Unlocking Ways To Get “Between the Ears”

Of The Operator

Robert D. Coovert

Exelon Human Performance Manager

The Goal Is Organizational Impact

“We know that training, CRM for example, does influenceoperational behavior…” (Helmreich & Foushee, 1993).

Highly Reliable Organization (HRO)

Develops common organization practices – “Standard operational procedures contribute to reliability if the outside

environment is stable, that is, if the decisions required of operators fall within a predictable set of contingencies. However, as seen on a daily basis this is clearly not the case. Operators must deal with unexpected and unique situations in a very rapid fashion”

“Anticipates the changing potential for failure, regardless of past success, because they appreciate that their knowledge is

imperfect and that their environment continues to change”

Creates safety by anticipating and planning for unexpected events

Simple Rules for Changing Behavior

Training

Reinforcement

Accountability

Simple Rules For How Adults Learn

Adults learn by doing• Experiential learning

Adults learn if it is personally important to them

KEY LEARNING:

It comes down to Associations

Experiential Learning

Adults behavior has been shaped by their experience, if you want to change behavior, you must provide new "experiences”

Studies indicate that most adults learn through "hands on" experiences

Performance Exercises are Experiential

Simple exercises designed to provide initial understanding of a new behavior

– Checking practices– Communications 1SI8801A

– Verification practices

Performance Exercises

Focus on observable behaviors

The following Self-Check (STAR) actions are expected to be observable:

StopPoint at or touch the equipment.Read the identification tag.Compare to the controlling document.Hesitate for a second or two, followed by:Manipulate the equipment.Verify actual system response.

Performance ExercisesProficiency Exercise

Self Checking

The intent of this proficiency exercise to demonstrate required knowledge andskill of self checking while performing a task.

A fundamental skill, which cannot be compromised, is component identification.Distractions, time pressure, multiple tasks, stress, and assuming you’re on theright train or unit can create an error likely situation. Using STAR correctly canensure the correct component is identified. Per HU-AA-101, Self-Check (STAR),SHALL be used for component identification and equipment manipulation.

The following Self-Check (STAR) actions are expected to be observable:

Stop.

Point at or touch the equipment.

Read the identification tag.

Compare to the controlling document.

Hesitate for a second or two, followed by:

Manipulate the equipment.Verify actual system response.

Instructions:1. Use a labeled component consistent with attachment 1, 2, or 3, (EXELON-

PE-SC-01, EXELON-PE-SC-02, EXELON-PE-SC-03) for this exercise.2. Call the individual to be evaluated into the area with the component.3. Using the associated procedure, (EXELON-PE-SC-01, EXELON-PE-SC-02,

EXELON-PE-SC-03), have the individual perform the action.4. Performing the action should include the following:

Reading the procedure Stop. Point at or touch the equipment. Read the identification tag. Compare to the controlling document. Hesitate for a second or two, followed by: Manipulate the equipment. Verify actual system response.

STAR PE

Peer Check PE

Simple Examples are Experiential

Poke Yoke

Markers

How can I convince a supervisor which jobs are the best observe?

Vulnerability of Removal or Installation

The requirement is to remove the nuts and then replace them in some predetermined order.

A B C D E F G I

How can I educate a crew on knowledge based errors?

GEMS

Generic Error Modeling System

90 feet

60 feet

30 feet

How can I educate a crew on the key to communications?

Communications

What are your communication standards?

What communication tools do you use?– Written– Verbal

• Three way communications• OPEN A VALVE

KEY LEARNING:

Create Understanding

Communication Assumptions

Airforce (P)Problems identified by pilots and

(S)Solutions determined by the maintenance crews

(p) Left tire almost needs replaced

(s) Almost replaced left tire

(p) Test flight OK except autoland very rough

(s) Autoland not installed on this aircraft

Communication Assumptions

Communication Assumptions

(p) Something loose in cockpit

(s) Tightened something in cockpit

(p) Evidence of leak on right main landing gear

(s) Evidence removed

Communication Assumptions

(p) Dead bugs on windshield

(s) Live bugs on order

(p) IFF inoperable

(s) IFF always inoperable in OFF mode

(p) Friction locks cause throttle levers to stick

(s) That’s what they’re there for

Communication Assumptions

(p) Number 3 engine missing

(s) Engine found on right wing after brief search

(p) Aircraft handles funny

(s) Aircraft warned to straighten up, “fly right” and be serious

How can I educate a crew on the dangers of overconfidence?

OVERCONFIDENCE

“The danger of overconfidenceis a tendency to become sloppy and careless. Workers and supervisors begin to take chances. Such an attitude is the perfect medium in which to grow an accident.”

H. C. Howlett II

What was going through your head prior to, during, and after the accident?

How can I educate engineers on the potential latent conditions in the new digital feed-water control system?

Air Bus A320

“Hazardous and complex systems are created with built-in errors waiting to be triggered.” James Reason

Air Bus A320

Dynamic Learning Activities (DLA)

Exercises created with multiple activities that are designed to teach and reinforce desired behaviors for an individual

Work Environment Simulators Simulators that are created that can support

multiple activities that are designed to teach and reinforce desired behaviors for an individual or group of individuals

Shop setups Hogan’s alley / Murphy's alley

Video Control room simulators

The plant

Shop Talk

Shop Experience

The Good

It works

All levels of workers can benefit

Training / reinforcement

It’s not the same old thing in the classroom

The Bad Return on investment

Competent instructors

Management support

Cost

Competition for availability

The Ugly

There is no consistent means to evaluate individual and team performance.

There is an absence of reliable data on events.

Training is lagging behind in organizations / departments that create latent conditions.

Aspects of increased automation are not being addressed yet are identified in a number of events.

Lessons Learned from the FAA

There is great variability in the impact of programs and performance even after training. Incomplete acceptance of concepts and practices by instructors and evaluators is a major source.

In the absence of continuing reinforcement, behavior and attitudes regress almost to pre-training levels. Human Performance programs between departments and stations show great variability in execution and impact.

“Training is not likely to leave the confines of the school house if the culture is not congruent with what is being taught.”

Questions