SAFER Dialogue Brian Harkins

Principles of Human Performance 1. People are fallible, and even the best make mistakes. 2. Error-likely situations are predictable, manageable, and preventable. 3. Individual behavior is influenced by organizational processes and values. 4. People achieve high levels of performance based largely on the encouragement and reinforcement received from leaders, peers, and subordinates. 5. Events can be avoided by understanding the reasons mistakes occur and applying the lessons learned from past events.

Organizational Processes & Values PROACTIVE MENTAL FRAMEWORK SAFER Dialogue Product Results Organizational Processes & Values Anticipate Error Traps Evaluate Defenses Summarize Critical Steps Post-Job Briefing PLAN PREPARE PERFORM SAFER STAR Worker Behavior W I T H LEARN MGT System Feedback Job-Site Conditions Review Experience PURSUE EXCELLENCE Stop Think Act Rigor Readiness Check Communicate Look Critically, Engage to Improve, Avoid Recurrence, Report Honestly, and Nurture Learning in Others Task Demands Work Environment Human Nature Individual Capabilities Foresee Potential Consequences Pre-job Briefing A Dialogue Task Preview Before & During Pre-job Briefing

SAFER Dialogue Summarize Critical Steps Task Anticipate Error Pre-job Preview Before & During Pre-job Anticipate Error Traps Pre-job Briefing A Dialogue Foresee Potential Consequences Evaluate Defenses Review Experience

Summarize Critical Steps Not all steps of a procedure are equally important. Critical steps include: Actions aimed at changing the state of facility structures, systems, or components Steps that are irrecoverable or actions that cannot be reversed Steps where the outcome of an error is intolerable for personnel or facility safety.

Anticipate Error Traps Review the job-site conditions using the error precursors list. Some error precursors are particularly powerful, depending on the performance mode of the individual performing the action. For instance; Distractions, simultaneous tasks, and fatigue strongly influence skill-based performance Mindset and confusing procedures influence rule-based performance Assumptions, first-time performance of the task, lack of knowledge, and inexperience influence knowledge-based performance

Foresee Potential Consequences If a mistake does occur at a critical step, what is the worst that can happen? What is likely to occur? Consider the production goals that would not be achieved. However, safety and prevention are more important than schedule. If the potential outcomes of an error are judged as too severe, the task should not proceed as presently planned.

Evaluate Defenses Review necessary defenses in light of potential errors. Determine contingencies for potential consequences of error. Evaluate if additional defenses. Evaluate recovery methods should undesirable errors or consequences occur.

Review Experience What errors have occurred with this activity in the past? How have people made mistakes with this task in the past? Choose operating experience that focuses on the critical steps of the task at hand. Look at both other similar activities and similar critical steps.

Review of Dive Activities

Review of Dive Activities Observed practice dive Attended walk down of KE Basin work area Interviewed personnel associated with the activity (Divers, Planner, Radcon, NCO, IH&S). Reviewed work instructions and dive company safety manual. Reviewed Lessons Learned from INPO, DOE, OSHA, and K Basins. Reviewed U.S. Navy Dive manual.

SAFER Dialogue with Industrial Health & Safety Summarize Critical Steps Performing the dive suit leak test Prevention of Diver heat stress Back up air supplies Un-suiting process Emergency use of the SCBA bottle by the diver Primary breathing air supply Unanalyzed work scope change Personnel fall in Basin water.

SAFER Dialogue with Industrial Health & Safety Emergency use of the SCBA bottle by the diver Anticipate Error Traps (error precursors list) Task Demands Work Environment Unexpected equipment conditions Individual Capabilities Natural Tendencies/ Human Nature Complacency Other Equipment donned in the wrong order Umbilical snagged/ damaged Diver not able to reach bottle valve Diver not able to get himself to ladder

SAFER Dialogue with Industrial Health & Safety Emergency use of the SCBA bottle by the diver Foresee Potential Consequences Worst Case: Death due drowning Expected Consequences: Work stoppage

SAFER Dialogue with Industrial Health & Safety Emergency use of the SCBA bottle by the diver Evaluate Defenses

SAFER Dialogue with Industrial Health & Safety Emergency use of the SCBA bottle by the diver Review Experience INPO Report (OE9455) dated 11-30-1998, related the experience of a loss of breathing air due to breaking off of the air fitting on his dive helmet by backing in to an object. Significance is that all of the diver’s air came through that one fitting and he experienced a total loss of air. The diver was unable to reach the dive platform before passing out. He was rescued by a second diver working in the water with him but was not breathing and his face was pale and blue in color when he removed from the water. He was revived by dive team personnel. Discussion of process and associated problems with rescue, treatment, and transport of diver are also worth reviewing. Also noted was the divers inability to drop his weight belt and surface due issues with suit up.

Performance Mode Impacts on critical step: SAFER Dialogue with Industrial Health & Safety Emergency use of the SCBA bottle by the diver Performance Mode Impacts on critical step: Knowledge base performance mode Strongly influenced by assumptions, first-time performance of the task, lack of knowledge, and inexperience Divers need to practice emergency use of the SCBA bottle and exiting pool Equipment needs to be donned in the correct sequence

SAFER Dialogue with Industrial Health & Safety Emergency use of the SCBA bottle by the diver Areas for improvement: To provide more assurance that diver will be able to act as expected, Management should consider having the diver’s practice disconnection from umbilical hose and return to the surface using SCBA bottle. Project should add a step to diver dressing check list to have the diver check to ensure that he can reach the SCBA bottle valve.

Review Results Review identified 28 Areas for Improvement. Review identified 24 Lessons Learned that the project should review against specific project activities.

Conclusion The SAFER Dialogue is a good pre-job or pre-task tool Its value is: Craft personnel readily accept and embrace the process Uses personnel associated with the area (who know how things are really done) to do the review Good low level review of the current condition of barriers Helps personnel review their response to events