Human Performance Considerations in Work Planning and Operations

Ray Karol

Pre-job Briefings, Walkdowns and Post-job Feedback at C-AD

Key Point of Course

1. Prepare workers for what is to be accomplished.

2. Sensitize workers for what is to be avoided.

To proactivelyprevent eventstriggered by human error

Events

Purpose of Course

Human Performance Fundamentals

Individuals Organization Leadership

Course Goals Work Planning and

Operations

Pre-job Briefings

Walkdowns

Post-job Feedback

Significant EventsFrom Study of Annual Nuclear

Industry Averages

2.38

1.66

0.85 0.880.77

0.460.28

0.08 0.04 0.03

0.30 0.300.21

0.1 0.07

0.0

0.5

1.0

1.5

2.0

2.5

3.0

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Sig

nifi

can

t Eve

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nit

Data Source: U.S. Nuclear Regulatory Commission

(Core Damage Potential)

Why a Human Performance Approach?

80% Human Performance

30% Individual

Weaknesses/Errors

20% Equipment Performance

70% Organizational Weaknesses/ Errors

Occurrences

Human Performance

Human Performance enables excellence and safety in mission accomplishment

3 out of 4 significant events due to human error

70 % caused by weaknesses in Organization

Why Human Performance?

Principles

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

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

(at R&D – avoid unrecoverable situations)

3. Individuals are influenced by organizational processes and values.

4. People achieve high levels of performance based on encouragement.

5. Events can be avoided by understanding the reasons mistakes occur.

Update DOE Directives & Training to Address Two Views of Human Error

The Old View of Human Error

Human error is the cause of accidents.

To explain failure, you must seek failure.

You must find people’s inaccurate assessments, wrong decisions, bad judgments.

The New View of Human Error

Human error is a symptom of trouble deeper inside a system.

To explain failure, do not try to find where people went wrong.

Instead, find how people’s assessments and actions made sense at the time, given the circumstances that surround them.

Human Error Rates

• Average of 5 per hour

• Very few have a negative impact

• Usually need more than one to cause an event

Myths about Human Performance

1. If there are no events, there is no Human Performance problem2. Training will solve Human Performance Problems3. Self-checking means good Human Performance4. Accountability is all that is needed5. Significance determines culpability6. Reward and reinforcement are the same7. Experience means error free performance8. Errors cause significant events9. Errors are bad

Two Kinds of Error

Active Error

Latent Error

Anatomyof an Event

Event

ErrorPrecursors

Vision, Beliefs, &

Values

LatentOrganizationalWeaknesses

Mission

Goals

Policies

Processes

Programs

FlawedDefenses(2 Green Lights)

InitiatingAction

Vision, Beliefs, &

Values

Common Traps of Human Nature

• People over-estimate their ability to maintain control.• Lack of appreciation of the limits of human capabilities.• You focus on goal rather than what should be avoided.• Pre-job briefings stress goals not avoidance.

Strategic Approach

1. Anticipate and prevent active error at the job site.

2. Identify and eliminate latent organizational weaknesses.

• Limited short-term memory• Personality conflicts

• Mental shortcuts (biases)• Lack of alternative indication

• Inaccurate risk perception (Pollyanna)• Unexpected equipment conditions

• Mindset (“tuned” to see)• Hidden system response

• Complacency / Overconfidence• Workarounds / OOS instruments

• Assumptions (inaccurate mental picture)• Confusing displays or controls

• Habit patterns• Changes / Departures from routine

• Stress (limits attention)• Distractions / Interruptions

Human NatureWork Environment

• Illness / Fatigue• Lack of or unclear standards

• “Hazardous” attitude for critical task• Unclear goals, roles, & responsibilities

• Indistinct problem-solving skills• Interpretation requirements

• Lack of proficiency / Inexperience• Irrecoverable acts

• Imprecise communication habits• Repetitive actions, monotonous

• New technique not used before• Simultaneous, multiple tasks

• Lack of knowledge (mental model)• High Workload (memory requirements)

• Unfamiliarity w/ task / First time• Time pressure (in a hurry)

Individual CapabilitiesTask Demands

Error Precursors short list

Task Demands Individual Capabilities

Work Environment Human Nature

Knowledge-Based

Patterns

Rule BasedIf - Then

Skill-BasedAuto

Performance Modes--Attending Problems

Familiarity (w/ task)Low High

High

Low

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Inattention

Misinterpretation

Inaccurate Mental Picture

Uncertai

n/

Unsure

Healthy Uneasiness/Wariness

Too Certain/

Too Sure

Questioning Attitude Meter

Organization

To facilitate the accomplishment of the missionmission in accordance within its norms, values, and strategies.

Safety

To consistently searchsearch for and eliminateeliminate conditions that provoke human error while reinforcing defenses.

