Event Free Performance Tool Book

Sharon Pluskis

ComEd

Director EH&S

April 29, 2015

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1. People are not perfect and even the best make mistakes

2. Goal is Event-Free performance, not Error-Free.

3. Individual behavior occurs within the context of organizational processes and values, which serve as the principal influence on the choice of behaviors

4. People achieve high levels of performance based largely on the encouragement and reinforcement received from leaders, peers and subordinates

5. Events can be avoided by understanding the reasons mistakes occur and applying the lessons learned from past events

6. Error-likely situations are predictable, manageable and preventable

7. The event-free performance tool book is only ONE of many elements to human performance

Exelon Utilities’ Human Performance 101

Exelon Utilities' Human Performance Program includes four elements:

• Prevention: Event Free Performance Tool Book

• Detection: Management and Safety Observations/Audits

• Correction: Corrective Action Program

• Sharing: Lessons Learned

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Improving Human Performance

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Provides “soft” tools to directly support everything we do to become “the best gas and electric energy delivery company in the world” • Safety – eliminate injuries

• Reliability – eliminate customer interruptions

• Customer Satisfaction – eliminate customer interruptions

• Cost – eliminate rework, improve productivity

The tools in this book will help you recognize error-likely situations and provide techniques to eliminate adverse events

Purpose of Event Free Performance Tools

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History of Tool Book

• First edition of Event Free Performance Tool Book (EFPTB) issued in 2007

• Over 2,000 employees trained in half-day classes

• In 2009, survey conducted regarding the format and usage

–Majority of comments concerned unnecessary verbiage and the book not being user friendly

–Common suggestion: simplified book with pictures

• EFPTB revised in late 2009

• Third edition issued in 2014, upon integrating BGE tools, post-merger

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1. Time Pressure

2. Stress

3. Overconfidence in work and/or abilities

4. High Work Load

5. Poor Communications

6. Vague or Poor Work Guidance

7. First Time Performing a Task

8. Distractions

9. First Working Day Following Time Off

10.30 Minutes After a Meal or Waking Up

Top 10 Human Error Traps

Event Free Performance Tools

1. Job Brief • Multi-Person

• Single Person/Multiple Location

2.Questioning Attitude • 4 Key Questions

3.Verification Practices • Self-Check (STAR)

• First Check

• Peer Check

• Independent Review

4.Three-Part Communication • 24-Hour Clock

• Phonetic Alphabet

5. Procedure Adherence • Procedure Levels

• Place-keeping

• Reader-Doer

• Fundamentals of Operational Execution

6.Stop When Unsure/OOPS

7. Visual Cues • Flagging

• Robust Operational Barriers

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7 Task Demand – Time Pressure

Signs

• Tight time schedule / tunnel vision / peer pressure to work fast

• Impatience towards co-workers / miscommunication

• Doing more than one task at a time / skipping steps

• Emotional outbursts / appears anxious

• Making minor skill-based errors

EFPTs to Use

• Self-Check/STAR, if alone; or Peer Check for skill of the craft work

• 4-Key Questions – take time to think it through

• Procedure Adherence for more complex tasks

• Stress Stop When Unsure/OOPS for unfamiliar/unknown conditions

• Up to 67% of time

pressure is self-

induced

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Human Nature – Stress

Signs

• Indifferent and rude to co-workers

• High absenteeism rate

• Frequent complaints about the jobs

• Inattention to assignments

• Avoidance of supervisors

• Persistent and simultaneous time pressure, distractions and high workload

• Poor supervision

• Uncertainty of employment

EFPTs to Use

• Perform Self-Check/STAR to remain focused

• Request a Peer Check or First Check

• Suggest performance of Independent Reviews

• 3-Way Communications to ensure clarity

9 Human Nature - Overconfidence in Work and/or Abilities

Signs

• Complacency

• Unnecessary risk taking

• Taking shortcuts

• First time performing a task – don’t know what they don’t know

• Inferred experienced – did or saw something similar so now an expert

• Short duration task – it’ll only take a minute

• Time pressure – tunnel vision limits thinking of possible scenarios

• Low involvement by and low expectations of supervisor – they do it how they think is best

