© 2015 Procedure Professionals Association Module 1: Human Performance for Procedures and Work Instructions Updated by Mike Brewer April 2018 (mxdxbx@yahoo.com) Information in Module 1 is taken from the following sources: INPO (Institute of Nuclear Power Operations) 06-003, Human Performance Reference Manual (alternative is DOE Standard, Human Performance Improvement Handbook Volume 1: Concepts and Principles) INPO 11-003, Guideline for Excellence in Procedure and Work Instruction Use and Adherence Human Error, James Reason Human Performance © 2015 Procedure Professionals Association All rights reserved. The material herein is NOT to be reproduced without the explicit and expressed written consent of the Procedure Professionals Association.

Introduction Safety message, welcome, and introductions The Writer Certification Program consists of: Module 1: Human Performance (this module) Modules 2A and 2B: Technical Writing Module 3: Introduction to the Procedure Process Classroom exercises Written exam The Writer Certification Program is based on three core principles. The Writer Certification Program is based on three core principles: Human performance permeates all aspects of technical writing, processing, and implementation. Procedures and work instructions are structured, human factored, and written in a manner that enables error free performance. Procedures and work instructions are safe, correct, and useable.

About Procedure Professionals Association History of Procedure Professionals Association (PPA) Who we are. What we do. Development of industry guidance: Why? PPA AP-907-001 (process) PPA AP-907-005 (writing) INPO 11-003 (use and adherence) Writer Certification Program Visit the Procedure Professionals Association at www.ppaweb.org .

Introduction - Why Human Performance? Documents must be both technically correct and human factored to prevent events. Why is human performance important? Human performance failures can cause events. Organizations that only focus on technically correct documents will continue to have events. Why is human performance important? Procedures and work instructions are the primary interface between humans and the asset. Experience has clearly shown that human factored procedures and work instructions can significantly reduce human error. This training is based on standards that have been proven to improve human performance and reduce error. Human performance failures can cause events. A technician operated the wrong switch due to an inconsistency between the procedure and the job-site labeling, resulting in an immediate unplanned equipment actuation. A writer included two valve manipulations in a single step. Later, a worker failed to perform the second action, leaving a critical sensor unknowingly out of service and inoperable. We will learn that multiple actions in a single step is an error trap. During a maintenance activity on an Lockheed L-1011, the worker failed to notice that the new oil sensors did not have O-rings. Later, all three aircraft engines failed at altitude due to oil loss. The pilots managed to restart one engine and successfully land the aircraft. Causes of this event included inaccurate assumptions for O-ring installation and a lack of critical detail for performing the required leak check (NTSB AAR-84-04).

Introduction - Human Performance Model The human performance model describes the organizational context of human performance as it applies to procedures and work instructions. The above graphic is used throughout this training to identify human performance issues. The successful implementation of procedures and work instructions involves much more than writers just doing their best. Understanding the organization and its culture can be the first step in resolving issues related to procedures and work instructions. Writers who were once workers in a line organization now find themselves in a support organization with a different culture and rules. Writers are knowledge workers whereas field (job site) workers spend most of their time in a skill and rule based environment. Organizational factors have the greatest impact on procedures and work instructions. Resources and priorities applied to document development, review, and approval Writer training and qualification Industry aligned standards for document writing, processing, and implementation Key stakeholder interactions (e.g., writers, reviewers, approvers, & users) Workforce training and experience Risk management strategies Management’s visible support of document quality and use and adherence Job-site conditions are factors regarding a worker about to perform a specific task. Procedure and work instruction quality Worker’s skills, knowledge, and qualifications Equipment labeling Human-machine interface Worker’s task preparation (e.g., task preview, pre-job brief, task walkdown) Worker behavior includes all actions or inactions by an individual at the job site. Use of human performance tools, including use and adherence General work practices, including component manipulation techniques

Module 1 Objectives 1.1 Describe the three performance modes and how they relate to procedures and work instructions. 1.2 Describe the key procedure and work instruction use tools for workers.

Human Performance 101 Human performance (HU): The system of processes, values, behaviors, and ultimately results that determine performance. HU applies to both physical and paper assets. HU principles: People are fallible. Error is predictable. Organization influences behavior. Behaviors are reinforced. Events are avoidable. Performance = behavior + results. It is not enough to just focus on results. The behaviors to achieve the results are important to achieve sustained high performance. Human performance happens when workers touch: Physical assets: Structures, systems, and components (e.g., pumps, valves, instruments, breakers, switches, wires) Paper assets: Design bases, specifications, drawings, calculations, procedures, and work instructions Principles of human performance: People are fallible: Even the best people make mistakes. Error is predictable: Error-likely situations are predictable, manageable, and preventable. Organization influences behavior: Individual behavior is influenced by the organization. Behaviors are reinforced: People achieve high levels of performance largely because of encouragement and reinforcement from leaders, peers, and subordinates. Events are avoidable: Events can be avoided through an understanding of the reasons mistakes occur and application of lessons learned from past events or errors.

Performance Modes and Error Types There are three human performance modes: Performance Mode Skill-based Rule-based Knowledge-based Skill-based performance mode: Definition: Highly practiced actions in a familiar situation Car example: How to start a car or use a clutch Skill-based errors (usually caused by distractions or failure of memory): Driver intended to select 87 octane gas but selected 93 instead (slip). Driver intended to get gas on way home, but he forgot to take the exit (lapse). Mechanic failed to install oil pan plug prior to adding oil to the engine (lapse). Rule-based performance mode: Definition: Selection of stored rules derived from one’s recognition of the situation Car example: Negotiating traffic (When traffic light turns yellow, brake to a stop. What can happen if the driver’s interpretation of the rule is to speed up?) Rule-based mistake: Hurried driver purposely entered intersection even though the light had just turned red. Knowledge-based performance mode: Definition: Response to an unfamiliar situation (e.g., problem solving, troubleshooting) Car example: Responding to a check engine light Knowledge-based mistake: The repair was inadequate due to a misunderstanding of how the electrical circuit worked.

