WELCOME to

Human Performance Tool Training Presented by:

Paul Merritt Principal Engineer

EHS & Continuous Improvement

To Minimize the Frequency and Severity of Events

Events

Purpose of HuP

What Is Human Performance (HuP)

 Birth In The Aviation Field  Used At Nuclear Utilities For Several Years With

Significant Impact Institute of Nuclear Power Operators (INPO)

 The Initiative Has Safety, Quality, & Equipment Impacts

 All Westinghouse Fuel Sites Have Implemented

Human Performance

Quality of Execution

Ease of Doing Business

Lean Enterprise Six Sigma Human Performance

Behavioral Differentiation

HuP Core Module/ Precision Leadership

SMP Human Performance Plan

Precision Leadership

HuP Fundamentals

HuP Observations

SMP HuP Excellence

HuP Learning Lab

Event Investigations

Observations

HuP Tool R

oll-Out

Com

munications

Benchm

arking

Event Clocks

Adjust Grow Learn

Hazard R

ecognition

Slide No: 7

The Fundamentals Our SMP Process Owners

Lisa Fox Organization

Paul Merritt & Laurie Kubala Continuous Improvement

Brian Jones Coaching and tool use to prevent events

Brian Jones Enhancing the ability of our people

Jim Cook Operations Focus

Mike Morris Maintenance and outage planning

Jeff Cerny

Maintaining, improving, monitoring and evaluating equipment performance and condition

SMP Human Performance

The Journey Continues

Food for Thought…

Human Performance

….our industry is, and forever will be, one major accident away from being permanently shut down!

Jim Rhodes former CEO INPO

Principles of Human Performance Management  Humans are fallible . . .  Error is predictable. . .  Organization influences behavior.  Behaviors are reinforced.  Events are avoidable.

Source: INPO, Excellence in Human Performance. 1997.

Event: any undesired occurrence that has an adverse effect on safety, quality, or production.

What is an Event?

Event

What is the difference between an Error and an Event?

To Minimize the Frequency and Severity of Events

Events

Purpose of HuP

New Paradigm

Re + Md → ØE

Limited short-term memory Personality conflicts Mental shortcuts (biases) Lack of alternative indications Inaccurate risk perception (Pollyanna) Unexpected equipment conditions Mindset (“tuned” to see) Hidden system response Complacency / Overconfidence Workarounds Assumptions (inaccurate mental picture) Confusing displays or controls Habit patterns Changes / Departures from routine Stress (limits attention) Distractions / Interruptions

Human Nature Work Environment Illness / Fatigue Lack of or unclear standards “Unsafe” 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 Capabilities Task Demands

Error Precursors short list

MANAGERIAL METHODS

TRAINING

WORK SCHEDULE WORK ORGANIZATION OR

SUPERVISORY METHODS

WRITTEN COMMUNICATIONS

CHANGE IMPLEMENTATION

VERBAL COMMUNICATIONS

DESIGN

WORK PRACTICES

ENVIRONMENTAL FACTORS

EVENTS

Defense -in-

Depth

Site Event Flags Vs. Area Learning Clocks

Site Event Flags Area Learning Clocks •  Notification that an event has occurred at the site with significant consequences

•  Trip Criteria is defined by site management

•  Goal is Zero Events

•  Forces Reactive Mode

•  Notification that an event has occurred in an area with significant consequences, or low to no consequences

•  Clock trips = learning opportunities that allow us to apply defenses to prevent recurrence. Some level of trips is desired.

•  Proactive mode

•  Reducing errors will drive toward elimination site events

Area Learning Clocks  Implement area-specific criteria

  Minimum criteria is expected (e.g., near-hit)

  As a team, develop meaningful criteria specific to your area

  Lower level than events   Learn and adjust to lower severity

issues in order to avoid high level events.

INPO Toolbox- Individuals Seven tools selected -

SMP  Peer Checking  Procedure Use and

Adherence  Pre & Post Job Briefs  Personal Safety

Assessment (2 Min Rule)  Questioning Attitude  Self Checking (STAR)  Time-Out

4PQST

Pre Job Brief

Pre-job Brief

 Heightens awareness before a task  Summarize critical steps  Anticipate error traps- precursors  Foresee consequences  Evaluate defenses  Review operating experience  OFTEN CONSIDERED THE MOST

POWERFUL HuP TOOL!

