ML043280466

Comment (2) of David M. Collins on Additional Information

ML043280466
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Site:	Millstone
Issue date:	11/12/2004
From:	Dan Collins Dominion Nuclear Connecticut
To:	Office of Administration
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NRCREP - Additional information NRCREP

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From: <David_M_Collins@domr.corin>

To: <nrcrep ©nrc.gov>

Date: Fri, Nov 12,2004 1:56 PM W yg?-e- 4 Vt2

Subject:

Additional information (See attached file: D.Collins Bio.doc)(See attached file: INPO HU Jobsite and Individual chapter2.pdf)(See attached file: INPO HU Leadership chapter4.pdf)

David M. Collins Engineering Analyst Millstone Power Station Dominion Nuclear Connecticut Phone 1-800-269-9994 x3710 Fax 860-437-5916 CC: <LUJnrc.gov>

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Additional information Creation Date: 11/12/04 1:52PM From: <DavidMGollins~dom.com>

Created By: Davi d-M-Collins~dom .com Recipients nrc.gov twvf2_po.TWFN_-DO NRCREP nrc.gov owf4_po.OWFNDO LLU CC (Lisamarie Jarriel)

Post Office Route twf2_po.TWFN_-DO nrc.gov owf4_po.OWFNDO nrc.gov Files Size Date & Time MESSAGE 290 11/12/04 01:52PM D.Collins Bio.doc 652800 MNO HU Jobsite and Individual chapter2.pdf 2052319 INPO HU Leadership chapter4.pdf 1825037 Mime.822 6201404 Options Expiration Date: None Priority: Standard Reply Requested: No Return Notification: None Concealed

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David M. Collins Bio I have a masters degree in Executive Engineering Management from the University of New Haven.

Since the events that unfolded at Millstone from 1996-1998 I have been studying the management of safety culture.

Since 1998 I have discussed the subject of safety culture management with many PhDs and Industry experts, written papers (including a thesis paper) on the subject, been quoted in a number newspaper articles (mostly related to Davis Besse), and presented to various Industry groups.

Presentations:

1. June 2003 ACRS Safety Culture Workshop

2. June 2003 9th Annual HPRCT Workshop

3. December 2003 University of New Haven (Thesis Defense)

4. May 2004 Spring INPO Human Performance Conference

5. June/July 2004 Millstone Employee Concerns Program Peer Group

6. August 2004 ANS Utility Working Conference I am currently preparing an article on Safety Culture Management for Reliability Engineering and System Safety Journalat the suggestion of the editor, NRC ACRS member and MIT Engineering Professor Dr. George Apostolakis.

I live with my wife Kathy in Old Lyme, Connecticut where the Connecticut River meets Long Island Sound.

~ -- 1

Job Site and Human Performance the Individual t , Fundamentals Course Reference CHAPTER 2 THE JOB SITE AND THE INDIVIDUAL HUMAN FALLIBILITY AND VULNERABILITY 18 Common Traps of Human Nature 18 Unsafe Attitudes 20 Uneasiness and Intolerance 22 Job-Site Vulnerabilities 22 ERROR-LIKELY SITUATION 23 Error Precursors 23 Common Error Precursors 24 PERFORMANCE MODES 26 Information Processing 26 Attention 26 Generic Error Modeling System 27 Skill-Based Performance 28 Rule-Based Performance . 29 Knowledge-Based Performance 30 ERROR PREVENTION 33 Avenues of Error Prevention 33 At-Risk Practices 34 Error-Prevention Techniques (and Their Bases) 35 TEAM ERRORS 50 ATTACHMENTS:

Error Precursors (long list) 53 Common Error Precursor Descriptions 55 REFERENCES 60 17

Job Site and o Human Performance the Individual Fundamentals Course Reference HUMAN FALLIBILITY AND VULNERABILITY Humans possess an innate characteristicto be imprecise-human nature. Human nature comprises all mental, emotional, social, physical, and biological characteristics that define human tendencies, abilities, and limitations. For instance, humans tend to perform poorly under high stress and undue time pressure. Because of human variability, the best any human being can be is 99.99+ percent reliable. The adage, To err is human..." reminds us that error is always to be anticipated. Because of 'fallibility,' human beings are vulnerable to external conditions that exceed the limitations of human nature. Vulnerability to such conditions makes people susceptible to error. This is especially true when people work within complex systems (hardware or administrative) that have concealed weaknesses-latent conditions that either provoke error or weaken defenses against the consequences of error.

