flight” functions.  It keeps our heart pumping, our lungs breathing, and our car on the road while we are tuning the radio, carrying on a conversation or just lost in thought.  After all, when was the last time we remembered our entire drive to work.  The more advanced part of our brain, or System 2, controls our conscious thought.  It is at the forefront when our subconscious brain can’t cut it.  When the car we are driving hits a patch of black ice, our brain’s System 2 kicks into action.  Is should also go without saying that our brains prefer to stay in System 1 as much as possible due to the ease of processing and energy savings.

This is important to understand for the Human Performance Practitioner because we need to understand where our instinctual behaviors come from.  We need to understand if the feeling of uneasiness we feel is just being unsure of a poorly written procedure or if we have something bigger to worry about.

Case in point – I was commissioning a new substation at the young age of twenty-six.  A technician was attempting to rack out a circuit breaker on the de-energized substation, but he was having difficulty.  He jokingly turned around and asked me to give it a go since I was the largest person around.  After putting a bit of tension on the wrench, I knew something wasn’t right.  I have never felt a racking mechanism this hard to turn.  But when you combine youthful arrogance with a slight apprehension to admit what my gut was telling me in front of others, you tend to get a bad situation.  This example was no different.  I put everything into the racking mechanism, broke the end of it off, and hit my elbow hard enough on the switchgear enclosure that I ended up in the office of an orthopedic surgeon.  It was a hard lesson.

So why don’t we listen to our guts more?

  • Inexperience: Oftentimes, young or inexperienced employees don’t want to embarrass themselves in front of other employees. When you feel that you have something to prove, you tend not to ask questions as much as you should.
  • Complacency: Before I explain this, let me start of by saying that I vehemently dislike the term complacency. Nothing does more to apply blame inappropriately to a person than this one.  It also does not constitute an appropriate Root Cause.  However, complacency can lead an experienced worker to disregard their intuition when they have completed a task hundreds of times.  Why should the 101st time play out any different from the last?
  • Missed queues: Sometimes, we just don’t see the faint indications that something is wrong.  It is one thing to disregard our gut, but another thing altogether to miss what it is trying to tell us.

So how do we learn to trust our intuition?  For me, it started with disregarding it until I started to understand that mine was right more than it was wrong.  This is the natural progression of gaining experience.  For other situations, the proper use of Human Performance Tools, such as Stop When Unsure, a Two-Minute Drill, or a self-check will take care of the vast majority of situations.  We must also drill the idea into people that any feeling of uneasiness must be investigated to be sure there isn’t more to it.  Ask questions and don’t be afraid to challenge authority in a respectful manner.  Even though HPI Tools and Techniques tend to focus on improving reliability, they can also be applied to improve Safety.  No one wants to have a serious injury or worse on their conscious because they didn’t ask.

For more information on trusting intuition or to see how we can help, please contact us.

Why Trend?

In this day in age, we are inundated with data. The problem is that data is sometimes necessary.


In this day in age, we are inundated with data.  From Fantasy Football to the barrage of the 24/7 news cycle, we can feel overwhelmed.

The problem is that this data is sometimes necessary.  Take Human Performance – How are we supposed to develop a plan to improve our Organization’s performance if we don’t know where our weaknesses lie?  In a prior position, I had the task of helping our employees roll out our first Human Performance Improvement (HPI) program.  It was also my first HPI program.

But we didn’t jump in with both feet.  We let people do their jobs, and then we sat back and watched.  When an issue would arise, we would perform a Cause Analysis (In a subsequent post, I’ll explain why I don’t typically use the term “Root Cause”).  Any issues at the time would be fixed, but we would save and analyze the data.  Over the course of two years, we began to see trends that would help guide and shape what would become our Human Performance program.

Creating a bunch of rules without reason or direction won’t solve your problems.  Rules and procedures must be created with purpose.  We have this problem, and we will deploy the following procedures to address it.

One of the issues we had was mis-operations of electrical equipment due to misuse of test switches.  Test switches are isolation devices typically used in a substation environment.  Employees were closing the wrong switches by mistake while testing equipment.  I even heard the phrase “I knew I was on the wrong switch, but couldn’t stop in time.”  And it wasn’t just one person, so I knew it passed the Substitution Test (I’ll explain this in a subsequent post).  We had an Organizational problem, and we need a tool that would address it.

One Tool fixed this issue.  We had to resolve the disconnect that was occurring between the speed at which people were moving and the rate at which their brains were processing the movement (and everything else going on – Situational Awareness).  We included “Touch-STAR (Stop, Think, Act, Review)” in our Human Performance Toolbox.  By having employees touch the device they wanted to operate, but then Stop prior to taking an action, we gave them an opportunity to catch themselves before escalating a mistake.  Note that I didn’t say stop making mistakes.  This HP Tool will not prevent someone from inadvertently touching the wrong piece of equipment.  We’re Human, and we will make mistakes.  Human Performance Tools allow us some breathing room and time to recognize that we made a mistake.  This gives us a chance to recognize and correct the mistake before it becomes something bigger.

For more information on trending or to see how we can help, please contact us.

HP Tools Primer

If you ask most people who are new to the field of Human Performance Improvement, most of them want to jump straight to the tools.

If you ask most people who are new to the field of Human Performance Improvement, most of them want to jump straight to the tools. What they don’t realize is this will often derail a Human Performance program before it gets off the ground.  There are a couple of reasons why this is.

First, a lot of new HP Practitioners think Human Performance Improvement is just about the Tools. By this, we mean that the Tools are sometimes viewed as a measuring stick to which all employees must work, similar to being tardy.  When this occurs, we tend to conclude a “Root Cause Analysis” once we find out which Tool was misapplied or not used and by which employee.  We then censure said employee and re-train the employee on the proper use of the Tool.  We can go home at night thinking we did a good job.

Secondly, and this is a symptom of the first problem, employees begin to see the Tools as another attempt by Management to place blame for failures. The Tools begin to be resented by employees, become seen as a waste of time, and lose their effectiveness as the reasons for undertaking an HP Program begin to become distant memories.  This is difficult to recover from.

One thing we must all remember is that Human Performance is not just about the Tools, and the Tools do not define Human Performance. The Tools are a way to for us to bring attention and focus to a task, and they should not be applied in a way that distracts or wastes time.  The Tools are just that – Tools used to complete a job or task.

We are currently working on a complete series on the common Human Performance Tools – What they are, how they work, and when they should be applied. However, a solid foundation needs to be laid prior to their application if an HP program is to be successful.

To request more information on the HP Tools or to see how we can help, please contact us.