1. Optimized Human Error Evaluation
3/27/2017
16th Annual HPRCT Conference
June · 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
P91 / T91 Workshop

2. 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 , Preservation of Failed Parts to Facilitate Failure Analysis of Nuclear Power Plant Components

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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