GLOSSARY

• Active Error
• Observable physical actions that result in immediate undesired consequences.  Such actions may be either acts of omission (leaving something out), or commission (doing the wrong thing).  Most active errors are trivial in nature, with minor (if any) consequence.  However, grievous errors may result in loss of life, major personal injury, significant or catastrophic damage, and/or major cost/litigation.
• Alignment
• A measurement or judgment of the extent to which the values, processes, management, and other existing factors within an organization influence human performance in a complimentary and non-contradictory way; [v] facilitating organizational processes and values to support desired behavior.
• At-Risk Behavior
• Actions or practices, typically adopted for expedience, convenience, comfort, or fun, that increase the potential for error.
• Barriers / Defenses
• Physical, organizational, or behavioral attributes that guard against error.  Physical attributes include such things as physical barriers, signs, postings, guard rails, safety devices, etc.  Organizational barriers include formalized processes and procedures, hierarchical checks and balances, and the structure through which work flows.  Behavioral barriers are reflective of the culture of an organization, and include such things as the use of specific tools to prevent mistakes, such as effective communications, questioning attitude, and self-checking.
• Behavior
• Observable activity (movement, speech, external emotional response), or non-observable activity (thought, perception, internal emotional response) performed by an individual.
• Benchmarking
• A process of comparing processes, products, methods, and/or practices against another, typically against one who is considered to be a leader in a given field or industry.
• Causal Assessment
• A systematic process of determining the fundamental reasons for a given performance gap or adverse trend.
• Coaching
• The process of influencing and facilitating changes in the behavior of another person through direct interaction, feedback, and collaboration.
• Cognitive / Cognition
• Types of mental processes used to process information that involves perception, judgment, problem-solving, and decision-making.
• Cognitive Strain
• Mental stress caused by choosing a course of action that runs against prevailing currents of habit or desire.  It is the cost associated with the struggle to assimilate new information.
• Complacency
• A state of being relatively unconcerned and not fully aware of parameters, deficiencies, or hazards.
• Concurrent Verification
• The act of having a second qualified individual verify the correctness of a component, action, and expected result before and during actual performance of the action (also known as Double Verification).
• Condition
• Any issue, event, occurrence, near miss, etc. that is appropriate to document, track, and trend.
• Conservative Decision-Making
• Reaching conclusions through a process of placing safety above production; the avoidance of activities that result in unnecessary or inappropriate risk-taking and the consequent decrease in safety margins.
• Corrective Action
• Activities undertaken to prevent / minimize the potential for undesirable conditions or events to occur/repeat.  Such activities typically involve problem identification, reporting, evaluation, correction, tracking, and trending.
• Corrective Action Program
• A defined process that administers and coordinates the activities involved with Corrective Action.
• Counseling
• Actions taken with the intent to influence the attitude or behaviors of an individual when such attitudes or behaviors are deemed to be below a minimum acceptable level of performance.
• Culture
• A system of commonly held values and beliefs amongst a group of people that influences the attitudes, choices, and behaviors of the members of the group.
• Defenses
• Measures, including expected behaviors, that protect against various hazards, or that mitigate the consequences of a hazard (see also Barrier).
• Defense in Depth
• The multiple functions and associated techniques (physical, administrative, and behavioral) built into a system or process that provides layers of protection against the consequences of mistakes.
• Error
• An occasion in which a planned sequence of mental or physical activities fails to achieve its intended outcome; a defined threshold where the unintended outcome of an action rises to some pre-determined level of consequence or potential consequence.
• Error-Likely Situation
• A work situation in which there is a heightened potential for error, caused by the presence of Traps, undesirable jobsite conditions, and/or process, programmatic, or organizational setups.
• Error Precursor
• A factor embedded in or influencing jobsite conditions that increases the chances of error during the performance of a specific task by a particular individual (see also Trap).
• Error Rate
• The number of Errors occurring over time, typically normalized to a number of hours worked.
• Event
• An undesirable change in the state of systems, components, or human / organizational conditions (health & safety, environmental, financial, etc.) that exceeds established significance criteria.
• Expectations
• Established descriptions or understandings of accepted safety performance, system / equipment outcomes, business orientation, methods and behaviors.
• Foresight
• The level of awareness and focus an individual puts forth to understand the nature and potential significance of actions about to be taken. (syn: Vigilance).
• Gap Analysis
• A process of comparing actual results or behaviors with expected results or behaviors for the purpose of discreetly identifying the specific differences (deltas) between the two.
• Human Factors
• Established descriptions or understandings of accepted safety performance, system / equipment outcomes, business orientation, methods and behaviors.
• Human Nature
• The innate characteristics and inclinations of being human; generic human capabilities / limitations that may incline individuals to err or succeed under certain conditions as they interact with their physical and social environments.
• Human Performance

