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What is Human Performance Improvement (HPI)?

Human Performance Improvement (HPI) is about reducing errors and managing defenses to prevent significant events. The application of HPI Principles in numerous organizations (medical, nuclear, chemical, etc.) has resulted in improved safety, quality, and productivity. The HPC exists as a resource for the Department's headquarters and field employees and contractors to implement and enhance HPI initiatives. The HPC provides resources, references, and training; and acts as a clearing house for HPI lessons learned from the DOE complex, other government organizations, and private industry. This web site is designed to share information on the purpose, process, and results of HPI which will assist you in implementation of practices to improve safety, quality, and productivity.

A New Way of Thinking

The graphic below illustrates what we know about the role of human performance in causing events or occurrences. About 80% of all events are initiated by human error. In some industries this number is closer to 90%. Roughly 20% of occurrences involve equipment failures. When the 80% human error is broken down further it reveals that the majority of errors associated with events stem from latent organizational weaknesses, (perpetrated by humans in the past that lay dormant in the system) whereas about 30% are caused by the individual worker touching the equipment and systems in the facility . Clearly, focusing efforts on reducing human error will reduce the probability of occurrences and events.

Error, Normal Accidents, Living with High-Risk Technologies, 1984; p. 183; Reason. Human Error. 1999, p.187.
Error, Normal Accidents, Living with High-Risk Technologies, 1984; p. 183; Reason. Human Error. 1999, p.187.

The traditional belief is that human performance is a worker-focused phenomenon. This belief promotes the notions the failures are introduced to the system only through the inherent unreliability of people. "Once we can rid ourselves of a few bad performers, everything will be fine. There is nothing wrong with the system." However, experience has shown that weaknesses in organizational processes and cultural values are involved in the majority of facility events. Accidents result from a combination of factors beyond the control of the worker. Therefore, the organizational context of human performance is an important consideration. Event-free performance requires an integrated view of human performance from those who attempt to achieve it — that is, how well management, staff, supervision, and workers function as a team, and the degree of alignment of processes and values in achieving the facility's economic and safety missions.


What is human performance? Good results can be achieved with questionable behavior. However, for long-term, sustained value-added results, one must look closely at behavior; what influences it, motivates it, provokes it, shapes it, inhibits it, directs it, etc. Very simply then, human performance is behavior plus results (P = B + R).


Behavior is what people do and say - a means to an end. During tasks involving manual effort, behavior is an observable act that can be seen and heard. It can be measured. If it can be measured, it can be changed. Consistent behavior is necessary for consistent results. For example, a youth baseball coach cannot just shout at a 10-year old pitcher from the dugout to "throw strikes." The child may not know how and will become frustrated. To be effective, the coach must teach specific techniques-behaviors-that will help the child throw strikes more consistently. This is followed up with effective coaching and positive reinforcement. People will make mistakes despite their best efforts. Therefore, behavior and its causes are extremely valuable as the signal for improvement efforts to anticipate, prevent, catch, or recover from errors. Whereas this discussion addresses individual behavior, it should be noted that individual behavior is strongly influenced by organizational behavior. Organizational behavior is in turn a reflection of its safety culture.


Performance connotes measurable results. Results, good or bad, are the outcomes of behavior — the mental processes and physical efforts to perform a task. In our industry the "end" is that set of outcomes manifested by people's health and wellbeing, the environment, the safe, reliable and efficient production of defense products, the discovery of new materials, the invention and testing of new products and the disposition of legacy wastes and facilities. Events usually involve challenges to reactor safety (where applicable), industrial/radiological safety, environmental safety and productivity. Event-free performance is the desired result. Event-free performance depends on reducing error both where people touch the facility and touch the paper (procedures, instructions, drawings, specifications and the like). Event-free performance is also dependent on ensuring the integrity of defenses, controls, barriers, and safeguards against the residual errors that still occur.


Events are caused. Typically, they are triggered by human action. In most cases, the human action causing the event was in error. However, the action could have been directed by a procedure; or it could have resulted from a violation -- a short cut to get the job. In any case, an act initiates the undesired consequences. The Anatomy of an Event graphic below provides an illustration of the elements that exist before a typical event occurs. Breaking the linkages will prevent events.