The job site is any location where either the physical or paper plant can be changed. The The ability to detect error-ikely physical plant comprises the systems, structures, situationsto head offpreventable events and components that function to support the depends largely on how well these production of electricity or to protect the reactor ctors are understood regarding their core. The 'paper' plant consists of the design bases and other documentation needed to help role BUS hmnan error.

control the configuration of the physical plant. -Dr. James Reason Flaws in the paper plant can lie dormant and can HIinan Error lead to undesirable outcomes in the physical plant or even personal injury. Front-line workers 'touch' the physical plant as they perform their assigned tasks. Supervisors observe, direct, and coach workers. Engineers and other technical staff perform activities that alter the 'paper' plant or modify processes and procedures that direct the activities of workers in the physical plant. Managers influence worker and staff behavior by their verbal or written directives and personal example. All this activity requires acontrol,' since all human activity involves the risk of error.

Common Traps of Human Nature There is always a chance of error. Because consequential error is a rare occurrence, people tend to overestimate their ability to maintain control during task performance. There is a general lack of appreciation of the limits of human capabilities. Whenever the limits of human capabilities are exceeded, the likelihood of error increases.

The following characteristics of human nature, among others, are commonly encountered whenever performing activities in a complex work environment.

Stress. Stress is the body's mental and physical response to a perceived threat(s) in the environment. The important word is perceived; the perception one has about his or her ability to cope with the threat. Stress increases as familiarity with a situation decreases. It can result in panic, inhibiting the ability to effectively sense, perceive, recall, think, or act. Anxiety and fear usually follow when an individual feels unable to respond successfully. Along with anxiety and fear, memory lapses are among the first symptoms to appear. The inability to think critically or to perform physical acts with accuracy soon follows. Effective strategies for reducing the effects of stress and improving performance include good health, skills training, procedure adherence, and teamwork.

Mental Strain Avoidance. Humans are naturally reluctant to engage in concentrated thinking as it requires high levels of attention for extended periods. Thinking is a slow, laborious process 18

Job Site and Human Performance the Individual 7Fundamentals Course Reference that requires great effort.' Consequently, people tend to look for familiar patterns and apply well-tried solutions to a problem. They are tempted to settle for satisfactory rather than the best solutions. Mental biases, or shortcuts, used to reduce mental effort include:

• assumptions - a condition taken for granted or accepted as true without verification of the facts

• habit - an unconscious pattern of behavior acquired through frequent repetition

• confirmation bias - the reluctance to abandon a current solution-to change one's mind-in light of conflicting information due to the investment of time and effort in current solution. This bias orients the mind to 'see' evidence that supports the original supposition and to ignore or rationalize away conflicting data.2

• similarity bias - the tendency to recall solutions from situations that appear similar to those that have proved useful from past experience

• frequency bias - a gamble that a frequently used solution will work; giving greater weight to information that occurs more frequently or is more recent

• availability bias - the tendency to settle on solutions or courses of action that readily come to mind and appear satisfactory; more weight is placed on information that is available (even though it could be wrong).3 . 4 This is related to a tendency to assign a cause-effect relationship between two events because they occur almost at the same time.5 Inaccurate Mental Models. Humans remember information in terms of key words, phrases, and pictures. All details typically cannot be remembered. Because human beings tend to minimize mental strain, representations or simple pictures of system statuses are inherently flawed since they do not contain all information. This is due in part to a limited working memory.

