BASIC PROFESSIONAL TRAINING COURSE Module XXII Human performance Case Studies Version 1.0, May 2015 This material was prepared by the IAEA and co-funded by the European Union. 

CASE STUDIES PREPARATION Class should be divided in smaller groups of 4 – 5 students. Each group is given an IRS Report and asked to apply an appropriate coding and explain the reasoning behind such decision. IRS reports containing human error or management deficiencies should be selected for this exercise by the lecturer. In case IRS reports are not available for the course, case studies from Module XXI can be used. In the early days of the nuclear industry development emphasis was placed on design, hardware reliability and quality assurance and quality control (QA/QC) with only intuitive interest in human factors. Human factors and ergonomics were an afterthought and only after the Three Mile Island (TMI) accident an increased importance was placed on human reliability. Accidents in complex industrial facilities (non-nuclear) like, Challenger, Bhopal or Exxon Valdes pointed out the importance of organizational and management factors and their influence on safety. The scope of what is meant by human performance includes organisational systems and is considerably broader than traditional views of human factors/ergonomics. Human performance should be included within a safety management system and should be managed and continually improved.

IRS CODING IRS Coding has 9 entries: Reporting categories; Plant status prior to the event; Failed/affected systems; Failed/affected components; Cause of the event; Effects on operation; Characteristics of the event/issue; Nature of failure or error; Recovery actions. Participants need to focus only on the entry 5 Cause of the event.

IRS CODING – cont. Cause of the event has the following subcategories: 5.1 Direct cause; ……….. 5.5 Human performance related causal factors and root causes; 5.6 Management related causal factors and root causes; ………… Students should use only subcategories 5.5 and 5.6 for this exercise.

IRS CODING – subcategory 5.5 5.5 Human performance related causal factors and root causes: 5.5.1 Verbal communication; 5.5.2 Personnel work practices; 5.5.2.0 Others (specified in text of the report); 5.5.2.1 Control of task/independent verification; 5.5.2.2 Complacency/lack of motivation/inappropriate habits; 5.5.2.3 Use of improper tools and equipment; 5.5.2.4 Self-check practices (e.g. STAR - Stop, Think, Act, Review) 5.5.2.5 Questioning attitude, dealing with uncertainty (e.g. assumption of competence of more experienced personnel). 5.5.3 Personnel work scheduling (including workload, work time provided); 5.5.4 Environmental conditions;

IRS CODING – subcategory 5.5 – cont. 5.5.5 Man-machine interface; 5.5.5.1 Alarm control & maintenance practices; 5.5.5.2 Equipment/controls labeling. 5.5.6 Training/qualification; 5.5.7 Written procedures and documents; 5.5.7.1 Procedure availability; 5.5.7.2 Procedure completeness/accuracy; 5.5.7.3 Procedure compliance. 5.5.8 Supervisory methods; 5.5.9 Work organization; 5.5.9.0 Others (specified in text of the report); 5.5.9.1 Shift/team size or composition; 5.5.9.2 planning/preparation of work.

IRS CODING – subcategory 5.5 – cont. 5.5.10 Personal factors; 5.5.10.0 Others; 5.5.10.1 Fitness for work (e.g. fatigue….); 5.5.10.2 Stress/perceived lack of time/boredom (including imposition of parallel and/or unexpected tasks); 5.5.10.3 Skill of the craft less than adequate/not familiar with job performance standards (including task difficulty). 5.5.11 Use of operating experience.

IRS CODING – subcategory 5.6 5.6 Management related causal factors and root causes: 5.6.0 Other (specified in text of the report); 5.6.1 Management direction; 5.6.1.1 Existence of policies, standards, expectations; 5.6 1.2 Communication/Enforcement of policies, standards, expectations; 5.6.1.3 Production pressure/perceived pressure; 5.6.1.4 Clarity of responsibility. 5.6.2 Communication or coordination; 5.6.3 Management involvement, monitoring and assessment; 5.6.4 Decision process; 5.6.5 Allocation of resources (e.g. planning and prioritization relative to safety…);

IRS CODING – subcategory 5.6 – cont. 5.6.6 Change management; 5.6.7 Safety culture; 5.6.8 Management of contingencies (e.g. alternate plans of action); 5.6.9 Management of contracted work (e.g. qualification, training, supervision and guidance…); 5.6.10 Management of staff training and qualification; 5.6.11 Knowledge management.

CASE STUDIES EVALUATION Each group should be given 2 – 3 hours to: Complete the coding; Prepare explanation/justification; Prepare a power point presentation for the plenary session. Students should focus their investigation on addressing: Active errors; Latent weakness; Individual or group behavior; Any other human performance issues. In their summary students should identify an action plan for improving human and organizational performance addressing the actual root causes.

CASE STUDIES EVALUATION –cont. Each group should present their findings in a final plenary that can last 1 – 2 hours depending on the time available – discussion in the plenary by all participants. Lecturer should make comments and suggestions to each working group presentation. The views expressed in this document do not necessarily reflect the views of the European Commission.