Improving Human Performance

Copyright Material IEEE

Paper No. ESW2012-05

D. Ray Crow Danny P Liggett

Senior Member, IEEE Senior Member, IEEE
DRC Consulting, Ltd. DuPont Company
336 36th Street #389 4415 Eagle Mountain Ct
Bellingham, WA 98225 Richmond, TX 77406
USA USA
draycrow@aol.com danny.liggett@ieee.org

Abstract - Electrical safety incidents and injuries can be the Equipment safety deals with the design and operation of the
result of inappropriate work behavior or what is referred to as tools. How things are manufactured is also involved in order to
“unsafe acts.” This occurs even though training and education protect and provide safety to the worker. The improvement of
have been provided on the electrical hazards and the possible electrical equipment has been a topic of much discussion.
consequences. Providing training to people is not enough to There have been improvements to make equipment more
motivate them to follow the procedures. When unsupervised, inherently safe. Many papers have been written about Safety by
those people who are aware of the hazards may still believe Design. This concept is now accepted, and work continues in
they are qualified to take risks because previous “unsafe acts” this area.
have not resulted in an incident. This presentation will provide In the past detailed attention has been given to the
information on what motivates people to intrinsically follow “Managing Systems” element of safety. This element involves
proper electrical safe procedures. By understanding these procedures and compliance with standards set by NFPA 70E
principles, human performance can be positively changed and and the OSHA regulations. These are important. Having the
the electrical work practices of personnel can be improved to right procedures and controls in place provide the boundaries
consistently follow safe work procedures. within which people can operate or perform. Compliance
programs, regular audits, safety teams and other types of
Index Terms — Human Behavior, Electrical Safety, programs commonly exist in companies today based on the
Performance efforts of the studies in the “Managing Systems” area.
The one element that has not had enough attention is how
I. INTRODUCTION we can improve the performance of people who interact with
electrical equipment. This paper will provide information on how
There is a difference between behaviors and performance. If to improve human performance. The overall electrical safety
we are to improve performance then changing behaviors is one performance of the organization is directly tied to the issues that
element to study. Certainly, it is not the only element as there drive human behavior. The people at facilities interact daily with
are many other factors that impact performance. Of the many, electrical equipment. These interactions can be uneventful or
three stand out. they can have disastrous results.
There are three critical elements to electrical safety [1]. In an effort to change the inappropriate behaviors that lead to
Figure 1 shows these elements. unsafe acts, it is easy to say “they need more training”. Training
is only one means of achieving improved performance. Most
problems in the workplace stem from the environment in which
workers perform the tasks, not new procedures or new
information about how to do the work. Training will not fix
problems that exist due to the work environment. Things such
as weather, timelines, lack of personnel, lack of information,
improper tools or equipment, etc. cannot be changed by
training.
Human performance improvement is a means to the end of
achieving improved safety results. Understanding the decisions
and actions that cause incidents is imperative to improving
electrical safety performance. Most studies have been focused
on the consequences of the incidents, injuries, or fatalities.
However, focusing on the root cause(s) and not the
consequences, leads to understanding the changes necessary
for improved human performance. Based on that root cause
data, positive steps can be taken for continuous improvement in
organizational safety performance.
Fig. 1 Critical Elements of Electrical Safety

978-1-4673-1062-8/12/$31.00 ©2012 IEEE

 II. FACTORS TO HUMAN PERFORMANCE obvious – which is not always obvious to everyone and not
getting too detailed are all problems companies face when
There are many factors that impact human performance. attempting to communicate important and vital information for
Below is a list of what experts in the field of human employees to understand and follow.
performance believe are the key factors [2]. Another example of the significant information is the scope of
a task and the schedule. These are important for a task to be
executed safely. Understanding where the boundaries are for
x Data and information the task is critical especially if lockout/tagout is involved. Both of
x Resources, tools, and environmental supports these examples clearly demonstrate the need for data and
x Consequences, incentives, and rewards information to be clear.