EFPTs to Use

• Thorough Job Briefs and the use of Questioning Attitude

• Independent Review to ensure impartiality

• Stress Stop When Unsure/OOPS – do not proceed in the face of uncertainty

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Task Demands – High Workload

Signs

• Constantly responding to emergent problems

• Multi-tasking – distractions pulling away from job

• Tunnel vision – not considering all possible scenarios

• Limiting or eliminating peer checks due to time constraints

• Taking short cuts – skipping steps in procedure

EFPTs to Use

• Self-Check/STAR for skill of the craft work; Peer Check to ensure accuracy

• 3-Way Communications to ensure assumptions are not made during critical steps

• Visual Cues to ensure work is performed on the correct equipment

11 Individual Capabilities – Poor Communications

Signs

• Inadequate 3-way communication

• Lack of clarifying questions

• Misinterpreting directions

• Lack of information being transmitted

• Employees making wrong assumptions

• Improper actions – including severe injuries

• Unnecessary rework due to misunderstanding

• Avoidance behavior – short, curt communications

EFPTs to Use

• Enforce the use of 3-way communication

12 Task Demands – Vague or Poor Work Guidance

Signs

• Not using procedures in the field

• Employees joking about errors in the procedures or maps

• Using unqualified or outdated procedures or maps

EFPTs to Use

• At a minimum, must use 3-way communications for all orders or directions involving operation of system equipment or exchange of critical information

–3-way communication is useful beyond this basic requirement

• Stop When Unsure/OOPS - reinforce expectation to STOP when encountering vague or incorrect procedures or maps

• Use First Check to ensure task is clearly understood

• Utilize Independent Review if task is critical

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Individual Capabilities – First Time Performing a Task

Signs

• Tasks performed for the first time

• Tasks performed after an extended period of time ( > ~ 6 months )

• Tasks performed under different circumstances

• Tasks performed by a new crew

EFPTs to Use

• Conduct extensive Pre-Job Brief

• Review associated procedures and work orders to ensure quality and accuracy to ensure Procedure Adherence

• Peer Check or First Check by tapping experienced individual(s)

14 Work Environment – Distractions

Signs

• Doing too many things at once

• Worker forgetting where he or she left off in a process

• Forgetting to return to the task

• Low level of concentration

• Not knowing, or forgetting about changes after returning to the task

• Original task out of control during the distraction

EFPTs to Use

• Peer Check

– Estimate how much time the worker can be away from the job without causing a problem and periodically check to ensure this time has not been exceeded

– Upon returning to task, check the as-found conditions to ensure they are consistent with expectations

• Self-Check/STAR – Proceed with caution on the original task after no inconsistencies are found

• Visual Cues to ensure the correct equipment is operated

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Individual Capabilities – First Working Day Following Time Off

Signs

• Returning from vacation

• Returning to a busy work schedule after four days off

• A new shift schedule (going from day to night shift or vice versa)

EFPTs to Use

• Self-Check/STAR for skill of the craft work

• Utilize Independent Review if task is critical

• Thorough Job Briefs

• Visual Cues to ensure the correct equipment is operated

16 Individual Capabilities –30 Minutes After a Meal or Waking Up

Signs

• Circadian rhythm troughs occur around 0100 to 0400 and after lunch

• Carbohydrates exacerbate post-lunch circadian trough

• Reduced alertness and increase the chances of making errors

EFPTs to Use

• Self-Check/STAR for skill of the craft work

• Utilize Independent Review if task is critical

• Ensure Job Briefs are held after lunch to stimulate thinking and re-energize workers

17 Embedding it in our Culture

• Training - Covered in each line progression school, meter reading and call center classes; each field employee gets at least one copy of the book

• Job Briefs - Integral part of the job brief sheet, which, as a result, is frequently referred to as the “STAR” sheet

• Constant Communications-

–Safety Alerts on adverse events referred to EFP Tools and how they can be used

–HP Alerts and text pages issued after long holiday weekends

–Rotating posters depicting one tool at a time

–EFPT clipboards

• Utilized by Contractors

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ComEd's Rolling 12-Month Human Performance Incident Rate,

Jan 1, 2007 to Mar 31, 2015

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Has The EFPTB Made A Difference?

Employee + Contractor