Optimized Human Error Evaluation 3/27/2017 16th Annual HPRCT Conference June 21-24 · Sheraton Inner Harbor Hotel Baltimore, MD Hosted by Constellation Energy Optimized Human Error Evaluation June 22nd, 2010 Presenter: Terry J. Herrmann, P.E. Associate, Structural Integrity Associates therrmann@structint.com P91 / T91 Workshop

Your Presenter Terry J. Herrmann, P.E. BS Mechanical Engineering & MS Engineering Management from Syracuse University Over 30 years experience in power generation in the areas of design, construction, testing, failure / root cause analysis, equipment reliability, and probabilistic risk assessment. Developed and implemented programs in root cause analysis, system engineering, and risk-based applications. Recipient of 2002 Kepner-Tregoe® International Rational Process Achievement Award. IEEE Subcommittee on Human Factors, Control Facilities and Human Reliability – Recommended Practice for Investigation of Events at Nuclear Power Plants. Contributor to EPRI Report 1016907, Preservation of Failed Parts to Facilitate Failure Analysis of Nuclear Power Plant Components

Optimized Human Error Evaluation Participant Input for this Presentation: Provide one brief example where you struggled to perform a human error evaluation. Provide one brief example of a success. Name one or two key “take-aways” you are most interested in getting from this presentation. Write down what people are most interested in where everyone can see it. Refine and clarify this so the group has a clear idea what we’re gong to focus on. 2010 HPRCT Presentation – Optimized Human Error Evaluation

Optimized Human Error Evaluation The objective of performing a Root Cause Analysis is to optimize the use of the organizations’ resources (time and cost) in achieving an effective, long-lasting solution to identified problems. 2010 HPRCT Presentation – Optimized Human Error Evaluation 4

Optimized Human Error Evaluation Presentation Outline: Human Error or Inappropriate Action? Providing a focused problem statement. Identifying factors that influenced what happened. Collecting relevant information. Selecting effective corrective actions. Trending effectiveness. Pitfalls to avoid. Topics for Discussion. 5

Optimized Human Error Evaluation Human Error or Inappropriate Action? It all depends on your definition: - a deviation from accuracy or correctness - a mistake - a moral offense Let’s use the following working definition to describe both: “A deviation from a desired condition occurred that is directly related to an action or inaction on the part of an individual.” Two basic approaches to the problem of human fallibility exist: the person and the system approaches. The basic premise in the system approach is that humans are fallible and errors are to be expected, even in the best organizations. Errors are seen as consequences rather than causes, having their origins not so much in the perversity of human nature as in "upstream" systemic factors. These include recurrent error traps in the workplace and the organizational processes that give rise to them. Countermeasures are based on the assumption that though we cannot change the human condition, we can change the conditions under which humans work. A central idea is that of system defenses. All hazardous technologies possess barriers and safeguards. When an adverse event occurs, the important issue is not who blundered, but how and why the defenses failed. 6

Optimized Human Error Evaluation Providing a focused problem statement: Keep it short (less than 10 words, try for less than 5). Make the deviation clear. Avoid making judgments. Done well, it’s much more cost effective. Discuss an example provided by someone in the class. 7

Optimized Human Error Evaluation ATTENTIONAL FAILURES Carry out a planned tasks incorrectly or in the wrong sequence SLIP UNINTENDED ACTIONS MEMORY FAILURES Missed out a step in a plan sequence of events LAPSES HUMAN ERRORS RULED-BASED MISTAKES Misapplication of a good rule or application of a bad rule KNOWLEDGE-BASED Inappropriate response to an abnormal situation MISTAKE INTENDED ACTIONS ROUTINE VIOLATIONS EXCEPTIONAL VIOLATION ACTS OF SABOTAGE VIOLATION 8

Optimized Human Error Evaluation Collecting and Applying Relevant Information: Determining What Information is Relevant: First consider the conditions under which the deviation occurred (latent weaknesses): How clear are performance expectations? Pre-job briefs, etc. Is needed information accurate and readily available? work package, procedures, drawings, displays, etc. Level of training/skills for the task. Presence of distracters job conditions, interruptions, time-critical task, etc. What else? 9