x Skills and knowledge – internal to the individual, People will do what they have always done unless they are
when skills and knowledge are missing this told what the expectations and procedures are to the point they
clearly understand. Too often managers and supervisors
leads to poor performance by the individual. assume that people know what the “right things” to do are and
x Individual capacity – Has to do with talents or will unfailingly do them. Many of the performance problems that
capability to perform. Different jobs require exist can be attributed to a lack of clearly stated expectations,
different talents. standards, and feedback.
x Motives – deeply embedded characteristics 2) Resources, Tools, and Environmental Supports. It is the
responsibility of supervision and management to provide the
possessed by people. Motives include why
resources for work to be accomplished. Supervision must
people do what they do, how they view provide adequate manpower so that the job can be finished in a
themselves, their needs, desires, and internal timely manner. If the installation standards are to be met then
personality traits. the right materials must be supplied. If the right materials are
not supplied then people will use what is available or leave
It is important to notice that the first three items are external things out.
influences and the second three are internal influences. Any, or The environment people work in does have an impact on
all of these, can have an impact on the performance of people. their performance. If the area is messy then people will continue
They can have a positive impact or they can become barriers to to allow it to be that way. Poor or messy housekeeping is a
performance. The external influences can cause a good contributor to incidents and injuries.
performer to become a marginal or bad performer or can Other items such as the correct type of test equipment,
improve their performance. The external influences will be voltage rated gloves and arc flash PPE must be supplied can
discussed in Section A of the paper. Internal influences will be also be an issue. Mismanagement of equipment is a factor in
reviewed in Section B. injuries and incidents. Failure to properly control equipment
type is commonly seen. Often employers allow the employee to
A. External Factors use personal equipment which may be inappropriate for the
environment or the task. The company may assume the
External factors are things that influence performance that employee knows and owns the proper type equipment for all
are beyond the control of the individual. These factors are circumstances in which the equipment will be used. Over time
typically under the control of the employer or a regulatory body. this would seldom be true. Poor, irregular or no maintenance of
Company procedures and OSHA regulations are two typical equipment can also be the case.
external factors people face within their work environment. The 3) Consequences, Incentives, and Rewards. Consequences
person cannot control these. It becomes imperative the can send an unintended or completely wrong signal when used
employer provide clear, correct and concise information incorrectly. Used appropriately, it can motivate people to act
regarding what is expected from the person in their job responsibly.
performance relating to those things beyond their control. There must be consequences for inappropriate actions and
1) Data and information. There are many elements to these performance. While there may be an expected level of
two factors. The one that is probably the most important is performance, consequences set the level of performance that is
expectations. Establishing and communicating the expectations perceived as acceptable. A lack of consequences sends the
to the individual is vital. If people do not know what is expected signal that there are no boundaries. Consequences must be
they cannot deliver the appropriate performance. They need to consistently applied or they will be constantly challenged until
know not only what to do, but how to do it. As an example, let’s the employees find the lowest level of acceptable performance.
look at how a procedure for a test for the absence of voltage If consequences are not handed out for an infraction, a new,
may be communicated. Some procedures may say only: “Test lower level of performance has been set. Consequences must
for the absence of voltage” and nothing more. This leaves the be immediate. Delayed consequences lose their impact; this
employee with questions (or not) about the type of equipment to can sometimes create the opinion that an action is allowed if
use, whether testing the tester before and after the actual test is you don't get caught. [3].
required, If there are installation standards to be met, what Rewards and incentives are influential to results. However,
materials must be used, and other factors encountered within they must be managed correctly to achieve the desired
special job site situations. Not all people will ask questions or outcomes. Rewards and incentives must be focused on specific
seek information when they are unsure. Making assumptions actions. Giving awards for getting the job done, when everyone
within communications is one of the most common errors in knows short cuts were taken, sends the signal that it is
procedure writing. Lack of clarity, or failing to mention the permissible to take shortcuts. How the job gets done is as
important as getting the job done. Too often we fail to provide III. Types of Errors
positive feedback. Giving positive, specific praise and feedback
reinforces the right things often more strongly than monetary There are two major types of errors or inappropriate
compensation. [4] behaviors, active or latent. Active errors are the result of
cognitive failures [5] while performing a task. Latent errors are
B. Internal Factors the result of external factors. When incidents occur due to an
error, there is usually a deficiency in the “managing systems”
Internal factors are things over which the person has some element of safety. A third type of error, while not major, is an
control or has some ability to change. Understanding what intentional error.
