While we are all familiar with the physical tools that help us do our jobs each day, there are also tools in the human performance improvement toolkit that help us perform our work safely and without incident.
The tools and skills listed in this article are not stand-alone items but interlocking skills that can and should be used together to improve efficiency and help you work safely on every job.
While some of these tools are well known, others are new or improved tactics developed over many years of trial and error and, unfortunately, lessons learned from incident investigations.
While there are no silver bullets to improve worker safety, adding these tools to your human performance improvement toolbox will help your operations run more efficiently and safely.
Self-Checking is one of the most fundamental human performance improvement tools. This tool enables you to focus on the task you are about to perform.
As with some of the other tools in your human performance improvement toolkit, we use an easy-to-remember acronym to remember the self-checking steps.
STAR
Stop Stop what you are doing, take a moment to focus, and mentally prepare for what you are about to do. Research proves that simply stopping to focus on the task increases the chance you will be successful.
Think - Think through the action you're going to take. Ensure that you're ready to perform the step. What should you expect to see happen when you take this step? Thinking about the step you're about to take will give you another chance to see if something is out of place.
Act Take the action that you stopped and thought about. Act conservatively, looking for any sign that something is not right.
Review Review what happened when you took the action in the previous step. Did you get the result you expected? Is anything out of the ordinary you need to consider before you perform your next step?
Self-checking is about personal responsibility while giving you the tools to help you succeed and work safely and safely.
When we communicate with our colleagues, be that peers, supervisors, or subordinates, we do so with the expectation that we are being understood. If you knew every time there was a misunderstanding, you would certainly take the time to clarify it, wouldn’t you? But we don’t always know, so we have to take the time to communicate in a way that leads to less confusion and misunderstanding.
To effectively communicate, our methodology focuses on three key aspects of any form of communication: Three-Part Communication, individual numbers, and the phonetic alphabet.
Three-part communication is also known as “closed-loop communication.” You might also be familiar with “echo protocol,” but three-part communication is more robust.
The process goes like this: 1) The sender provides the information, 2) The receiver hears the information and repeats it back to the sender, 3) The sender closes the communication loop with 'That's Correct' or 'STOP - that's wrong.'
Depending on the type of numerical information being communicated, we communicate that information differently at different times. When telling someone a two or three-digit number, we often speak the entire number: 14 is said fourteen, and 200 is two hundred. But when we encounter numbers with four or more digits, we use the comfortable format: U.S. phone and Social Security numbers are broken into groups of three and four digits. At the same time, dates are spoken in various combinations of numbers and abbreviations.
To ensure numerical information is understood, using single digits or individual numbers is the best way to communicate. As an example, the number 215 should be expressed as '2-1-5', instead of "two-fifteen." With the right noise conditions, "two fifteen and "two fifty" are very difficult to tell apart.
Similar to individual numbers, using the Phonetic Alphabet is an important way to communicate alpha-numeric information. Using the word instead of the letter prevents the receiver from mishearing the letter. For Example: Communicate the switch number BC13D as "Bravo, Charley, One, Three, Delta." For a complete phonetic alphabet list, you can refer to the Knowledge Vine Field Guide or find a copy of it on military.com.
Though not always applicable to the job you are working on, the peer check tool puts the adage "two heads are better than one" to good use. When performing tasks that may have an immediate, adverse consequence using a Peer Check will reduce the chance of an error.
A Peer Check is NOT someone who is “supervising” or “overseeing” the work. It is a person who is actively engaged and invested in the performance of the work. To be an effective Peer Check, they must be equally qualified to the primary worker (performer) and knowledgeable of the job. If the Peer Check doesn’t understand the work, how can they identify if the performer is about to make an error?
Often the performer will get wrapped up in work and take action before the Peer Check has a chance to either confirm or stop the action. Additionally, the performer needs to wait for the Peer Check's confirmation before taking action. Here's how it should work:
Find an equally qualified, knowledgeable coworker and ask them to perform a peer check on your work. The Peer Check should be involved in the pre-job brief and know work conditions before assisting.
Once work has commenced, the performer should clearly state their intended action: "Per the procedure, I need to open valve ALPHA-3-4, pump discharge valve.” The performer should touch or point out the component to be operated and wait for agreement from the Peer Check.
Only when the person performing the peer check understands the task and agrees with your next course of actions should they respond in the affirmative; "I agree" or “That’s correct.”
It’s that easy; the Peer Check process doesn’t need to be any more complicated. Trouble occurs when the Peer Check is not engaged and just trusts that the performer knows what they are doing. Also, it’s not unheard of to have a Peer Checker working part of the job separate from the performer (divide and conquer vs. peer checking). Avoid the temptation to “help” by taking some of the work independently. A good Peer Check doesn’t say, “I’ll get this, you go get that done,” to expedite the job when they are supposed to be engaged with the performer.
Peer Checker engagement is vital; they should address the possibility that the performer’s next actions should NOT be taken. Suppose you are operating a valve, as in the example above. In that case, the person performing the peer check must ensure the lineup is correct, the path is clear, and there are no other hazards associated with operating the valve in question.
Stay engaged, and don't fall into the trap of "pencil whipping" the peer check by not looking at the potential for failure before you give your stamp of approval.
Post-job reviews, also known as after-action reviews or capturing lesson learned, is an unavoidable step in the continuous improvement of human performance improvement process. It is also the most helpful tool for preventing repeat errors on reoccurring jobs.
At Knowledge Vine, we use the acronym TOAST to remember Traps, Organizational Weakness, Additions, Simplify, and Tools.
· Traps - Were traps involved in the job that you didn't anticipate initially? Are there things you can do to help avoid that trap in the future?