…Pre Job Brief

  What   A planned interactive discussion that

occurs just prior to the task and involves ALL personnel related to the specific task

…Pre Job Brief

  When   When performers determine a PJB is

beneficial   When required by procedure

…Pre Job Brief

  How   Have we done this job before ?   What are the critical steps ?   What mistakes might be made?   What’s the worst thing that could

happen ?   What kind of defenses should be

used?

…Pre Job Brief

…Pre Job Brief   At Risk Practices

  Failure to consider SCOPE   Discussing generalities   Failure to plan for PJB   Failure to hold PJB in an area

conducive to holding proper meetings   Failure to incorporate lessons learned

from previous Post Job Briefs   Failure to identify contingency actions

or back out plan if the worst thing does happen

  Failure to identify a lead for the job

Post Job Brief

 Don’t perform only if something has gone wrong

 Should be Quick but effective review  Validates the process used for the job or task  Opportunity to refine the process  Opportunity for supervisor to reinforce

appropriate behaviors

Findings of the post job brief are detailed below;

What Went Well? What Went Wrong? What Should be Done Differently? • Equipment drawings and parts lists were immediately available. • No Injuries • Asset is currently operational. • On time in full delivery. • Craftspeople and engineers dedication to completing the project was outstanding. • Turnover from third shift was outstanding. • Mechanical job scope was increased because the upgrade was going so well.

• Pipefitter support was scarce. • Maintenance supervision needed to be more visible. • Craftspeople pulled randomly with no coordination with project team. • Area cleanup prior to job start and after job completion was not thorough. • A dedicated millwright crew could not be assigned due to other conflicting plant needs. • Air and electrical service to power tools was scarce and inconvenient. • The lack of an overall job lead led to a lack of communication and coordination. • Crafts thrown at job with no coordination between crafts or specific plan only an idea of what needed done. • Movement of parts being repaired and painted was not followed well.

• Establish and enforce a plan for pulling dedicated project workers.. • Coordinate work between crafts so crafts don’t get in each others way. • Identify outstanding problems and PM’s and complete everything at once and go in with awareness of all known problems. • Make sure outside vendor has a plan prior to startup to eliminate wasted time figuring out what they need to do.. • Establish a Project Lead for each repair. • Define the interface between Equipment Engineers and the Maintenance Department. • Create standard work practices. • Include dock in pre job brief in future to let them know the importance of receiving UPS red items expeditiously.

CPM 19 Electrical and Mechanical Upgrade

Save to O Drive!!!!!!

Human Performance / Post Job Brief

Questions To Ask In A Post Job Brief

  Was the task accomplished with the expected results?   Were the Procedures accurate? Is this the way the job

should be performed in the future?   What errors occurred during the task / job?   Was the Supervisor made aware of conditions that, if

uncorrected, could lead to human error the next time the task / job is performed?

  Were there any lessons learned from this job that should be recorded, retained, or immediately passed on to others?

  Where will we retain this information for future use?

SMP Human Performance Tools Pre- / Post-Job Briefs & Time Out - Review

  Pre-Job Brief 1.  Have we done this job before? 2.  What are the critical steps? 3.  What mistakes might be

made? 4.  What is the worst thing that

could happen? 5.  What defenses should be

used?

  It is a thought process!   These 5 questions should

always be asked!

 Post-Job Brief   Was the task accomplished

with expected results?   Were the procedures

accurate?   What errors occurred?   Lessons learned?

 Time Out   Stop   Get help   Never proceed if uncertain

Time Out !!!!!!!!!!!

Time Out Tool

 When the situation / task / environment is not safe or clear ----- TIME OUT

…Time Out

  What   A brief stoppage of the task

…Time Out

  When   Has a lot to do with Questioning

Attitude   Warning Flags   Something different than

expected

…Time Out

  How   STOP   Inform Supervisor   Never proceed if you are

uncertain

…Time Out

  At Risk Practices   Not asking for help   Management not reinforcing properly

the behavior - You did good “BUT”

…Time Out – Wooden Spoon

Time Out……

Severity Pyramid

600

1

30 10 Significant

events

Major Accident

Nonconsequential Errors

Near Misses

Source: Frank Bird, Jr., Practical Loss Control Leadership, Det Norske Veritas (formerly International Loss Control Institute), 1969.