drives behaviors is necessary in order to change the behaviors. 1) Active Errors. Active errors are caused by some failure in
Internal factors such as a person’s own beliefs drive their the thinking process of the person. Examples of this are
behavior. Changing what a person believes works best to inattention, memory failure or a lack of knowledge.
improve human performance because it will influence behaviors Lack of concentration often causes active errors to occur.
on a long-term basis. Once a belief has been changed, This is a common risk when performing repetitive tasks. Being
behavior automatically changes in-line with the new belief. on “Automatic Pilot” works as long as things are the same but
1) Skills and knowledge. These are two absolutely critical when things change our subconscious cannot deal with it and
elements to good work performance. There is a difference an error is likely to occur.
between knowing what to do and knowing how to do it. Forgetting important information occurs frequently when
The first external factor discussed in this paper was data and people are busy or there are multiple demands on their
information. The employer can provide the information but the attention. Safety requirements or safe work practices can be
person must attempt to become knowledgeable of the temporarily forgotten in just such a situation. Forgetting
information. The person must seek assistance when the important details happens all the time.
information is not clear or the person does not understand what The company or site may have good procedures to cover
is being shared. “First-hand knowledge” is often referenced what is required but sometimes the information is not effectively
when information or data has been learned by an individual and communicated. The person simply may not know what the
they have complete understanding and experience of the requirements are because of the lack of effective
subject matter. communication. Management believes they have conveyed the
Skills are essential. If the person does not have the right skills information to all the right parties only to find that those who
then errors will be made. A person can read all the material on needed the information the most were left out of the
how to do electrical work, memorize it and repeat it; h owever, “information loop.”
that person will not be able to go into the field and perform work 2) Latent Errors. These errors are caused by a void in
with any degree of effectiveness. The opposite is also true. A procedures, lack of training, unsafe designs, or the culture of
person can be very skilled at doing tasks but not truly have the the organization. If the procedures do not cover all hazards at
necessary level of knowledge and information that is critical to the site and do not provide information on safe work practices
his/her safety. Both of these elements, knowledge and skills, to be used, then latent errors or inappropriate behaviors are the
must be present in personnel in enough quantity and quality to most likely outcome. The design of equipment can hamper the
effectively manage their tasks. employees’ awareness of electrical hazards which cause
2) Individual capacity. This factor involves the physical incidents, injuries, and fatalities to occur. Inherently safer
abilities of the person. Does the person have the physical designs can prevent incidents from occurring. For example, the
capability to perform the task? While a person cannot design may limit the ability to see exposed parts that may be
completely control their physical attributes, it is a key energized. It can be said in this case the person was not
consideration when a supervisor is assigning tasks. A person qualified because the person was not knowledgeable of the
with vertigo is not the best person to assign to a high climbing construction of the equipment. The person may have been
task. The individual being assigned a job also has the aware of the hazard but was exposed due to the design of the
responsibility to say when a task is beyond their personal equipment.