The Organization MUST Satisfy Dual Purposes

Defenses

Source: Maurino (1995)

• Create awareness and understanding of the risks and hazards• Detect and warn of the presence of dangers• Protect people and the environment from injury and damage• Recover from off-normal conditions and restore to a safe state

• Contain the accidental release of harmful energy or substances

• Enable potential victims to escape out-of-control hazards

MANAGERIAL METHODS

TRAINING

WORK SCHEDULEWORK ORGANIZATION OR

SUPERVISORY METHODS

WRITTEN COMMUNICATIONS

CHANGEIMPLEMENTATION

VERBALCOMMUNICATIONS

DESIGN

WORK PRACTICES

ChallengesChallengesTo the PlantTo the Plant

ENVIRONMENTALFACTORS

EVENTS

Defense in Depth

Assume that mistakes will happen

Have in place barriers to catch and correct

Defense-in-Depth Operations

Degree of DependabilityR

elia

bili

ty o

f D

efen

se

Degree of Human Control

Low High

High

Self-checking

PPE (Personal Protective Equipment)

ACS Interlocks

AcceleratorShield Wall

Caution and LOTO Tags

Supervision

Engineered Safeguards (ODH fans)

Procedure Use

Document Reviews

Leadership

Events

Leader Defined

• Any individual who takes personal responsibility for their performance and the organization’s performance – A leader attempts to influence the improvement of organizational

processes and values

– A leaders influences others through relationships characterized by respect, honesty, and fairness

– When perceived as successful, they provide a positive peer pressure

Leadership Behaviors

1. Facilitate open communication

2. Promote teamwork

3. Reinforce desired behaviors

4. Eliminate organizational weaknesses

5. Value prevention of errors

6. Provides constructive feedback

Challenge to Communicate

Managers:

“Ask for what you need to hear, not for what you want to hear.”

Subordinates:

“Tell what they need to hear,not what you want to tell them.”

Roger BoisjolyFormer chief engineer for Morton-Thiokol, Inc.

Poor Communication

Good Communication

Desired Outcomes High-Reliability Organizations

Uneasiness & intolerance

Error-prevention tools

Communication

Structured mental framework

Pre-job Briefings

1. Prepare workers for what is to be accomplished.

2. Sensitize workers for what is to be avoided.

Healthy Uneasiness

• Have a keen sense of uneasiness toward any activity:– Managing, operating, repairing, engineering, procedure writing, reviewing

• A nagging doubt sees the current job situation as ‘hiding something’– Prompts you to expect success but anticipate failure– Fosters an intolerance for error traps

• Plant equipment and safety are vulnerable to the mistakes of workers– However, the ‘paper’ plant can impact safety as well– People are vulnerable to conditions at the worksite or error-likely situations

Maintaining Coordination and Control

• The desired results of a task are known in advance• Activity risks and hazards are known in advance• External conditions are known and controlled• The activity is coordinated with other work • Ensure no surprises!

Task Preview

• Give workers time to review task • Workers get familiar with what is to be done and avoided

S A F E RS A F E R

S – SUMMARIZE S – SUMMARIZE safety-critical steps of task

A – ANTICIPATEA – ANTICIPATE error-likely situations

F – FORESEE F – FORESEE consequences

E – EVALUATE E – EVALUATE defenses

R – REVIEWR – REVIEW operating experience

Summarize Critical Steps

• Not all steps are equally important

• Some steps are irrecoverable

• Identifying Critical Steps:– Safe execution depends solely on an individual worker– The outcome of the error is intolerable

• Limited short-term memory• Personality conflicts

• Mental shortcuts (biases)• Lack of alternative indication

• Inaccurate risk perception (Pollyanna)• Unexpected equipment conditions

• Mindset (“tuned” to see)• Hidden system response

• Complacency / Overconfidence• Workarounds / OOS instruments

• Assumptions (inaccurate mental picture)• Confusing displays or controls

• Habit patterns• Changes / Departures from routine

• Stress (limits attention)• Distractions / Interruptions

Human NatureWork Environment

• Illness / Fatigue• Lack of or unclear standards

• “Hazardous” attitude for critical task• Unclear goals, roles, & responsibilities

• Indistinct problem-solving skills• Interpretation requirements

• Lack of proficiency / Inexperience• Irrecoverable acts

• Imprecise communication habits• Repetitive actions, monotonous

• New technique not used before• Simultaneous, multiple tasks

• Lack of knowledge (mental model)• High Workload (memory requirements)

• Unfamiliarity w/ task / First time• Time pressure (in a hurry)

Individual CapabilitiesTask Demands

Anticipate Error-likely Situations

Task Demands Individual Capabilities

Work Environment Human Nature

Foresee Consequences

• What is the worst that can happen– To people? – To environment? – To equipment? – To schedule?

• Safety and prevention are more highly valued

• If consequences are intolerable, STOP

Evaluate Defenses

• Defenses should prevent, catch or recover from error• Think of contingencies before the job starts• Avoid “sliding” from skill based or rule based

situations to knowledge based situations – stop at that point to get others involved

Skill Based to Knowledge Based Situation

MANAGERIAL METHODS

TRAINING

WORK SCHEDULEWORK ORGANIZATION OR

SUPERVISORY METHODS

WRITTEN COMMUNICATIONS

CHANGEIMPLEMENTATION

VERBALCOMMUNICATIONS

DESIGN

WORK PRACTICES

ChallengesChallengesTo the PlantTo the Plant

ENVIRONMENTALFACTORS

EVENTS

Defense in Depth

Review Operating Experience

• Evaluate what has gone wrong in the past

• Dispel the attitude that nothing can go wrong

Pre-Job Briefings• Help workers understand the scope

– Big picture– Limits and precautions– Task sequences– Required PPE– What to avoid – Roles and responsibilities

• All participants must be present

Conducting the Pre-Job BriefingDialogueDialogue

• Must occur face-to-face with all participants

• Try to do at job site

• Usually by supervisor or work planner

• Ask “Are you prepared to do this job error-free?”