…HuP Strategic Approach

Re + Md → Ø Re + Md →ØE

Top 10 Error Traps 1. Stress 2. High Work Load 3. Time Pressure 4. Distractions 5. Vague or Poor Work Guidance 6. Poor Communications 7. Overconfidence 8. Infrequent or First Time Task 9. First Working Day After Time Off >4 Days 10. The End of a Shift or Week

…Personal Safety Assessment (two minute rule)

PSA

…Personal Safety Assessment (two minute rule)

 What  A personal safety assessment

involves deliberate, focused review for potential safety concerns prior to starting a job. Taking two minutes to make this assessment improves your chance of accomplishing the task without an event.

…Personal Safety Assessment (two minute rule)

 When  We need to include with EVERY task

 Immediately following a Pre-Job Brief, just prior to starting work.

…Personal Safety Assessment (two minute rule)

 How  Look up and down and all around

 Ask yourself:  What are the hazards?  How can I get hurt?  What is different?

 Take action to understand / mitigate any hazards

 Call a Time Out if appropriate

…Personal Safety Assessment (two minute rule)

 At Risk Practices

 Making assumptions  Not asking for help  Ignoring warning flags (error precursors)

Personal Safety Assessment

Self-Check STAR (Stop, Think, Act, Review)

STAR

S

T A R

• STAR is an effective Error Prevention Tool that helps us briefly “refocus” on the task when we are doing routine activities

• We don’t need to STAR everything we do

What is it?

When do I use Self Check?

• When performing critical steps where an error could cause bad things to happen. (Refer to page 27 of the HuP Handbook for discussion of Critical Step)

• When performing tasks where inattention or complacency can allow the performer to make an error that can result in an event

• If interruptions occur while performing a task

STAR

STAR

STAR

S top

T A R

STOP! Pause and clear your mind of distractions. Slow your mind down so you can stay focused on the task you are about to perform.

STAR

S top T hink A R

THINK: • Focus your attention on the step to be performed.

• Verify your intended action is appropriate for the equipment/system status. Point to or touch the equipment, system, or component. VERBALIZE!

• Anticipate the expected result of your intended action and how you will know the desired outcome is achieved.

• Consider what actions you will take should an unexpected result occur (contingency plan).

• If uncertain, use a Questioning Attitude and / or Time Out before proceeding with the task.

STAR

S top T hink A ct

R

ACT: • Without losing eye contact, touch the component, label, etc., with checklist , procedure step or drawing.

• Without losing physical contact established earlier, perform the action.

S top T hink A ct

R eview

REVIEW: • Verify you get the intended results.

• If not, exercise contingency actions.

STAR

Avoid these at-risk practices

• Continuing with the action when questions or discrepancies occur

• Failing to eliminate distractions, such as continuing to talk on the telephone or converse with another person during a manipulation or critical action

• Trying to perform more than one action at a time

• Not calling a Time Out when it is needed

STAR

Where Have you used STAR????

…Self-Checking (STAR)

…Questioning Attitude

…Questioning Attitude

…Questioning Attitude

…Questioning Attitude

 What  A questioning attitude creates awareness of uncertainty, hazards and significance of action before proceeding. (RISK)

…Questioning Attitude

 When  When conditions change  When procedures cannot be followed as written  ALL OF THE TIME

…Questioning Attitude

 How  Consider What Ifs  Be open and receptive  If question not resolved call time out

…Questioning Attitude

 At Risk Practices  Making assumptions  Thinking the task is routine  Believe nothing bad can happen

Questioning Attitude….???

…Peer Checking

…Peer Checking

  What   Peer Checking is an error prevention

tool involving a verbal agreement between two individuals PRIOR TO a specific action or task to prevent an error.

…Peer Checking

  When   When required by procedure   When there is a history or unfavorable

operating experience   When you’re not sure

…Peer Checking

  How   Peer Check is = TWO STARS

…Peer Checking

  At Risk Practices   One person being led by another

without separation of thought   Too Proud   Too Shy   Too Sure

…Procedure Use and Adherence

…Procedure Use and Adherence Dupont Video

…Procedure Use and Adherence

  What   Following the intent and direction

provided in the procedures

…Procedure Use and Adherence

  When   Procedures must be used for all

physical work and activities that involve manipulation, monitoring or analysis of plant equipment and processes.

  How   Review procedures frequently to stay

familiar with the details   If desired results are not achieved,

STOP – and contact your supervisor

…Procedure Use and Adherence

  At Risk Practices   Not rigorously following procedures   Using an out of date procedure   Performing task without considering

critical steps

…Procedure Use and Adherence

The Power Of One!!