Optimized Human Error Evaluation Collecting and Applying Relevant Information: Determining What Information is Relevant: Next consider individual performance factors: Fitness for the job. fatigue, medical condition, etc. Level of commitment to the task. Behaviors overconfidence, friction between co-workers, etc. Past practices performing similar tasks. What’s worked before, may not be appropriate for the current situation. What else? 10

Optimized Human Error Evaluation Collecting and Applying Relevant Information: Determining What Information is Relevant: Consider feedback / consequences: What impact did the situation have on the individual? e.g., injury to self or others, got , etc. What was the perceived level of risk to the individual? What was the perceived burden to the individual? e.g., physical, mental, emotional What level of feedback / coaching has the individual received when performing similar tasks? e.g., from supervisor, co-workers, customers, etc. What else? The potential for procedure non-compliance has been studied by Performance Improvement International and others. The relationship for the factors which can be used to estimate non-compliance rate is provided below: Perceived effort or burden (physical, mental, emotional) Non-compliance rate = Individuals’ risk perception + Coaching effectiveness 11

Optimized Human Error Evaluation Collecting and Applying Relevant Information: Determining What Information is Relevant: Evaluate barriers to inappropriate actions: The potential for procedure non-compliance has been studied by Performance Improvement International and others. The relationship for the factors which can be used to estimate non-compliance rate is provided below: Perceived effort or burden (physical, mental, emotional) Non-compliance rate = Individuals’ risk perception + Coaching effectiveness 12

Optimized Human Error Evaluation Collecting and Applying Relevant Information: Collecting Relevant Information: Do it soon – before people leave for the day, if possible. Information that is most likely to change with time includes. Individual’s memory and observer recollections. Volatile computer information (e.g., event logs). Equipment configuration, prior to troubleshooting, disassembly and repair. Have a plan. It’s best if you develop a standard set of interview questions and a template report. There is a significant savings in cost and manpower required to determine the cause(s) so that appropriate corrective actions can be taken to prevent similar problems. 13

Optimized Human Error Evaluation Selecting Effective Corrective Actions: The corrective actions should be lasting. We maximize benefits when we implement the actions with the least amount of delay. We maximize benefits when the corrective actions can be performed using available resources. We maximize benefits when we make use of industry and plant OE to gain additional insights on the issue. We maximize benefits when we use the most cost-beneficial approach. 14

Optimized Human Error Evaluation Selecting Effective Corrective Actions: Types of Actions Problem Cause Effect Adaptive Corrective (Fix) Eliminates the cause Limits the effect Action Interim action can be either corrective or adaptive 15

Optimized Human Error Evaluation Selecting Effective Corrective Actions: When developing a plan, it’s important to obtain input from: People who have to provide the resources People who have to implement the actions People who will be affected by the actions If these people are not committed to implementing the plan, the plan is unlikely to be effective. 16

Optimized Human Error Evaluation Trending Corrective Action Effectiveness: How do we know if we’ve really optimized our human error evaluations? Is the rate of related events decreasing? Is the time to perform the evaluation decreasing? Have the corrective actions become how we do business? What else might we want to evaluate? How can we capture this information most effectively? 17

Optimized Human Error Evaluation Pitfalls to Avoid (The “law of unintended consequences”.) The possibility that something can go wrong is increased when: You don’t have a good handle on what caused the original problem. You take action without considering that the action itself can create similar or new problems. Example: “Coaching” individuals to follow the procedure instead of reducing the difficulty of implementing the procedure. Discipline was used when an individual committed an error due to lack of knowledge and misleading directions from a senior member of the staff. 18

Optimized Human Error Evaluation Topics for Discussion: Difficulties in dealing with “soft” issues. How many people have pre-defined interview questions and an evaluation template for performing evaluations? What works well? What could be improved? Others??? 19