capacities to do the job safely and effectively. A supervisor may Training plays a key role in safety. Personnel need to be
be unaware of a physical limitation such as vertigo, especially if trained in the construction and operation of the electrical
it is a temporary condition due to illness. People must equipment they will interact with. The equipment may look alike
understand their own capacities on an on-going basis and but may be designed differently. This situation demonstrates an
responsibly act on that awareness. error could occur from either a lack of knowledge or an unsafe
3) Motives. Everyone has a reason for the things they do. design. The culture of the organization can influence the
Some times the reasons are different than what other people behaviors of personnel. This is easily identified when you hear
think. It is important to understand through communication comments like “we’ve always done it this way” or “real
exactly what it is that motivates the people working with you. electricians don’t wear voltage-rated gloves”. Understanding
Intrinsic or internal beliefs can have a major impact on the and working within the organization’s culture will determine
behaviors of people. If the person wants to make a good safety outcomes. Being aware of and striving to improve safety
impression or enhance their reputation by getting tasks done cultures within organizations is a vital function of people within
quickly then there is a chance that shortcuts may be taken in that company in order to reduce latent errors.
order to accomplish that. This type of motive can have a 3) Intentional Errors. While not considered as a major type of
negative impact on safety. Conversely, establishing a good error it is still a cause of incidents, injuries and fatalities. When
safety record and reputation due to performing work in a safe the person knows the requirements, understands the risks and
manner that prevents injuries can be a positive motivator. makes unsafe decisions that result in incidents, injuries and
fatalities it is considered an intentional error. This becomes a 10) Tasks Performed Infrequently. If a person only performs a
disciplinary issue and employees should have immediate, task once every two years the details become lost. Our minds
appropriate consequences for their decisions and actions. cannot access information infrequently requested. When we
forget the details we set ourselves up for failure or errors.
IV. Error Traps 11) Distractions. Multi-tasking is the best example of being
distracted. The increased car accident rates from cell phone
In the previous section of the paper, types of errors were use while driving has shown that distractions will not allow one
outlined. In this section, a list of potential traps leading to be completely successful in either task. While everyone
personnel to make errors is explained. deals with a certain amount of distraction on a daily basis, there
1) Communication. George Bernard Shaw once stated “The is a limit beyond which someone cannot perform their work
single biggest issue with communications is the illusion that it without errors.
has occurred”. Too often we assume we have effectively 12) Lack of Focus. If we are preoccupied or have our mind on
communicated a thought or a requirement. People often feel another subject, we will most likely make an error with the
uneasy asking questions. Also a completely different concept subject at hand. Inattention is a common malady within the
may have been communicated than was intended. Information workplace and cause for many incidents and injuries.
is filtered through our beliefs and people try to make it fit within 13) Overconfidence. Making a positive assumption about the
what they believe and understand is right. level of knowledge attained is an easy mistake to make. How
2) Excessive Work Load. Heavy workloads can lead to does one measure what they don’t know? In a world of ever
stress on personnel. When under stress people will make increasing rates of change, making assumptions about
decisions they would not make under normal conditions. Any knowledge can only become more dangerous. Be cautious
compromised decision is error prone. when phrases like “I’ll figure it out” or “I know what I am doing”
3) Time Pressure to Complete Work. Shortened time frames are used. The world is in a constant state of change. The
cause people to become nervous, lose their concentration on practical application of listening and learning at every stage is
the task, focus only on time, and generally complete their tasks critical to continued success on the job.
at a lower level of performance. Pressure is counter-productive 14) Impatience. Getting in a hurry can lead to shortcuts or can
to completing error free work. cause a person to miss something critical within the process.
4) Time Near the End of Shift. As we near the end of the day, it Taking the time to recognize the hazards of the task and
is easy for us to become distracted with thoughts about other ensuring all of the steps necessary have been taken can control
obligations or activities. We will rush tasks in order to get them the error rate and reduce incidents.
done before the end of the day. This is a common trait and 15) Lack of Control of Work. Understanding who can make the
incidents occur due to the lack of attention or focus on the job at call on performing hazardous tasks is critical to appropriate
hand. planning. If there are several tasks being done simultaneously
5) Long Hours. Many studies have shown productivity is there must be someone who is coordinating the overall effort
reduced the more hours worked. The ability to think clearly is and keeping everyone safe.
