1. Dr. Bill Corcoran June 22, 2010 16th Annual HPRCT Conference June 21-25 · Baltimore Inner Harbor Hosted by Constellation Energy President, Nuclear Safety Review Concepts Corporation, Windsor, CT 860-285-8779 Human Quality ( Lines of Inquiry When Human(s) Dont Perform Satisfactorily in Service and/or Arent Suitable for Their Intended Purpose ) © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu

2. PECO NUCLEAR A Unit of PECO Energy

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5. Needed to Probe Human Quality (HuQ) Some knowledge of Human Behavioral Technology (HBT) Some knowledge of Business Issue Investigation (aka RCA) Empathy, compassion, curiosity, skepticism Perspective: A good investigation makes the despicable explicable. 5 © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu

6. Human Quality (HuQ) Whats the Problem about HuQ? What is HuQ? Looking at the Problem as a Quality Problem Lines of Inquiry Conclusions 6 © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu

7. Whats the Problem about HuQ? All reported consequential events resulted from Inactions of humans Behaviors of humans and/or Conditions affected by humans Established by humans Desired by humans Tolerated by humans and/or Undetected by humans 7 © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu

8. What is HuQ? I A Quality Item Is demonstrated to meet its qualitative and quantitative (Q/Q) acceptance criteria Will perform satisfactorily in service Function-what its supposed to do Situation-conditions under which it is supposed to do it Time-when its supposed to do it and for the time its supposed to do it Is suitable for its intended purposes 8 © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu

9. What is HuQ? II Is it the same for humans? What are the Q/Q acceptance criteria? What is satisfactory performance in service? What are the intended purposes? 9 © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu

10. Looking at the Problem as a Quality Problem The Item Its source Its history How it was treated How it was used The environment that it was used in Accountability for quality 10 © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu

11. Lines of Inquiry (LOIs) I Facts HuQ is never a direct cause HuQ is never the root cause HuQ is never a root cause LOIs What is the nature, the magnitude, the location, and the timing (NMLT) of the HuQ Issue? What are the factors that resulted in the NMLT of the HuQ Issue? 11 © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu

12. Lines of Inquiry (LOIs) II What are the factors that resulted in the NMLT of those factors? For each factor Creation Non-discovery Failure to effectively address 12 © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu

13. Lines of Inquiry (LOIs) III For each factor Missed opportunities Barrier inadequacies Earlier, better, cheaper, safer, more risk- informed, more safety culture indicative, more compliant ways of identifying and/or addressing the HuQ Issue and/or its factors before the event 13 © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu

14. Lines of Inquiry IV For each HuQ Issue Significance Significance of HuQ Issue Significance of each factor Extent Extent of HuQ Issue Extent of each factor Factors resulting in the extent 14 © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu

15. Conclusions HuQ issues are like other Q issues Perform satisfactorily in service Suitable for intended purposes Meet Q/Q acceptance criteria HuQ issues have logical Lines of Inquiry 15 © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu

16. 16 Questions? © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu