This document outlines a 5-step process for improving human performance in operations through a systematic approach. The steps are: 1) Specify performance requirements; 2) Develop good measures and advertise them; 3) Measure current performance; 4) Re-engineer the people systems through a human performance engineering approach; 5) Continuously measure and improve system performance through operational experience feedback. The goal is to take a total systems approach to reduce human errors by addressing underlying causes related to personnel selection, procedures, interfaces and culture, rather than focusing solely on punishing individuals.

1. Five Steps
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Why Do Good People Do Bad Things, And
What Can We Do About It?
Five Steps to Attaining Excellence in Operations Performance
Operations and process safety managers frequently ask why experienced, knowledgeable
people still make errors. “I know we’ve got good operators, yet we continue to have incidents.”
“He knew better, but just went ahead and did it.” Why do good people do bad things? Managers
usually have one of two different basic answers. One I call the God theory, “To err is human
(i.e., God did it). It’s just human nature to make mistakes. No matter what you do, humans will
make errors. So, it really is fruitless to spend too much effort on trying to ‘design out’ human
error. People just have to learn by experience.” Actually, there’s a lot to be said about the
benefits of learning by experience, IF you can afford the mistakes that occur in the learning
process. In many high-risk operations, this is not the case. Some mistakes can be catastrophic;
others just extremely expensive!
The second answer is “The devil made them do it.” Murphy’s law exists. If there is some
way for a person to screw up, he will. The unfortunate corollary of this devil theory is that
somehow, error is “sin,” and punishment is the appropriate corrective action. “They just need an
attitude adjustment!”
My response to the question is that in most cases the devil did make them do it; but, the devil
is us – the designers, and builders, and managers of the systems. We set the operators up for
failure when we design and build and operate systems without proper consideration of human
performance capabilities and limitations. Technical systems for the most part are built and
operated by “technical” people. Engineering and technical education typically does not prepare
us to design and operate people systems.
What can we do about it? The solution is to develop a comprehensive, systematic and
continuous approach to improving design and management of the human side of the system. You
need an approach to engineer human performance, just as you engineer all of the hardware
elements of the system. This human performance engineering approach will: define precisely
what performance and what level of performance is required; assure that the “design
requirements” for people on the job (the knowledge, skills, abilities, and attitudes that they bring
to the job) are sufficient; assure that all of the support and maintenance systems (procedures,
operator aids, administrative controls, supervision, etc.) are available and are used. You can
dramatically decrease the frequency of human errors, and the consequence of human error,
thereby reducing equipment damage, unplanned outages, lost product, and risk to personnel, the
public and the environment. Below are five basic steps to establishing a human performance
engineering program that will lead your facility out of the “valley of compliance” to the “peaks of
excellence”.
Step 1: Specify your performance requirements. The idea that we should know what
performance we need before we try improve is so basic that it frequently is overlooked. Every
job has minimum requirements for human performance – knowledge and skill level, physical
requirements, personality traits, attitudes toward safety, etc. And it is possible to specify those
requirements – to clearly identify and document them. In a systems-engineering design approach,
human performance requirements are specified as part of the total system performance
requirements. System functions and specific performance requirements are allocated to humans,
to hardware, to software, to facilities, or to some combination of these major system elements.
Formal job and task analysis (JTA) is used to identify specific human performance requirements.
It also identifies the implications of those requirements on knowledge, skill and ability levels, on
human-machine interface design, staffing levels, etc.

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While caution should be exercised to not overkill on the level of formality and detail,
applying the basic concepts and techniques of JTA to each job and task can produce a wealth of
basic data for improving human performance. JTA is a means to identify who has to do what,
where, when? What information is required? What equipment items are manipulated? What
tools are required? What are the unusual or particular demands on the human for accuracy, time
allowed, communication, or other performance attributes? What are the major constraints (e.g.,
high stress, confined space, etc.)? Personnel selection, training and qualification programs,
design of operations and maintenance procedures, design of control and display interfaces,
performance evaluations and other areas of human performance can draw on information
collected and assessed in a job/task analysis. In order to get good performance you have to define
what good performance is – what is required to do the job well.
Step 2: Develop good measures and advertise them. The JTA results provide a firm basis for
specifying the underlying knowledge, skills, abilities, attitudes, etc. that are necessary for human
performance that will meet system design requirements. These individual attributes can be
measured in controlled settings. That’s what training tests or examinations do. But direct
observation and measurement of those necessary components usually is not practical outside of
the classroom, and more importantly, doesn’t get to the ultimate goal of tapping on-the-job
performance.
We all know that performance on the job at any given time is affected by many factors other
than basic knowledge and skills. What are needed are measures that discriminate levels of
performance on the job. And, to the extent possible, an understanding of relationships between
job performance and the underlying factors that influence performance. Then we can measure
actual job performance and, when performance is less than required/ desired, determine the
underlying (systemic) cause of the performance problem and fix it.
Furthermore, by advertising, i.e., by clearly specifying and communicating those
performance measures, you can guide people to attain the desired performance. People tend to
produce the performance for which they will be rewarded. Knowing what performance is desired
clearly gives everybody a head start. It tends to eliminate “mushroom-farm management” (keep
‘em in the dark and feed ‘em lots of manure). Performance measures become a tool for attaining
the performance you desire, not just a scorecard on how well you’ve been doing.
The complexity of the task of building good measures is often underestimated. The number
of factors potentially influencing human performance on the job can be overwhelming. Those
factors can vary greatly from person to person, within a single person from task to task, and even
within the same person performing the same task on different occasions. To some degree, each
performance of a task by each person is unique. Further, it is difficult to quantify the impact of
many of the variables on overall “goodness” of performance. As a colleague once noted, “There
is no calculus of human behavior”.
However, there are “experts” who can rate performance on the job, and usually they are
readily available in your facility or organization. They are the highly experienced job
incumbents. They are senior technical specialists, trainers who have been operators in the past
and have had lots of experience evaluating trainees, current operators who are recognized (usually
unofficially) as the best operators. These experts, or “authorities,” know good performance when
they see it. And, they can discriminate levels of performance precisely and reliably. A problem
is that it is very difficult for them to explain to anyone else precisely how they do what they do –
what they see and how they put information together to make judgments. 1
That information has to be carefully and painstakingly extracted from the experts and turned
into straightforward “observable” indicators that can be used to both measure performance and to
make explicit to all involved what is being measured and why. There are systematic techniques
for extracting such rating strategies, and once captured they are powerful tools, not only for
assessing performance, but for setting standards of performance, and for capturing the deeper

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“expert knowledge” that comes only from years of experience on the job. A side benefit of
developing such subjectively based measures is that the job incumbents (through the selected
representative “experts”) at each level become intimately involved in setting their own standards
of performance, in identifying collectively what is good performance, and in focusing on how
good performance demonstrates itself.
Note that performance measures are not just for workers “on the floor,” but for all levels.
Ideally, performance measures are developed for each job level with input from all “customers,”
including internal customers at least one level above and one level below the job position. A
comprehensive, integrated set of performance measures (or “family of measures” 2) is the goal.
The process for developing measures should identify a comprehensive listing of what to
measure. A good process will also identify how to measure. That is, a characteristic of a good
indicator to be used in a measure is that data is reasonably and practically available. This does
NOT mean (as so often is the case) that you simply identify the data that’s easy to collect and use
that to get “the best measure you can”. This “looking under the lamppost” approach has led to
many failed attempts at performance measurement. It does mean, however, that the most elegant
psychological concept for human performance measurement is essentially useless if the data are
too difficult or too expensive to collect. Your measurement development process should identify
what data sources are to be used for indicators, how often they will be collected, in what form and
by whom.
In general, a comprehensive set of measures will include three levels of indicators:
organizational, functional, and individual3 - and at least three basic types of indicators: outcome,
process, and behavioral. Organizational measures have to do with how well the organization
identifies, communicates, and achieves its performance goals as an entity, whether it is the entire
corporate organization or a sub-unit. They tend to be more global “outcome measures,” e.g.,
profit, availability, lost workdays. Functional measures focus on the performance of complete
processes or business functions, which often cut across organizational lines – production,
training, quality control. They tend to use process indicators and focus on how well the process is
designed, installed, operated, maintained and evaluated. Most traditional audits involve process
measures. Individual measures deal with the performance of individuals or teams of people as
they perform the job. These typically are “behavioral” measures. Indicators involve observed
behaviors or directly observable results of behaviors and are concerned with how well the human
is performing the required task in comparison to specified requirements.
Again, there are behavioral measures for all levels of employees, from entry level to top
management. Each individual or job-position measure is related to the organizational level
measures for the organization of which that person is a part, and to functional level measures
associated with the processes and functions in which that individual has some responsibility.
There can be outcome, process or behavioral measures at any of the three levels, but typically
organizational measures tend to use outcomes as indicators, functional measures tend use process
indicators, and individual measures tend to use observational indicators. The challenge in
building an effective family of measures is not just to identify all the indicators, but to identify
and make explicit how they all relate to each other and to overall “system” performance.
Note that this is distinctly different from benchmarking. Why should your performance goals
be determined by someone else’s standards of “excellence”? You know good performance when
you see it. Your performance goals and your system performance requirements should drive the
human performance requirements for your facility. Certainly, benchmarking is valuable.
Understanding what the competition is doing well or not doing well is important. It is part of the
information you can use to set your goals. But, the focus of your operations and your
measurement process should be the processes, behaviors and outcomes you need to attain the
optimum level of system performance. And, the target for human performance is the human
performance that optimizes system performance. Recognize that the term system here is used

4. Five Steps
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generally and is applied top-down starting from the highest level. Each sub-level has
performance requirements derived from above.
Step 3: Measure current performance. You can’t figure out how to get where you want to go
until you find out where you are. Given a clear idea of required performance and effective
measures of performance, it is necessary to determine the current level of performance. A key
concept to establish early is the culture of continuous improvement. There is no permanent fix.
Performance measurement, evaluation, and improvement must be a continuous process. The
initial measurement establishes where you are with respect to currently defined performance
requirements and goals. As the system changes, as competition changes, as the economic
conditions change, the desired/necessary performance levels will change. The only answer to
“How good is good enough?” is “As good as you need to be to reach your goals at this time.”
If you have developed an effective measurement system as described in Step 2, your initial
measure will be addressing not only outcomes, e.g., frequency of human errors, but processes,
such as the training system design. A common mistake is to treat all human performance
deficiencies as a “training” problem. In fact, human resource development specialists now
recognize4 that only a small fraction of identified human performance problems are completely
resolved by improved training. At a minimum, the measurement and evaluation of human
performance should address the following areas:
- Personnel Selection, Training, and Qualification
- Administrative Controls (Conduct of Operations)
- Procedures – operating and maintenance procedures used by workers on the job
- Ergonomics – the design of the human-machine interface
- Organizational Culture – how the organization establishes and nurtures values such as
safety, learning, and excellence.
These are the fundamental areas to consider in engineering human performance. Since very few
current systems have been designed in accordance with a total systems engineering process,
initial examination of these areas is likely to indicate there are some fundamental process
improvements that need to be made to the human side of the system; that it is necessary to do
some human performance engineering, or “re-engineering.”
Step 4: Re-engineer the people systems. The measurement and evaluation process must be
capable of identifying systemic problems in these areas. Systemic problems are those of the
underlying structure of the people system for which long-term basic solutions are possible.
Problem identification focused on blame will not lead to long-term improvements. “The operator
should have known better; he wasn’t paying attention; he should be disciplined.” Punishment
rarely is effective for long-term behavior modification. Further, such solutions usually do not
address the underlying cause of the error. This particular operator may not make the same
mistake next time, but if there is a basic problem with the system, the error will occur again.
What is most often found is that there are fundamental deficiencies in the design and management
of the human system, largely because designers and managers were never trained in “humansystem technology.”
The engineering (or re-engineering) of the people system needs to be accomplished from a
total systems perspective. And, it needs to address the five areas listed above – personnel
subsystems, conduct of operations, procedures, ergonomics, and organizational culture. A
framework for engineering these people systems already exists. It is the formal systems
engineering process that evolved in the military and aerospace industries for design and
development of complex systems. Two key concepts are: 1) top-down definition and allocation
of functions and performance requirements; and, 2) clear specification and management of
interfaces among different system elements (e.g., human-machine interfaces). These systems

5. Five Steps
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engineering design concepts can be applied to existing operational systems. In our company we
refer to this as “systems performance engineering”. We aren’t engineering the system, but we are
engineering performance of the existing system.