Anatomy of an Event

Anatomy of an Event
Anatomy of an Event


An event is an unwanted, undesirable change in the state of facility structures, systems, or components or human/organizational conditions (health, behavior, administrative controls, environment, and so on) that exceeds established significance criteria. Events involve serious degradation or termination of the equipment's ability to perform its required function. Other definitions include: an outcome that must be undone; any facility condition that does not achieve its goals; any undesirable consequence; a difference between what is and what ought to be. The following paragraphs describe in some detail how events come about.

Initiating Action

The initiating action is an action by an individual, either correct, in error, or in violation, that results in a facility event. Active errors are those errors that have immediate, observable, undesirable outcomes in the physical facility. They can be either acts of commission or omission. The majority of initiating actions are active errors. Therefore, a strategic approach to preventing events should be the anticipation and prevention of active errors.

Flawed Defenses

Flawed defenses are defects under the right circumstances that may inhibit the ability of defensive measures to protect facility equipment or people against hazards or fail to prevent the occurrence of active errors. Defenses or barriers are methods that
  • protect against various hazards (such as radiation, chemical, heat)
  • mitigate the consequences of the hazard (for example, reduced operating safety margin, personal injury, equipment damage, environmental contamination, cost)
  • promote consistent behavior. When an event occurs, there is either a flaw with existing defenses or appropriate defenses are not in place.

Error Precursors

Error Precursors are unfavorable prior conditions at the job site that increase the probability for error during a specific action, that is, error-likely situations. An error-likely situation — an error about to happen — typically exists when the demands of the task exceed the capabilities of the individual or when work conditions aggravate the limitations of human nature. Error-likely situations are also known as error traps.

Latent Organizational Weaknesses

Latent organizational weaknesses are hidden deficiencies in management control processes (for example, strategy, policies, work control, training, and resource allocation) or values (shared beliefs, attitudes, norms, and assumptions) create workplace conditions that can provoke error (precursors) and degrade the integrity of defenses (flawed defenses). The decisions and activities of managers and supervisors determine what is done, how well it is done, and when it is done, either contributing to the health of the organization or further weakening its resistance to error and events. Consequently, managers and supervisors should perform their duties with the same uneasy respect for error-prone work environments as workers are expected to at a job site. Understanding the major role the organization plays in the facility's performance — a second strategic thrust to preventing events — should be the identification and elimination of latent organizational weaknesses.

Strategic Approach for Human Performance

The strategic approach to improving human performance within the DOE community embraces two primary challenges:

I. Anticipate, prevent, catch, and recover from active errors at the job site.
II. Identify and eliminate latent organizational weaknesses that provoke human error and degrade defenses against error and the consequences of error.

If opportunities to err are not methodically identified, preventable errors will not be eliminated. Even if opportunities to err are systematically identified and prevented, people still err in unanticipated and creative ways. Consequently, additional means are necessary to protect facility equipment from errors that are not prevented or anticipated. Reducing the error rate minimizes the frequency, but not the severity of events. Only defenses prevent an event, which is the severity of the outcome of error. Defense-in-depth-defenses, barriers, controls, or safeguards arranged in a layered fashion — provides assurance such that if one fails, remaining defenses will function as needed to reduce the impact on the physical facility.
To improve human performance and facility performance, efforts should be made to 1) reduce the occurrence of errors at all levels of the organization and 2) enhance the integrity of defenses, barriers, controls, or safeguards discovered to be weak or missing. Reducing errors (Re) and managing defenses (Md) will lead to no significant events (OE). Eliminating significant facility events will result in performance improvement within the organization.


Part of the 'new way of thinking' about human performance is expressed in five simple statements referred to as the Principles or underlying truths of human performance. Excellence in human performance can only be realized when individuals at all levels of the organization accept these principles and embrace concepts and practices that support them. These principles are the foundation blocks for the behaviors described and promoted in this Standard. Integrating these principles into management and leadership practices, worker practices, and the organization's processes and values will be instrumental in developing a working philosophy and implementing strategies for improving human performance within your organization

1. People are fallible, and even the best people make mistakes.

Error is universal. No one is immune regardless of age, experience, educational level, status of health or any other demographic discriminator. The saying "to err is human" is indeed a truism. It is human nature to be imprecise — to err. Consequently, error will happen. No amount of counseling, training, or motivation can alter a person's fallibility. Dr. James Reason, author of Human Error (1990) wrote: It is crucial that personnel and particularly their managers become more aware of the human potential for errors, the task, workplace, and organizational factors that shape their likelihood and their consequences. Understanding how and why unsafe acts occur is the essential first step in effective error management.

