1. SAFER Dialogue
Brian Harkins

2. 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.

3. 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

4. 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

5. 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.

6. 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

7. 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.

8. 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.

9. 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.

10. Review of Dive Activities

11. 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.

12. 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.

13. 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

14. 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

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

16. SAFER Dialogue with Industrial Health & Safety Emergency use of the SCBA bottle by the diver
Review Experience
INPO Report (OE9455) dated , 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.

17. 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

18. 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.

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

20. 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