Dr. Bill Corcoran

June 22, 2010

16th Annual HPRCT ConferenceJune 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) Don’t Perform Satisfactorily in Service and/or Aren’t Suitable for Their Intended Purpose)

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

PECONUCLEARA Unit of PECO Energy

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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

Human Quality (HuQ)

What’s 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

What’s 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

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 it’s supposed to do Situation-conditions under which it is supposed to do it Time-when it’s supposed to do it and for the time it’s 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

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

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

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

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

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

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

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

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Questions?

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