Human Performance Tools – Part II

8/3/2020

I would like to begin with a technique used in many industries. That is, the self-checking process known as STAR: STOP – THINK – ACT – REVIEW.

Self-checking is particularly effective during skill-based tasks that could be performed without much conscious thought. This technique helps boosts attention at important points in an activity before an important action is performed. If attention is not focused, error is likely. Once attention is focused, the individual then takes a moment to think about the intended action and its expected outcome. If uncertain, questions should be answered before proceeding.  If visual or physical contact is broken, then self-checking should be repeated. When the performer is physically and mentally prepared, the action can be taken, followed by a review of the results of the action.

Stop – Pause before performing the operation/manipulation, especially at critical steps, decision points, or touch points. Eliminate distractions, if necessary.

Think – Focus attention on the step to be performed. Verify the action is appropriate for equipment/system status. Anticipate expected result(s) of the action and its indications. Consider what actions to take should an unexpected result occur (contingency). 

Act – Without losing physical contact with a piece of equipment to-be operated, compare component label with the equipment checklist, procedure step, or drawing. State the component name aloud (without distracting others). Then, without losing physical contact, perform the action.

Review – Verify anticipated result obtained. Perform contingency, if expected result does not occur.

At-Risk Behaviors that can reduce the effectiveness of the STAR process: 

• Not self-checking again, when distracted after initially self-checking or losing physical contact.
• Talking on the telephone or conversing with another person during a manipulation or critical    action
• Self-checking without the guiding document 
• Attempting to perform more than one action at a time; two-handed operations
• Continuing with the action when questions or discrepancies occur
• Looking at something other than the component to be manipulated

Another effective – and practical – technique in the field of HPI is Peer Checking. Peer checking is an error-prevention technique involving a verbal agreement between two individuals prior to a specific action and/or task, such that one will observe or check the behavior of the other to prevent an error by the performer. One person acts as the performer, and the second person, an experienced peer familiar with the activity, acts as the checker.

The purpose of peer checking is to prevent error for a specific action. Peer-checking is merely two persons (performer and checker) self-checking in parallel, agreeing together that the action is the correct action to be performed and on the correct component. This technique takes advantage of a fresh set of eyes not trapped by the performer’s task focused mind-set. The checker may “see” hazards or potential consequences the performer does not see. In most cases, workers can ask for a peer check, especially when they feel the risk or conditions warrant it. The tool may be required by management for certain high-risk actions. If a person, other than the performer, anticipates an action by the performer may be unsafe, or at risk, he or she may question the performer to verify the intent and desired outcome before the action is taken.

Potential weaknesses in Peer Checking include:

• Checker not experienced with activity 
• Checker not paying close attention to performer
• Believing performer will not err because of performer’s experience or proficiency.
• Swapping roles during the task

The next HPI tool is Independent verification (IV). IV is the act of verifying the condition of a component, system, or document, etc., that is independent from the original act that placed it in that condition, to find errors by the performer. It is an act of checking a component’s or product’s status or quality independent of the person that established its present state.  IV has a higher probability of catching an error than peer-checking since the second person is not influenced by the first person and has freedom of thought.

IV catches errors after they have been made. The individual performing the IV must physically check the condition without relying on observation or verbal confirmation by the initial performer. True independence requires separation in time and space between the individuals involved to ensure ‘freedom of thought.’ In fact, the two individuals probably should not even walk to a room or location of the component together. True independence cannot be established if one individual is looking over the shoulder of the other, even from a distance.

Behaviors to Avoid

• Performer and verifier should not be in close proximity at the time the performer acts.  
• The performer is perceived by the verifier as experienced, as an expert, and unlikely to make a mistake.
• Performer is less attentive to the action thinking the verifier will “catch” any problems.

Stop Work When You Are Unsure: Whenever a question is encountered and what to do about it is uncertain, stop and get help.  Given the chances for error are particularly high in a knowledge-based situation, the best course of action, when unsure, is to take a time-out and get another person’s ‘mind’ focused on the problem. For effective problem solving to occur, people must recognize they are in a knowledge-based situation. Get help from those who possess the expertise, not necessarily from those of higher rank. Also, when that “gut feeling” is telling you that something is not right…stop!  This also applies when one experiences, “What am I doing here?” or “I’m here but can’t remember what I am supposed to do.” Don’t be embarrassed, stop and get help!

Behaviors to Avoid:

• Assuming
• Rationalizing an anomaly away
• Not asking for help
• Being too embarrassed to ask for help
• Thinking the task is ‘routine’ or ‘simple’
• Believing nothing bad can happen
• Ignoring subtle differences 
• Unaware of critical parameters 

And finally, there is Post-job reviews.  This is sometimes known as Lessons Learned; a policy that gives employees that were involved in the work activity to provide feedback.  A post-job review is conducted to determine if planning and briefings were effective. 

The post-job review is performed with those who participated in the pre-job briefing and performed the work.   Various issues that can decrease the effectiveness of post-work reviews include believing that any changes or problems encountered are minor and do not need any further correction. Not having principal workers involved can render the entire port-job review process ineffective. Other short falls of this process include not providing adequate time for the post-job critique, and not performing the review face-to-face with follow-up action items assigned to specific persons.  All post-job reviews need to be documented. Remember, as the saying goes – if isn’t documented, it wasn’t done!

Plans are nothing; planning is everything

Dwight D. Eisenhower