1. Procedure Lab
Procedures use lab  follow procedure and build the electric click circuit.
This lab’s Primary designed focus:
Procedure use
Attention to detail
Latent procedure errors
Communication
Secondary focus:
Ensure/Verify meaning

2. Theory to Practice De-Brief Procedure Use Lab
Thoughts?
Was this an error prone instruction?
Did you miss that prerequisite step? Why?
How did you do with those batteries?
Why did some of the Fans fly off?
What are some of the error precursors?
Were there any critical steps?
HPI Tools your team used?
Situational Awareness
Self Checking
Procedural Use  Any incorrect step will result in beeper and end of the scenario (built in)
WITH  Time pressure
etc.  Key point of wrap up discussion after Labs.
DOE HPI Handbook:
Critical Step -- A procedure step, series of steps, or action that, if performed improperly, will cause irreversible harm to equipment, people, or the environment.
HPI Tools Focus:
STAR  Purpose Built for this focus area
Peer Checking  When there are three in the team (Normally will be), one will be doing peer checking of the doer.
Communications Use of the reader/doer in this scenario ensures this. Focus will be on 3 way Coms
Phonetic Alphabet  Use will be required during procedure.
Self Checking  Very complex nomenclature
Procedural Use  Any incorrect step will result in beeper and end of the scenario (built in)/Placekeeping .

3. Error Likely situations (Hide this slide)
Skipping Parts list check  Bottom of page and follows silly sounding age step (Actually from manufacturer of the toy)
Wrong motor direction  Tendency to put on with letters facing normally. Step didn’t say what to ATTEND to.
Missing last step  Step on a page by itself when the last step on previous page led you to think you were done.
Related discussions
Repeat backs
Skill of the Craft -- “Batteries in correct position”
What were the Critical Steps? -- Capacitor on bottom of battery Holder – ESRange Rocket fatality

4. ESRange Rocket Accident
Other Possible headlines:
Employee killed by lack of situational awareness
Employee killed by poor design
Employee killed by 1.5V battery
Employee killed by continuity check
Employee killed by manager working unsupervised
On February 22, 1993 an Orion sounding rocket was being prepared for launch the following say at the European space range.
100kg instrument package to do Ozone studies.
Lying in a horizontal cradle undergoing final checkout which included an igniter continuity check.
The launch director had stayed late the night before and changed all the batteries in the test equipment.
When he changed the battery in the continuity checker (Alinco instrument) he put the battery straight into the instrument without the voltage limiting battery holder, it didn’t look important.
The continuity check fired the igniter which cause motor ignition.
Launch Technician Bror Torneus was killed and 3 others were injured.

5. Event pyramid
We’ve all seen one of these models before, but have you ever asked yourself one simple question – WHICH ONE OF THOSE 600 NEAR MISS/AT RISK BEHAVIOURS IS THE ONE THAT RESULTS IN THE FATILITY?