Performance Mode Failures & Rates Failure Rate Skill based actions have a very low failure rate that can be minimized by: The proper use of human performance tools to ensure full attention is applied to the task. Memory enhancing devices such as checklists. Rule based actions have a higher failure rate that can be minimized by the use of well written rules that minimize the chance for misinterpretation. Knowledge based actions have a very high failure rate, which is why this performance mode should never be at the job site. Methods to minimize risk in this area include a thorough review process that challenges assumptions and looks for blind spots (e.g., troubleshooting plans).

Performance Mode Implementation When implementing procedures and work instructions, workers should be in either: Skill-based performance mode Rule-based performance mode Workers should NEVER be in knowledge-based performance mode while at the job site. PPA AP-907-005 (writer’s manual) is written to: Support both skill and rule based performance modes. Prevent knowledge-based performance mode for workers at the job site. Skill-based performance mode success: Level of detail is suitable for a newly qualified worker. Sufficient checks or verifications are included for key aspects of the task (anyone can forget or become distracted). Worker is qualified for the task. Worker uses all of their human performance tools to avoid error. Rule-based performance mode success: Worker makes correct decisions by following well written conditional steps (covered in Module 2B). If worker finds their self in knowledge-based mode (document lacks adequate detail, is unclear, is unsafe, or does NOT work), the worker safely stops job and contacts supervisor.

Use & Adherence Adherence: Understanding the document purpose, scope, and intent, and following its direction. Key use rules are discussed in the following slides: Level of use Sequence of steps Use of Not Applicable (NA) Signoffs and placekeeping INPO 11-003 provides guidance for the use and adherence of procedures and work instructions for the nuclear industry. It is important that writers understand the rules for using documents as they help determine how the documents are written. More on this in modules 2A and 2B.

Use & Adherence - Level of Use Level of Use: A classification based on potential impact and consequences that designates the minimum requirements for use during an activity Level of Use Default Continuous Technical Procedures Reference Work Instructions Information Administrative procedures Multiple NA Continuous Use: When: Consequences of improper action may be immediate or irreversible. Where: Copy is in direct or immediate possession, or be in direct contact with someone who has a copy in hand. How: Read and understand each step before performing it. Placekeep each step after completion and before proceeding to next step. Reference Use: When: Consequences of improper action are not immediate and are not irreversible. Where: Copy is at job site. How: Refer to document at least once and as often as required. At a minimum, review and placekeep document at the completion of the task. Information Use: When: Do NOT involve contact with plant equipment Are performed frequently No immediate consequences if performed improperly Are within worker’s knowledge and skills How: Review document as needed before performing task. Task may be performed from memory provided it is performed per the document. INPO 11-003 contains a flow chart to help determine the level of use.

Use & Adherence - Sequence of Steps Regardless of the level of use, perform numbered and lettered steps in the order written. Perform bulleted steps in any order but complete prior to the next numbered or lettered step. Documents may allow specific steps to be performed in any order, but do NOT provide blanket allowances. Subsections may be performed out of sequence if allowed by the document or program. INPO 11-003 allows a supervisor to approve (in writing) the performance of certain numbered/lettered steps out of sequence provided there is no change of intent and no effect on safety (other restrictions may apply). When implemented at a specific facility, this allowance should be the exception. Note that some facilities may not allow supervisors to approve the performance of steps out of sequence.

Use & Adherence – Use of Not Applicable Use NA to identify steps that will not be performed. Conditional steps may be marked NA without justification or supervisor approval. Contains conditional statement (IF…THEN) Provides specific conditions for being marked NA All other steps (non-conditional) may only be marked NA with supervisor permission. Do NOT use NA to bypass inadequately written steps. Regarding non-conditional steps: Supervisor may approve (in writing) the use of non-conditional NA if there is no change of intent and no effect on safety (other restrictions may apply per INPO 11-003 and the specific facility). Use of non-conditional NA should be the exception, not the normal practice.

Use & Adherence - Signoffs & Placekeeping Use placekeeping for: Numbered, lettered, and bulleted steps Notes, cautions, and warnings Placekeeping methods: Initials, signatures, checkboxes, circle/slash Options for placekeeping in repeated steps: Writer includes repeating step structure in document. Worker places sequential number starting at one next to step each time performed. Worker makes copies of pages with steps to be repeated. Steps may require verification signoffs. The structure for repeating steps is covered in Module 2B. Two types of verification signoffs (initials): Concurrent: A series of actions by two individuals working together at the same time and place to separately confirm the condition of a component before, during, and after an action. Used when the consequences of an incorrect action would lead to immediate and possibly irreversible harm to the asset or personnel. Independent: A series of actions by two individuals working independently to confirm the condition of a component after the original act that placed it in that condition. Used for configuration management.

Human Performance Focus – Modules 2 & 3 Module 2 (technical writing) HU focus: Write human factored procedures and work instructions. Recognize and fix potential error traps. Module 3 (process) HU focus: Writers use a questioning attitude and self-checking to avoid error. Writers confirm any potential error traps have been identified and fixed. Error traps are weaknesses in procedures and work instructions that can cause the user to fail.

End of Human Performance for Procedures and Work Instructions Review Module Objectives