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
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.
2010 HPRCT Presentation – Optimized Human Error Evaluation2010 HPRCT Presentation – Optimized Human Error Evaluation
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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.”
2010 HPRCT Presentation – Optimized Human Error Evaluation2010 HPRCT Presentation – Optimized Human Error Evaluation
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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.
2010 HPRCT Presentation – Optimized Human Error Evaluation2010 HPRCT Presentation – Optimized Human Error Evaluation
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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:
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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.
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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
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