Human performance engineering (HPE) is the application of systems performance
engineering to human (sub)systems. For example, in the field of training, the application of
systems performance engineering to training systems is the “Instructional Systems Design” or
ISD process. It is a top-down process of analysis, design, development, implementation and
evaluation to produce performance-based training (and by extension, personnel selection and
qualification). A central concept of human performance engineering is “user-centered design,”
i.e., that all human interfaces – equipment, tools, procedures, facilities – should be designed to
meet the needs, capabilities and limitations of the user. User-centered design helps to produce
computer interfaces that are easier to understand and procedures that are easy to follow. In all
areas, the human performance engineer seeks to identify and eliminate problems with the
underlying design and management processes that are causing less than optimum human
performance.
Step 5: Continuously measure and improve system performance. The final step in establishing
a process for attaining operations excellence is to assure that there are mechanisms in place for
continuous measurement, evaluation and improvement of human performance, and that they are
fully supported by management. Figure 1 is the typical continuous quality improvement model
applied to systems performance engineering. The focus here is on total system performance; and,
as we’ve discussed, human performance is simply a part of overall system performance.
A critical element for improving human performance is a system for collection, analysis and
feedback of operational experience – of successes and, especially, failures. And, a critical
requirement for success of such a feedback system is an enlightened management attitude intent
on learning from experience. A culture that views human error as simply a deficiency in the
person involved, and the cure for human error a matter of identifying the guilty party and
“correcting” that person, will never succeed in establishing a learning organization that benefits
from mistakes and eliminates underlying causes of human error. A culture that eliminates
“blame” and looks for systemic causes for error, that rewards self-critical evaluation, and that
proactively seeks out and eliminates “error-likely situations” will drastically reduce the frequency
of human errors.
A central element to a successful operational-experience-feedback program is a
comprehensive root cause analysis program that includes root causes for human error and relates
those causes back to basic human-system elements that management has the power to fix. The
performance measures established in Step 2 will include direct measures of on-the-job
performance that provide data for evaluation that also will be a powerful source of feedback.
Other examples of data sources are “behavior-based” safety programs that involve systematic
observation of performance on the job, industry information on events/occurrences applicable to
your facility, and results of internal and external audits. An important issue in many facilities is
how to retain the vast store of knowledge and experience that often is lost due to retirement or
downsizing efforts. Some companies are setting up systematic programs for capturing this expert
knowledge and incorporating it in training, procedures, required reading and other means of
feedback to operations personnel. All of these sources of operational experience feedback can be
valuable sources of data for improving performance, if they are systematically collected, analyzed
and communicated to the right people.
Why do good people do bad things? Because they are people, of course. The design specs for
people include intelligence, creativity, flexible thinking, adaptability, a modest level of sensory
capabilities and physical capabilities, and many other attributes. Humans are extraordinarily,
even uniquely, qualified for certain tasks. But they also have many limitations. High intelligence

6. Five Steps
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and creativity can mean low tolerance for mundane repetitive tasks. While good memory is a
distinct survival advantage, so is a good “forgettery”. Imagine life without being able to forget
the infinite input of data we absorb in ordinary living each day. People have tasks and
environments that they are inherently better suited for. It is the job of system designers to design
the system, and the job of managers to manage the system, in a way that accounts for the inherent
strengths and weaknesses of the human element.
Performance-based selection, training and qualification of personnel will help to assure a
sufficient and consistent level of knowledge, skills, abilities and attitudes. User-centered design
of procedures will help to assure that knowledgeable and skilled operators don’t “slip” and omit a
key step. Well-designed displays and controls, labeling, lighting, etc. can help reduce both
“cognitive” and “manual” errors. Rigorous administrative controls on simple things like
exchanging information at shift turnover, tagout/lockouts, making changes to procedures, and
numerous other routine activities can increase consistency and reduce possibilities for mental
slips that all humans make. Management actions, such as rewarding those who self-report human
errors that caused, or could have caused, an injury or process incident, will make clear that
management really does mean those lofty statements about safety and the value of employees.
And they will help eventually to inculcate the “safety culture” that we all claim we desire.
