1. Unlocking Ways To Get “Between the Ears” Of The Operator Robert D. Coovert Exelon Human Performance Manager

2. The Goal Is Organizational Impact

3. Highly Reliable Organization (HRO)  Develops common organization practices –“Standard operational procedures contribute to reliability if the outside environment is stable, that is, if the decisions required of operators fall within a predictable set of contingencies. However, as seen on a daily basis this is clearly not the case. Operators must deal with unexpected and unique situations in a very rapid fashion”  “Anticipates the changing potential for failure, regardless of past success, because they appreciate that their knowledge is imperfect and that their environment continues to change”  Creates safety by anticipating and planning for unexpected events

4. Simple Rules for Changing Behavior  Training  Reinforcement  Accountability

5. Simple Rules For How Adults Learn  Adults learn by doing Experiential learning  Adults learn if it is personally important to them KEY LEARNING: It comes down to Associations

6. Experiential Learning  Adults behavior has been shaped by their experience, if you want to change behavior, you must provide new "experiences”  Studies indicate that most adults learn through "hands on" experiences

7. Performance Exercises are Experiential  Simple exercises designed to provide initial understanding of a new behavior –Checking practices –Communications 1SI8801A –Verification practices

8. Performance Exercises  Focus on observable behaviors The following Self-Check (STAR) actions are expected to be observable: Stop Point at or touch the equipment. Read the identification tag. Compare to the controlling document. Hesitate for a second or two, followed by: Manipulate the equipment. Verify actual system response.

9. Performance Exercises

10. Simple Examples are Experiential Poke Yoke Markers

11. How can I convince a supervisor which jobs are the best observe?

12. Vulnerability of Removal or Installation  The requirement is to remove the nuts and then replace them in some predetermined order. A B C D E F G I

13. How can I educate a crew on knowledge based errors?

14. GEMS Generic Error Modeling System

15. 90 feet 60 feet 30 feet

16. How can I educate a crew on the key to communications?

17. Communications  What are your communication standards?  What communication tools do you use? –Written –Verbal Three way communications OPEN A VALVE KEY LEARNING: Create Understanding

18. Communication Assumptions  Airforce (P)Problems identified by pilots and  (S)Solutions determined by the maintenance crews

19. (p) Left tire almost needs replaced (s) Almost replaced left tire (p) Test flight OK except autoland very rough (s) Autoland not installed on this aircraft Communication Assumptions

20. (p) Something loose in cockpit (s) Tightened something in cockpit (p) Evidence of leak on right main landing gear (s) Evidence removed

21. Communication Assumptions (p) Dead bugs on windshield (s) Live bugs on order (p) IFF inoperable (s) IFF always inoperable in OFF mode (p) Friction locks cause throttle levers to stick (s) That’s what they’re there for

22. Communication Assumptions (p) Number 3 engine missing (s) Engine found on right wing after brief search (p) Aircraft handles funny (s) Aircraft warned to straighten up, “fly right” and be serious

23. How can I educate a crew on the dangers of overconfidence?

24. OVERCONFIDENCE “The danger of overconfidence is a tendency to become sloppy and careless. Workers and supervisors begin to take chances. Such an attitude is the perfect medium in which to grow an accident.” H. C. Howlett II

25. What was going through your head prior to, during, and after the accident?

26. How can I educate engineers on the potential latent conditions in the new digital feed-water control system?

27. Air Bus A320 “Hazardous and complex systems are created with built-in errors waiting to be triggered.” James Reason

28. Air Bus A320

29. Dynamic Learning Activities (DLA)  Exercises created with multiple activities that are designed to teach and reinforce desired behaviors for an individual

30. Work Environment Simulators  Simulators that are created that can support multiple activities that are designed to teach and reinforce desired behaviors for an individual or group of individuals  Shop setups  Hogan’s alley / Murphy's alley  Video  Control room simulators  The plant

31. Shop Talk

32. Shop Experience

33. The Good  It works  All levels of workers can benefit  Training / reinforcement  It’s not the same old thing in the classroom

34. The Bad  Return on investment  Competent instructors  Management support  Cost  Competition for availability

35. The Ugly There is no consistent means to evaluate individual and team performance. There is an absence of reliable data on events. Training is lagging behind in organizations / departments that create latent conditions. Aspects of increased automation are not being addressed yet are identified in a number of events.

36. Lessons Learned from the FAA There is great variability in the impact of programs and performance even after training. Incomplete acceptance of concepts and practices by instructors and evaluators is a major source. In the absence of continuing reinforcement, behavior and attitudes regress almost to pre-training levels. Human Performance programs between departments and stations show great variability in execution and impact.

37. “Training is not likely to leave the confines of the school house if the culture is not congruent with what is being taught.”

38. Questions