2. Error-likely situations are predictable, manageable, and preventable.

Despite the inevitability of human error in general, specific errors are preventable. Just as we can predict that a person writing a personal check at the beginning of a new year stands a good chance of writing the previous year on the check, a similar prediction can be made within the context of work at the job site. Rigorously structuring one's thinking (focusing attention) can help people identify error traps that provoke errors more consistently prior to performing the task or activity. Recognizing error traps and actively communicating these hazards to others proactively manages situations and prevents the occurrence of error. By changing the work situation to prevent, remove, or minimize the presence of conditions that provoke error, task and individual factors at the job site can be managed to prevent, or at least minimize, the chance for error.

3. Individual behavior is influenced by organizational processes and values.

Organizations are goal-directed and as such their processes and values are developed to direct the behavior of the individuals in the organization. The organization mirrors the sum of the ways work is divided into distinct jobs and then coordinated to conduct work and generate deliverables safely and reliably. Management is in the business of directing workers' behaviors. Historically, management of human performance has focused on the "individual error-prone or apathetic workers." Work is achieved, however, within the context of the organizational processes, culture, and management planning and control systems. It is exactly these phenomena that contribute most of the causes of human performance problems and resulting facility events.

4. People achieve high levels of performance largely because of the encouragement and reinforcement received from leaders, peers, and subordinates.

The organization is perfectly tuned to get the performance it receives from the workforce. All human behavior, good and bad, is reinforced, whether by immediate consequences or by past experience. A behavior is reinforced by the consequences that an individual experiences when the behavior occurs. The level of safety and reliability of a facility is directly dependent on the behavior of people. Further, human performance is a function of behavior. Because behavior is influenced by the consequences workers experience, what happens to workers when they exhibit certain behaviors is an important factor in improving human performance. Positive and immediate reinforcement for expected behaviors is ideal.

5. Events can be avoided through an understanding of the reasons mistakes occur and application of the lessons learned from past events (or errors).

Traditionally, improvement in human performance has resulted from corrective actions derived from an analysis of facility events and problem reports — a method that reacts to what happened in the past. Learning from our mistakes and the mistakes of others is reactive — after the fact, but important for continuous improvement. Human performance improvement today requires a combination of both proactive and reactive approaches. Anticipating how an event or error can be prevented is proactive and is a more cost-effective means of preventing events and problems from developing.

Suggested HPI Reading

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Event Analysis - Human Error - Human Performance - Maintenance - Mental Process - Organizational Culture - Safety Management

Event Analysis

"The Field Guide to Human Error Investigations"; Dekker, Sidney

This field guide assesses two views of human error - the old view, in which human error becomes the cause of an incident or accident, or the new view, in which human error is merely a symptom of deeper trouble within the system. The two parts of this guide concentrate on each view, leading towards an appreciation of the new view, in which human error is the starting point of an investigation, rather than its conclusion. The second part of this guide focuses on the circumstances which unfold around people, which causes their assessments and actions to change accordingly. It shows how to "reverse engineer" human error, which, like any other component, needs to be put back together in a mishap investigation.

Human Error

"Human Error"; Reason, James

Modern technology has now reached a point where improved safety can only be achieved through a better understanding of human error mechanisms. In its treatment of major accidents, the book spans the disciplinary gulf between psychological theory and those concerned with maintaining the reliability of hazardous technologies. Much of the theoretical structure is new and original, and of particular importance is the identification of cognitive processes common to a wide variety of error types.

"Ten Questions About Human Error"; Dekker, Sidney"

The ten questions about human error are not just questions about human error as a phenomenon, but also about human factors and system safety as disciplines, and where they stand today. In asking these questions and sketching the answers to them, this book attempts to show where current thinking is limited--where vocabulary, models, ideas, and notions are constraining progress. This volume looks critically at the answers human factors would typically provide and compares/contrasts them with current research insights. Each chapter provides directions for new ideas and models that could perhaps better cope with the complexity of the problems facing human error today. As such, this book can be used as a supplement for a variety of human factors courses.


"Managing Maintenance Error"; Reason, James & Hobbs, Alan

Central to the book is a comprehensive review of error management, followed by chapters on: - managing the person, the task and the team; - the workplace and the organization; - creating a safe culture; It is then rounded off and brought together, in such a way as to be readily applicable for those who can make it work, to achieve a greater and more consistent level of safety in maintenance activities.

