2010 HPRCT Presentation – Optimized Human Error Evaluation2010 HPRCT Presentation – Optimized Human Error Evaluation

June 22nd, 2010

Presenter: Terry J. Herrmann, P.E.

Associate, Structural Integrity Associates

therrmann@structint.com

16th Annual HPRCT ConferenceJune 21-24 · Sheraton Inner Harbor HotelBaltimore, MDHosted by Constellation Energy

Optimized Human Error Evaluation

2010 HPRCT Presentation – Optimized Human Error Evaluation2010 HPRCT Presentation – Optimized Human Error Evaluation

Your Presenter

• 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 1016907, Preservation of Failed Parts to Facilitate Failure Analysis of Nuclear Power Plant Components

Terry J. Herrmann, P.E.

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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.

2010 HPRCT Presentation – Optimized Human Error Evaluation

2010 HPRCT Presentation – Optimized Human Error Evaluation2010 HPRCT Presentation – Optimized Human Error Evaluation

Optimized Human Error Evaluation

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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.

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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.

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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.”

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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.

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HUMANHUMAN

ERRORSERRORS

UNINTENDEDUNINTENDED

ACTIONSACTIONS

INTENDEDINTENDED

ACTIONSACTIONS

SLIPSLIP

LAPSESLAPSES

MISTAKEMISTAKE

VIOLATIONVIOLATION

ATTENTIONAL FAILURESATTENTIONAL FAILURES

Carry out a planned tasksCarry out a planned tasks

incorrectly or in the wrongincorrectly or in the wrong

sequencesequence

MEMORY FAILURESMEMORY FAILURES

Missed out a step in a planMissed out a step in a plan

sequence of eventssequence of events

RULED-BASED MISTAKESRULED-BASED MISTAKES

Misapplication of a good Misapplication of a good

rule or application of a bad rulerule or application of a bad rule

KNOWLEDGE-BASEDKNOWLEDGE-BASED

Inappropriate response to Inappropriate response to

an abnormal situationan abnormal situation

ROUTINE VIOLATIONSROUTINE VIOLATIONS

EXCEPTIONAL VIOLATIONEXCEPTIONAL VIOLATION

ACTS OF SABOTAGEACTS OF SABOTAGE

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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?

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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?

Optimized Human Error Evaluation

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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?

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Collecting and Applying Relevant Information:

Determining What Information is Relevant:

• Evaluate barriers to inappropriate actions:

Optimized Human Error Evaluation

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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.

Optimized Human Error Evaluation

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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.

Optimized Human Error Evaluation

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Selecting Effective Corrective Actions:

Types of Actions

Cause Effect

Action

ProblemCorrective (Fix)

Eliminates the

cause

Adapt

ive

Limits

the e

ffect

Interim action can be either corrective or adaptive

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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.

Optimized Human Error Evaluation

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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?

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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.

Optimized Human Error Evaluation

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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???

Optimized Human Error Evaluation