impaired without adequate breaks and rest between work
periods. V. HUMAN PERFORMANCE TOOLS
6) Returning After Absence. It takes some time to readjust
back to the routine of work. People need to be retrained when Before we try to change the performance we need to
they return to work after a long absence. Memory cannot be understand what the performance is. Simply stating “we haven’t
relied upon to unfailingly support the person in assuming their had injuries” is not a true indication of performance. Having
work duties. Changes happen within workplaces on a injuries is one indicator. While having “no injuries” is desirable,
continuing basis and many are not recorded. It is important all there are other indicators that need to be considered.
procedures be reviewed when an absence has occurred. How many electrical shocks are occurring within your facility
7) Improper Work Instructions/Guidance. Closely tied in with or company? Typically electrical shocks are not reported unless
communications is another element about assuming people they are seen or cause an injury. Most people do not want to
already know what needs to be done. This sets up the situation admit they made a mistake.
where people have to make their own decisions based on what How many “near miss” incidents are occurring?
they know from previous experience or lacking that, they must Understanding the number and type of “near miss” incidents
guess what needs to be done. that are occurring will tell you where to focus your attention.
8) Guidance Does Not Match Previous Experience. If new Metrics need to be developed to measure what is truly
guidance is given without explanation or clarification, people will occurring. Misconceptions due to the lack of valid information
revert to what experience has told them has worked in the past. can drive human performance efforts in the wrong direction and
New procedures are often not implemented by personnel due to cause more harm than good [6].
the lack of information and guidance. When people do not Auditing actual work is another way to identify areas that may
understand something, they will not risk their life to do it. need improvement. Are all of the safe work practices for a
9) Lack of Use of Existing JSAs and SOPs. People do not do a specific task being utilized? Do personnel understand how to
job safety analysis (JSA) or use standard operating procedures use electrical PPE? Are the appropriate testers being used? Is
(SOPs) because they believe they already know what to do and the right level of planning being performed?
what the hazards are in this current situation based on past Once we understand what the performance is we can start
experience. Things change. Without a job safety analysis these the necessary actions to correct the behaviors that drive the
changes go unrecognized. performance. There are many tools on the market that can help
with driving change.
 One item that is typically not addressed when trying to create [1] Danny Liggett, “Refocusing Electrical Safety”, IEEE
change is what people think about the procedures and Transactions on Industry Applications, Sept/Oct 2006
standards they are asked to follow. Involving those who have to
execute the procedures in creating the change is important. [2] T.F. Gilbert, Human Competence: Engineering Worthy
Only with their buy-in will meaningful sustainable change occur. Performance, New York, NY, McGraw Hill, 1978

[3] Krause, Hidley, and Hodson, The Behavior-Based Safety

VI. CONCLUSIONS Process,1990

If we want to make improvements in electrical safety [4] Daniel H. Pink, Drive: The Surprising Truth About What
performance we must make improvements in the three critical Motivates Us, Riverhead Books, Copyright 2009
elements of safety performance. Equipment, Managing
Systems, and People are all parts of the equation of people [5] E Scott Geller. The Psychology of Safety Handbook, New
who interact with electrical equipment. York, NY, Lewis Publishing, 2001
Measurements in each area, root cause analysis, and
action plans to change the status quo equip each company to [6] Mary Capelli-Schellpfeffer, H Landis Floyd, Kim
make forward progress in reducing incidents, injuries and Eastwood, Danny Liggett, “How We can Better Learn
fatalities. From Electrical Accidents”, IEEE Industry Applications
To begin, determine what the current performance is in Magazine, May/June 2000
each area. Where are the incidents and injuries occurring?
Break down the incidents and analyze and understand what
behaviors are causing the incidents. Once the behaviors are IX. VITA
identified, a plan can be put in place to change the behaviors.