Mental Process

"blink - The Power of Thinking Without Thinking"; Gladwell, Malcolm

Rapid cognition is the sort of snap decision-making performed without thinking about how one is thinking, faster and often more correctly than the logical part of the brain can manage. Gladwell sets himself three tasks: to convince the reader that these snap judgments can be as good or better than reasoned conclusions, to discover where and when rapid cognition proves a poor strategy, and to examine how the rapid cognition's results can be improved. Achieving three tasks, Gladwell marshals anecdotes, statistics, and a little bit of theory to persuasively argue his case.

Performance Improvement

"Bringing Out the Best in People"; Daniels, Aubrey

The classic bestseller on performance management is updated to reflect changes in today's working environment. What has made Daniels the man with the answers? His ability to apply scientifically based behavioral stimuli to the workplace while making it fun at the same time. Now Daniels updates his ground-breaking book with the latest and best motivational methods, perfected at such companies as Xerox, 3M, and Kodak. All-new material shows how to: create effective recognition and rewards systems in line with today's employees want; Stimulate innovations and creativity in new and exciting ways; overcome problems associated with poorly educated workers; motivate young employees from the minute they join the workforce.

Organizational Culture

"Organizational Culture and Leadership"; Schein, Edward

How to transform the abstract concept of culture into a practical tool that managers and students can use to understand the dynamics of organizations and change. Organizational pioneer Schein updates his influential understanding of culture--what it is, how it is created, how it evolves, and how it can be changed. Focusing on today's business realities, Schein draws on a wide range of contemporary research to redefine culture, offers new information on the topic of occupational cultures, and demonstrates the crucial role leaders play in successfully applying the principles of culture to achieve organizational goals. He also tackles the complex question of how an existing culture can be changed-- one of the toughest challenges of leadership. The result is a vital resource for understanding and practicing organizational effectiveness.

Safety Management

"Cognition and Safety"; Sträter, Oliver

Ingenious technologies and systems are designed, assessed and innovated throughout time. Sträter addresses the gap between the design of safety systems, on the one hand, and operation, on the other. Methods and models for human behavior in design focus on system workload or situational awareness, while operation relates to human error. A homogeneous approach towards notions like human error, workload and situational awareness is aimed at being integrated in this book by making use of existing knowledge of human cognition without, as the author claims, 'reinventing the wheel'.

"Managing the Risks of Organizational Accidents"; Reason, James

Human factors expert James Reason provides a comprehensive review of the causes and consequences of a wide variety of accidents. Strategies for accident prevention and mitigation come in frameworks that organizations can easily adopt.

"Managing the Unexpected"; Weick, Karl & Sutcliffe, Kathleen

High reliability organizations (HROs) such as ER units in hospitals or firefighting units are designed to perform efficiently under extreme stress and pressure. Using HROs as the model for the 21st century organization, the authors show readers how to respond to unexpected challenges with flexibility rather than rigidity and to reduce the disruptive effects of change by using tools such as sensemaking, stress reduction, migrating decisions, and labeling. Introducing the powerful new concept of "mindfulness," the authors outline five qualities of the mindful organization and the organizational skills needed to achieve them. Each concept is clearly expressed in vivid case studies of organizations that demonstrate mindful practices in action.

"Resilience Engineering"; Hollnagel, Erik; Woods, David; Leveson, Nancy

Resilience engineering is a paradigm for safety management that focuses on how to help people achieve success in the face of complexity and pressure. It stands in contrast to the current paradigm of tabulating errors as if they were things that can be counted, followed by interventions aimed at reducing this count. A resilient organization treats safety as a core value, not a commodity that can be counted. Resilience may be viewed in terms of the capacity of an organization to handle disruptions, variations, disturbances and surprises that fall outside of those that it was designed to accommodate.

"The Psychology of Safety"; Geller, E. Scott

Safety performance cannot be brought to enviable levels without addressing human behavior and attitude effectively. The only comprehensive reference on the psychology of human dynamics of safety, The Psychology of Safety Handbook shows how to apply psychology to improve safety and health in any organization. Revised and expanded from the bestselling book that has become required reading for achieving Certified Safety Professional status, this is the only comprehensive resource on the human dynamics of safety.


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- DRisley DRisley on Oct 5, 2011 8:24 am