This is the job of the human performance engineer. It is a tough job. “Hardware managers,”
that think the word “system” is synonymous with “hardware” do not make it easier. Increased
demands on management to “do more with less” make it difficult for even the most enlightened
plant manager to obtain the funding and manpower to rebuild poorly designed and implemented
human systems. The good news is that there are well- established techniques for improving
human performance. More managers are becoming aware, if only by the continued unacceptable
level of occurrence of incidents, that all of the improvements to equipment that have been made
will not assure safe and effective performance until the human element is addressed. The really
good news is that these approaches will work and will improve human performance and,
therefore overall system performance. And, while they do require initial investment, the cost is
usually far less than hardware managers are used to spending on hardware fixes while the
performance improvement can be much greater. You can attain operations excellence in your
facility!
FOOTNOTES
1. Connelly, E.M., P.M. Haas, and K.C. Myers, “Method for Building Performance Measures
for Process Safety Management,” International Process Safety Management Conference,
Center for Chemical Process Safety, AIChE, San Francisco, CA, 1993.
2. Thor, Carl G., The Measures of Success, Creating A High Performance Organization, Oliver
Wright Publications, Inc., Essex Junction, VT, 1994.
3. Geary A. Rummler and Alan P. Brache, Improving Performance, How to Manage the White
Space on the Organization Chart, 2nd Addition, Jossey-Bass Publishers, San Francisco, CA,
1995.
4. Shirley, T., Performance In Practice, American Society for Training & Development
Newsletter, Fall, 1997.

7. Five Steps
Page 6 of 6
and creativity can mean low tolerance for mundane repetitive tasks. While good memory is a
distinct survival advantage, so is a good “forgettery”. Imagine life without being able to forget
the infinite input of data we absorb in ordinary living each day. People have tasks and
environments that they are inherently better suited for. It is the job of system designers to design
the system, and the job of managers to manage the system, in a way that accounts for the inherent
strengths and weaknesses of the human element.
Performance-based selection, training and qualification of personnel will help to assure a
sufficient and consistent level of knowledge, skills, abilities and attitudes. User-centered design
of procedures will help to assure that knowledgeable and skilled operators don’t “slip” and omit a
key step. Well-designed displays and controls, labeling, lighting, etc. can help reduce both
“cognitive” and “manual” errors. Rigorous administrative controls on simple things like
exchanging information at shift turnover, tagout/lockouts, making changes to procedures, and
numerous other routine activities can increase consistency and reduce possibilities for mental
slips that all humans make. Management actions, such as rewarding those who self-report human
errors that caused, or could have caused, an injury or process incident, will make clear that
management really does mean those lofty statements about safety and the value of employees.
And they will help eventually to inculcate the “safety culture” that we all claim we desire.
This is the job of the human performance engineer. It is a tough job. “Hardware managers,”
that think the word “system” is synonymous with “hardware” do not make it easier. Increased
demands on management to “do more with less” make it difficult for even the most enlightened
plant manager to obtain the funding and manpower to rebuild poorly designed and implemented
human systems. The good news is that there are well- established techniques for improving
human performance. More managers are becoming aware, if only by the continued unacceptable
level of occurrence of incidents, that all of the improvements to equipment that have been made
will not assure safe and effective performance until the human element is addressed. The really
good news is that these approaches will work and will improve human performance and,
therefore overall system performance. And, while they do require initial investment, the cost is
usually far less than hardware managers are used to spending on hardware fixes while the
performance improvement can be much greater. You can attain operations excellence in your
facility!
FOOTNOTES
1. Connelly, E.M., P.M. Haas, and K.C. Myers, “Method for Building Performance Measures
for Process Safety Management,” International Process Safety Management Conference,
Center for Chemical Process Safety, AIChE, San Francisco, CA, 1993.
2. Thor, Carl G., The Measures of Success, Creating A High Performance Organization, Oliver
Wright Publications, Inc., Essex Junction, VT, 1994.
3. Geary A. Rummler and Alan P. Brache, Improving Performance, How to Manage the White
Space on the Organization Chart, 2nd Addition, Jossey-Bass Publishers, San Francisco, CA,
1995.
4. Shirley, T., Performance In Practice, American Society for Training & Development
Newsletter, Fall, 1997.