Facilitating Safe and Reliable Operations! MME-1

Managing Maintenance ErrorUsing Human Performance Improvement

Department of EnergyHuman Performance Center

Facilitating Safe and Reliable Operations! MME-2

Error = Unintended Deviation

• The plan is appropriate, but the actions themselves do not go as planned (active).

• The actions go as planned, but the plan is inadequate to achieve desired goals (latent).

Versus• Violations – actions intentionally deviate

from the specified method of working.

Facilitating Safe and Reliable Operations! MME-3

Why a Human Performance Approach?

30% Individual Mistakes

20% Equipment Failures

Human Errors

Events

70% due to Organization Weaknesses

80% Human Error

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Maintenance Error causesMajor Accidents

• Apollo 13 oxygen tank blow out (1970)• Three Mile Island loss of coolant (1979)• Chicago DC 10 crash at O’Hare (1979)• Bhopal India release of methyl isocyanate gas (1984)• Piper Alpha oil & gas platform explosion North Sea (1988)• Clapham Junction rail collision in England (1988)• Phillips 66 chemical explosion in Texas (1989)• Embraer 120 in-flight structural break in Texas (1991)• Loss of B-757 in Dominican Republic (1996)• DC9 oxygen generator fire over Florida (1996)• Southwest Air landing accident in Chicago (2005)?

Called the worst industrial accident in history

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42-65 % of Human Performance Problems occur in Maintenance

Data from surveys (3 US & 1 Japanese)

associated with nuclear power plant events

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Omission Management

• Omission errors account for >50% of human factors maintenance problems

• Omissions can create common mode failures that affect numerous downstream components

• Omissions can lie concealed and interact with local triggering events to cause an accident

Facilitating Safe and Reliable Operations! MME-7

Types of Omission errors- from aviation maintenance

• Fasteners left undone or incomplete 22%• Items left locked or pins not removed 13%• Caps loose or missing 11%• Items left loose or disconnected 10%• Items missing 10%• Tools or spare fasteners not removed 10%• Lack of lubrication 7%• Panels left off 3%• Other 14%

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The Good News is -Maintenance Error can be

managed!

• Most maintenance errors fall into systematic and recurring patterns

• Problems are more likely error-inducing situations

• Limited resources can be targeted to achieve maximum remedial effect

Facilitating Safe and Reliable Operations! MME-9

A Systems Approach

Organizational Factors – the system as a whole

Local Conditions – at the worksite

Task Factors – the job

The Worker

Events

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The Principles ofHuman Performance

Humans are fallible Error-likely situations are predictable Individual behavior is influenced by

organizational processes and values People achieve high levels of

performance by encouragement Events can be avoided

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What can you do?

Instead of trying to change the human condition – change the conditions under which people work

• Reduce the error-provoking nature of the task, the team, the workplace and the organization

• Strengthen and improve defenses to limit and contain the bad effects of those errors that will still occur

Facilitating Safe and Reliable Operations! MME-12

Supervision’s role

• Available tools/equipment• Reduce Interruptions and

distractions• Housekeeping and tool

control• Manage fatigue –Work

schedules• Manage boredom - by

task assignment• Appropriate rules-

procedures

• Reduces action slips• Reduces memory lapses

that cause omissions• Improves task completion

• Improves attention and memory

• Reduces complacency & overconfidence

• Reduces risky decision making

Facilitating Safe and Reliable Operations! MME-13

The HPI Vision:

Re + Md →→ ØE

Reducing error +

Managing defenses →→

leads to Zero Events(Occurrences/Accidents)

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Managing Maintenance Error Course Topics

1. Human Performance Problems in Maintenance2. The Human Risks3. Fundamentals of Human Behavior4. Varieties of Error5. System Failure & A Model of Organizational Accidents6. Error Provoking Factors & The Workers’ Toolbox7. Workplace Tools & Considerations8. Leader & Organizational Tools9. Safety Culture 10. Making It Happen

– Managing Error Management