Conducting the Pre-Job BriefingAssumptionsAssumptions

• This is no time for professional courtesy• Be concerned with WHAT is right, not WHO is right

Conducting the Pre-Job BriefingChangesChanges

• If job has error traps, it can still proceed safely• Taking proper precautions can let it take place• Define clearly work stop criteria before task starts

Common Pre-job Briefing Shortcomings

• Generalities, rather than specifics, used

• No discussion of error traps

• Error-prevention techniques or other defenses not adapted

• Conducted as a monologue

• No planning for the conduct of the pre-job briefing

• No time allowed for workers to prepare

• Principal participants not present for briefing

• Supervisor conducts multiple pre-job briefings at the same time

• No consideration of when the original task becomes a “new” task

• A checklist of several hundred items used during a pre-job briefing

• Conducted in a distracting location

Why Do Pre-job Walkdowns?

• Opportunity to see the job firsthand and assess physical aspects of the job site– Interferences of equipment or other work done simultaneously– Verify adequate clearance boundary– Safety equipment needs– Lighting or temporary power– Contamination– Tools and parts needed

• Verify correct resources for job• Validate job scope• Chance to discuss previous problems encountered with this or similar work• Increases ownership of work quality and safety

When Do You Do Pre-job Walkdowns?

• Job could trip major equipment or stop program

• Job presents a moderate or high hazard

• Job is complex – many steps

• Job involves coordination of several groups

• Job is performed infrequently – once per year

• Workers not familiar with the work area

Some Common Feedback Questions• Were there any surprises? • Was the task accomplished with expected results?• Were procedures (or work packages) accurate? • Is this the way the job should be performed in the future?• What specific errors occurred during the task (for trending purposes only)? • What job-site conditions were associated with errors, flawed defenses, or near misses?• Was the supervisor aware of conditions (precursors) that could lead to human error?• Were planning and scheduling optimized to reduce the potential for human error?• Were job-site resources and information sufficient?• Was training for the job appropriate and effective?• Were work processes efficient and supportive?• Were any lessons learned from this job that should be recorded and passed on to others?• Did supervision provide needed support and appropriate guidance when necessary?

Management Expectations for Documentation for Medium and High

Hazard Jobs• Document the pre-job briefing, walkdown or post-job

review– Save work planning documents (e.g., work permit)

– Save references such as JRAs

– Keep a brief log showing agenda of discussions

– Keep a log of walkdowns

– Document that area was cleaned at end of job

– Post error pre-curser list in meeting rooms

– Post common feedback questions in meeting rooms

Determine if the Job is Classified as Skill of the Worker

• Default to Green Work Permit unless proven otherwise

• JTA or training completed for work to be performed

• Work Planner/Technical Supervisor knowledge of the worker’s skills and experience

• Use applicable JRA to determine hazards and risks• Use ‘boundaries’ defined in C-A-OPM 2.28

Management Expectations for Work Planning Logbooks

• Peter Cirnigliaro will cover separately

Management Expectations for Documentation for Low Hazard Jobs

(Skill of the Worker)• Perform the pre-job briefing, walkdown or post-job

review– Identify the job in the Work Planning Log

– Identify references such as JRAs

– Log that you did pre-job briefing, walkdown and post-job review

– Log that the area was cleaned up after the job is done

– Post error pre-curser list in meeting rooms

– Post common feedback questions in meeting rooms

The Lone Ranger and Tonto stopped in the desert for the night. After they got their tent all set up, both men fell sound asleep.

Some hours later, Tonto wakes the Lone Ranger and says, "Kemo Sabe, look towards sky, what you see?"

The Lone Ranger replies, "I see millions of stars."

"What that tell you?" asked Tonto.

The Lone Ranger ponders for a minute then says, "Astronomically speaking, it tells me there are millions of galaxies and potentiallymillions of planets. Astrologically, it tells me that Saturn is in Leo. Time wise, it appears to be approximately a quarter past three in the morning. Theologically, it's evident the Lord is all-powerful and we are small and insignificant. Meteorologically, it seems we will have a beautiful day tomorrow.

What's it tell you, Tonto?"

Tonto is silent for a moment, then says, "Kemo Sabe, you dumber than buffalo sh... Someone stole tent."

Communicate!!!

• Tell Building Manager of work

• Tell Experimenters of work in their area

• Let HP know if radiations condition can be affected

• Tell MCR/CAS about abnormal configurations

Exercise

Examples

• Review significant errors at C-AD and determine error precursors using “yellow cards”

The End