· Organizational Weakness Sometimes the "problem" comes from part of the organization's system. Was something in how the job was scheduled, drawn up, designed, or assigned that made it difficult for you to succeed?
· Additions Are there additional tools, resources, or other error defenses that need to be added to the job next time? Identify those needed additions the next time this job is worked.
· Simplify What (if anything) can be done to make the job simpler - to reduce chances for error by removing unnecessary steps?
· Tools – Were there any tools (physical tools or TOPI Tools) we should have used to improve performance?
Post-job reviews are best performed as soon as the work is completed and should involve every workgroup member.
Jobs used to be done when the work was complete, then the mindset shifted to the understanding that the work was not complete until all the tools were put away. The new normal is now one where the work is only done once the post-job review has been performed.
When performing a post-job review, identify what went right. Hardworking employees benefit from positive reinforcement, so take the time to celebrate the wins. Ensure you recognize what contributed to the successful execution of work so it can be used again and again.
Identify the opportunities for improvement. Capture the lessons learned from the work and make the necessary changes to the procedure or job plan. Include any newly identified hazards in the job risk assessment and include appropriate mitigating actions for those hazards. Was there anything you encountered that was outside of your control? Sometimes you find an improvement opportunity that you and your co-workers can't make happen. This information needs to be passed on to a supervisor or manager, so ensure they get it.
Post-job reviews are the best time to identify and formally capture opportunities for improvement. Don't let your desire to get to the next job allow you to skip this critical tool in the human performance improvement process.
The use of procedures and checklists helps ensure the right actions are taken at the right time while identifying the correct tools and hazard avoidance/mitigation measures to keep your personnel working in a safe and controlled manner.
If you have a question or concern, elevate it to get answers. Remember, people write procedures, and people make mistakes. Use a questioning attitude to ensure it's the correct action. You are following the procedure but asking if it makes sense given current conditions. This is called “thinking compliance.”
While not every procedure is perfect, it is important to avoid skipping steps or taking shortcuts, also known as procedural drift.
If you need to deviate from the written procedure for whatever reason, you should follow your company's policy. While the long-term solution will likely require a Management of Change (MOC) to modify the existing procedure, supervisory approval should allow you to perform the work, provided a proper risk assessment is performed for the deviation.
A common theme in the human performance improvement toolkit is developing a Questioning Attitude.
A Questioning Attitude involves considering the possible consequences of your actions if performed incorrectly rather than the likelihood of something going wrong.
"What's the worst thing that can reasonably happen to me, my coworkers, or my team if this action goes wrong?"
If you consistently focus on the relationship between the worst possible outcome and the likelihood that that outcome will happen, then you are playing with the law of averages. Instead of avoiding or mitigating hazards, you are gambling with the possibility of the outcome.
You put on your seatbelt not because you will likely get in an accident today but because it’s reasonable that you could, and the consequences can be deadly if you don’t take steps to control the outcome of being in a wreck.
You recognize the possible consequences when you start by considering the worst thing that can reasonably happen if something goes wrong. This focus on outcomes will allow you to address the potential causes of those adverse consequences appropriately.
There is no perfect time to use a questioning attitude. A questioning attitude is the tool that should get the most use. Every step of every job, every group decision you are a part of, and every action taken can benefit from a questioning attitude.
Treat this human performance improvement tool like a knife that is sharpened every time you use it. This tool will never wear out but becomes more effective the more frequently exercised.
A Second Check involves getting a co-worker to check your work after you've completed it, verifying it was done correctly. If errors are found, they can be corrected before any permanent damage.
Unlike a peer check, a second check is performed once a task has been completed. The securing of a line or fitting a piece of safety equipment are good examples of when to use the second check.
Timing is still crucial for the second check to successfully prevent an incident. Don't ask for a double check of lifting gear after the load is suspended or request a second check of your SCBA when you're already in a low-oxygen environment.
To be successful, the second check should be performed with as little input as possible from the one that did the work.
The idea is to get a fresh set of eyes on the work you just completed. That person is more likely to spot a mistake if you don't give them step-by-step comments and create a group think environment.
Quite frequently, there are Critical Steps in a process that must be performed correctly to avoid adverse consequences or cause irreparable harm to personnel or equipment; it is the point of no return. Once this step is taken, any consequences, either positive or adverse, are going to occur. It's crucial to ensure this action is correct and conditions allow us to proceed.
A suitable procedure will highlight each critical step with potential hazards and risk mitigation methods. Without a "good procedure," a skilled worker with a Questioning Attitude will still be able to identify critical steps in their work.
Once a critical step has been identified, the acronym SAFE will help you or your employee work through the job safely.
The letters in SAFE stand for Summarize, Anticipate, Foresee and Evaluate. While this sounds like a formal process, depending on the task, a quick SAFE assessment can be done in as little as a few moments. Let's use the action of firing a gun at a gun range and walk through the SAFE acronym.
· Summarize the critical step: pulling the trigger. This is our point of no return. The bullet will exit the barrel, and there is no going back.
· Anticipate error-likely situations: Is the range clear? Is the safety on until I'm ready? Is my finger off the trigger until I'm ready? Are others aware of my intended action and not presenting distractions?
· Foresee consequences: What are the potential adverse outcomes? Don't focus on the likelihood but rather on the consequences. Is it likely that someone is standing downrange? No. But there is the potential that they are, and the results could be deadly if we aren't checking to ensure it's all clear.
· Evaluate Defenses: Ensure protective measures are in place. Is everyone clear? Is everyone ready to move forward? Are conditions as expected, and is it still safe to proceed?
The human performance improvement tools listed in this article are there for you and your employees to be successful on every job. Still, they can be applied to every aspect of your personal and professional life.
No tool can ensure every job is performed without incident, but the combined use of the tools listed above closes the gap and sets your employees up for success on every job.
