1. Using HPI Tools in Tank Farm Work Control and Hazard Analysis Process U.S. Department of Energy Enhancing Integrated Safety Management through Event Prevention

2. U.S. Department of Energy 2 HPI & Work Control Performance GAPs Critical Tasks Developing Work Instruction Controls –Job Hazards Analysis –Job Safety Plan –Work Instruction Conclusions & Benefits

3. U.S. Department of Energy 3 Performance GAPs in Work Control Use of the Critical Task concept Proactive planning using error precursors Tailoring controls to the critical task Ensuring controls are not buried in extraneous information Ensuring workers attention is properly focused

4. U.S. Department of Energy 4 Critical Task Not all aspects of a job are equally important –Some actions/tasks are irrecoverable; once the action is taken, the reverse action cannot recover. Some steps have more chances for error Need to consider as part of hazards analysis –Is changing the state of the facility, system, or component or well-being of the individual dependent on the individual worker? –Is the outcome of the error intolerable from a personnel safety or facility perspective? Helps focus attention on potential consequences so appropriate defenses can be put in place

5. U.S. Department of Energy 5 Developing a Work Instruction Safety Plan Job Hazards Analysis Work Instruction Work Steps Precautions Warnings How we Identify Error Precursors & Critical Tasks How we Define defenses against Error Precursors & Critical Tasks How we Implement the defenses

6. U.S. Department of Energy 6 HPI and Job Hazards Analysis Critical task Those tasks or group of tasks that need to be performed correctly or harm may come to the worker, environment or equipment Error precursors First time performance Simultaneous multiple task Time critical task

7. U.S. Department of Energy 7 HPI Impacts in Hazard Analysis Before 4 Major tasks 26 Sub-tasks 41 Hazards (most slips trips falls) 152 Controls (most skill-of-craft) No error precursors Missed critical task After 4 Major tasks 26 sub-tasks 1 Hazard for Critical task 6 Controls Error precursors identified Controls focused on critical task

8. U.S. Department of Energy 8 HPI Impact on Work Instructions Before 17 Precautions 15 Prerequisites 8 Notes 4 Cautions 2 Hold Points 63 steps for skill-of-the-craft 47 steps for unidentified “critical task” buried in extraneous information After 5 Precautions 4 Prerequisites 0 Notes 2 Warnings (Hazard for critical task) 2 Hold Points 11 steps to augment skill-of-the-craft 42 steps for “critical task”

9. U.S. Department of Energy 9 Conclusions & Benefit Identified error precursors Proactive event prevention Improved focus on hazards with consequences for incorrect performance Removed skill-of-the craft controls Un-buried critical hazard controls Worker attention focused on hazard controls