• [Individual Sense] A series of behaviors executed to accomplish specific tasks. 

  [Organizational Sense] The sum of what organization members (leaders, managers, individuals) do and have done in the effort toward fulfilling organizational objectives; the aggregate system of processes, influences, behaviors, and their ultimate results that become (at some point) physically manifest.
• HU Factor^TM
• The combined skills, talents, commitment, and creative energies of the members of an organization that, when properly tapped and leveraged, rapidly elevates the performance of the organizations.
• Independent Verification
• The act of physically and separately checking the position or condition of a system or component following the completion of specific actions by another individual.  The verification is physically separate in time and thought from the actions of the first individual.
• Jobsite
• A specific work location at a specific point in time.
• Jobsite Conditions
• The conditions of a specific work location at a specific point in time that influence worker behaviors in the performance of the tasks at hand; factors embedded in the immediate work environment that influence the behavior of the individual during work.

• Knowledge & Skill
• The comprehension, understanding, awareness and abilities that an individual possesses relative to a particular job position or for a specific task.
• Lagging Indicator
• Discreet information regarding a specific measurable arena of past performance, as typically measured by events, observations, problem reports, and/or similar occurrences.
• Lapse
• An error that results from some failure in the storage (memory) phase of the action sequence, such that the action taken is not the original action directed or intended.
• Latent Error
• An error, act, omission, or decision that results in organizational weaknesses or system / equipment flaws that lies undetected until revealed either by human error, testing / operation, or some means of self-assessment
• Latent Organizational Weakness (LOW)
• Undetected deficiencies in organizational values, structures, programs, or processes that increase the potential for (provoke) error and/or degrade the integrity of defenses.
• Leader
• Any individual who takes personal responsibility for his or her actions and who positively influences the behaviors and actions of others.
• Leadership

• [1] The actions / modeling of a Leader that positively influence the values, actions, and behaviors of others.

  [2] The group of employees given the responsibility to create and promote the vision, values, and goals of the organization (senior management team).
• Management
• The group of employees given the responsibility for directing and monitoring the performance of the organization.
• Mental Model
• An individual’s structured organization of knowledge about how something works.
• Mission
• What an organization does.
• Mistake
• A deficiency or failure occurring in the planning phase of an action sequence involving either a wrong objective or inappropriate means to achieve the objective.
• Near Miss
• Any occurrence that could have resulted in undesirable consequences but did not.
• Organization
• A group of individuals (managers, supervisors and workers) with a shared Vision, a common purpose (Mission), and structures, policies, and procedures used to apply resources toward the achievement of common objectives.
• Organizational Effectiveness
• The ability of an organization to accomplish its goals safely and efficiently.
• Organizational Factors
• Management and leadership practices, values, culture, corporate structures, processes, technology, resources, and controls that combine to result in conditions that affect the behaviors of individuals at the jobsite.
• Peer Checking
• Objective monitoring by a qualified individual of another individual performing a task, or of a specific piece of work performed by another individual, for the purpose of ensuring error-free performance.
• Performance Improvement
• A systematic process of discovering and analyzing gaps in organizational performance, and implementing relevant interventions or corrective actions to eliminate the gap and promote higher levels of performance.
• Performance Indicator
• A measure of performance (after the fact) using quantitative parameters that provides insight on the condition or direction / momentum of key result areas.
• Positive Control
• A level of control maintained by an individual during the performance of a task such that what is intended to happen is exactly what does happen (and that is all that happens).
• Post-Job Review
• An evaluation of the performance of a specific job or task after the fact, used to identify and capture lessons learned (both positive and negative) such that the information can be used to enhance future performance of the same or similar jobs or tasks (also known as Post-job Critique).
• Pre-Job Brief

• A discussion of the people involved in a job/task before the job/task begins, used to promote understanding of the entire job (the ‘big picture’), precautions and limitations, task sequences, and participants’ roles and responsibilities.  The discussion includes not only clarification of desired task accomplishments, but also what to avoid (see also Task Preview). 

  An acronym commonly used to identify the key parts of a Pre-job Brief is “SAFE”, which stands for:

   

  • Summarize critical steps
  • Anticipate error-likely situations
  • Foresee consequences
  • Evaluate defenses
• Proactive
• A mode of conduct where anticipatory measures are identified and acted upon to prevent events or minimize the potential for errors to occur.
• Questioning Attitude
• An engaged state of mind that challenges given conditions in order to identify discrepancies in the status quo that might result in error or inappropriate action.
• Safety Culture
• The shared beliefs, attitudes, and assumptions amongst the members of an organization relative to production versus prevention.
• Self-Assessment
• Processes, either formal or informal, that compare present organizational practices and results with desired goals and expectations, thereby identifying organizational opportunities for improvement.
• Self-Checking

• An attention management technique used by an individual to promote focused engagement when performing a task to ensure that the right thing is done to the right thing; when manipulating components, verifies attention is focused on the correct component and prompts the individual to think about the intended action and its expected outcome before taking the action.  A common acronym used for the technique is:

• • Stop
  • Think
  • Act
  • Review

   

• Significance
• The severity of a particular error based upon either the actual or potential consequence of the error.
• Slip
• An error that results from some failure in the execution phase of the action sequence, such that the action taken is not the original action intended.
• Task Preview
• A structured thought process using information about a planned task and the assigned individual(s) to help anticipate critical steps, error-likely situations, potential consequences, flawed defenses, and associated contingencies before performance of the task is begun (see also Pre-job Brief).
• Trap

• A condition of the workplace that sets a person up to make a mistake.  Typical Traps fall into four basic categories, including Task Demands, Work Environment, Individual Capabilities, and Human Nature.  Experience has shown that there are a number of Traps that are somewhat universal, and tend to be present in some capacity in most work environments.  These include:

   

  • Time Pressure
  • Distraction/Interruption
  • Multiple Tasks
  • Overconfidence
  • Vague or Interpretive Guidance
  • Peer Pressure
  • Change from normal status
  • Physical Environment
  • Mental Stress
• Unsafe Atitudes
• Unhealthy beliefs and assumptions about workplace hazards that blind people to the precursors of human error or personal injury.
• Values
• The central core beliefs held in high esteem by the members of an organization, around which decisions are made and actions are taken.
• Violation
• Intentional circumvention of known rules, policies, procedures, etc.  Violations are rarely acts of sabotage, in that they generally arise from a genuine desire to get a job done according to management expectations.  In many cases, task constraints or improper scheduling may force an individual to ‘violate’ expectations to get the job done (a behavior which may be tacitly accepted by managers or supervisors).
• Vision
• A picture of why an organization exists; a picture of the fundamental aspects of an organization in the future that is both desirable and feasible.  Vision should form a guide for the day-to-day choices made by employees while encouraging initiative to make it happen.
• Work Practices
• The methods used by an individual while performing tasks.  Healthy / desirable Work Practices promote the correct, safe, and efficient completion of tasks while minimizing the potential for human error.

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