Changing safety performance is not just about how people Daryld Ray Crow (S’68, M’72, SM’03, LSM’07) graduated
act. The equipment people must interact with needs to be from the University of Houston in 1969 with a BSEE degree.
critically reviewed to determine if it is setting traps for After graduation Ray went to work for the Aluminum Company
personnel or if it can further assist in reducing hazard of America where he provided engineering support for Alcoa
exposure. Utilizing inherently safer designs will assist in plants worldwide on the design, installation, and operation of
improving organizational safety performance and reduce power and rectifier systems, provided plant engineering support
incidents and injuries. which included electrical safety, served as team leader for
The managing systems need to be carefully reviewed and writing a number of Alcoa electrical standards including the
revised to cover all of the hazards at the facility and provide the development of and training for Alcoa’s electrical safe work
safe work practices necessary for personnel to use to improve practice standard. He retired from Alcoa in 1996. After retiring
performance. This must be done on an on-going basis as from Alcoa, Ray worked for Fluor Global Services and Duke
change is ever present in the environment. Communication is Energy as a Principal Technical Specialist providing design and
key in remaining focused and clear about the safety and consulting electrical engineering for plant power distribution
performance of the organization. systems and safe work practice programs, standards, and
Improvements can always be made within any program or assessments/audits.
organization. Understanding how these elements connect to Ray presently is the Principal Technical Specialist for DRC
improve the lives and safety of all concerned is a vital piece of Consulting Ltd. and performs consulting work on electrical safe
information most do not have. All three of the elements work practices standards, assessments/audits, electrical safe
discussed at the beginning of the paper need to be addressed work practice training, and electrical engineering projects.
to substantially improve the safety program of an organization. He was chair of the Petroleum and Chemical Industry (PCIC)
The recommendations for steps to improve each area Safety Subcommittee 2004-2006, chair of the 2004 IEEE IAS
contained within this paper will lead to more effective safety Electrical Safety Workshop, is an alternate member on the
programs and more lives saved. NFPA 70E technical committee “Standard for Electrical Safety
in the Workplace”, a member of the IEEE 1584 Committee, and
VII. ACKNOWLEDGEMENTS was the working group vice chair for the 2007 revisions to IEEE
463 “Standard for Electrical Safety Practices in Electrolytic Cell
Ray Jones had a tremendous impact on the authors’ Line Working Zones”.
understanding of this concept. Ray has promoted this concept Ray has co-authored and presented papers and tutorials on
for over 20 years. Participants at the IEEE IAS Electrical Safety electrical safety and auditing for the PCIC and has presented
Workshop have also provided influence on the development of safety topics and tutorials at the IEEE Industry Applications
this paper. The authors would like to express gratitude to Society Electrical Safety Workshops and IEEE IAS Pulp and
everyone we have had a discussion with on electrical safety. Paper Industry Conference. In 2010 Ray received the IEEE IAS
Each person brings a unique perspective to electrical safety Petroleum and Chemical Industry Committee Electrical Safety
because of their experiences and beliefs. These discussions Excellence award.
impact our thinking and lead to advancing electrical safety.
Danny P. Liggett (M’91, SM’98) has been employed by
VIII. REFERENCES DuPont since 1989. He was employed by an
engineering/construction firm from 1968 until his employment
with DuPont. During his employment with the
engineering/construction firm he worked as an electrical Subcommittee. Danny served as Chair of the 2000 IEEE IAS
superintendent for 15 years. During his employment with Electrical Safety Workshop. He has served on the NFPA
DuPont he has worked as an Electrical Consultant with National Electrical Code Panel 8 representing the Cable Tray
primary focus on construction activities and electrical safety. Institute and the NFPA National Electrical Code Panel 6
His work also involves work with maintenance activities at the representing the American Chemistry Council. He currently
DuPont sites. He is a member of the DuPont Corporate represents the American Chemistry Council on the National
Electrical safety Team, Senior Member of IEEE, Past Chair of Electrical Code Technical Correlating Committee, as an
the IEEE IAS PCIC Safety Subcommittee and Past Chair of alternate on National Electrical Code Panel 3 and as an
the PCIC Tutorials Subcommittee. He currently serves as alternate on NFPA 70E. He has authored or co-authored 15
Chair of the PCIC IAS Electrical Safety Workshop papers on electrical safety, 10 of which have been published.