Limited Working Memory. The mind's 'workbench" for problem-solving and decision-making is very forgetful. This Machrines arefast, temporary, attention-demanding storeroom is used to remember accurate, and dussb. i new information and is actively involved during learning, storing, Hiinais are slow, sloppy, and recalling information. 6 Most people can reliably remember and brilliant.

three or four items at a time while the upper limit is five to seven -unknown suibnariner items. Using peacekeeping techniques while using complex procedures accommodates this limitation.

Limited Attention Resources. The limited ability to concentrate on two or more activities challenges the ability to process information to solve problems. Studies have shown that the mind can concentrate on, at most, two or three things simultaneously.7 Stress usually leads to the "tunneling" or "vagabonding" effects in the ability to accurately focus on available and relevant information. Tunneling occurs when an individual focuses on only one source of information to the exclusion of others. Vagabonding occurs when a person looks at everything without really understanding its meaning. Important information may be ignored or overlooked.

Attention can be improved by experience, training, procedures and teamwork. 8 Mind-Set. People tend to focus more on what they want to accomplish (goal) and less on what needs to be avoided because human beings are primarily goal-oriented by nature. As such, people tend to "see" only what the mind expects, or wants, to see.9 The human mind seeks order, and, once established, it ignores anything outside that mental model. Information that does not fit a mind-set may not be noticed and vice versa, missing that which is not expected or 19

Job Site and wig Human Performance the Individual Fundamentals Course Reference seeing something that is not really present.10 Prejob briefings, if done mindfully, help people recognize what needs to be avoided (noticed) as well as what needs to be accomplished.

Difficulty Seeing One's Own Error. Individuals, especially when working alone, are particularly susceptible to omissions. People who are too close to a task, or are preoccupied with other tasks, may fail to detect abnormalities. People are encouraged to 'focus on the task at hand." However, this is a two-edged sword. Because of our tendency for mind-set and our limited perspective, something may be missed. Peer-checking, concurrent and independent verification techniques help detect errors that an individual can miss.

Limited Perspective. Humans cannot see all there is to see.

The inability of the human mind to perceive all facts pertinent to ... the mind cannot reallj' a decision challenges problem solving. This is similar to notice all there is to notice.

attempting to see all the objects in a locked room through the -Dr. Edward de Bono door's keyhole. It is technically known as 'bounded Pracica Thinkin rationality."' Only parts of a problem receive one's attention Practical while other parts remain hidden to the individual. This limitation causes an inaccurate mental picture, or model, of a problem and to underestimate the risk.'2 A well-practiced problem-solving methodology is a key element to effective control room team performance during plant upsets as well as for the management team during meetings to address the problems of operating and maintaining the plant.

Susceptibility To EmotionallSocial Factors. Anger and embarrassment adversely influence team and individual performance. Problem-solving ability especially in a group may be weakened by emotional obstacles. Pride, embarrassment, and the need to belong to the group may inhibit critical evaluation of proposed solutions, possibly resulting in team errors. (See Team Errors at the conclusion of this chapter.)

Motivated Toward Goal Accomplishment. People want to succeed. They are naturally motivated to adopt behaviors that result in achievement, comfort, convenience, efficiency, and even fun. However, a focus on goal tends to conceal hazards, leading to inaccurate perception of risks. Errors, hazards, and consequences usually result from either incomplete information or assumptions. Also, humans are naturally drawn toward positive experiences and avoid negative consequences, especially if these are immediate and certain. If error-free performance (active errors) is not held up as an important value, or is not established as the standard for performance, then at-risk behavior in the pursuit of job accomplishment can actually be encouraged.

Fatigue. People get tired. Physical, emotional, and mental fatigue can lead to error and poor judgment. Fatigue is affected by both on-the-job demands (production pressures, environment, and reduced staffing) and off-duty life style (diet and sleep habits).' 3 Human beings possess biological clocks, referred to as circadian rhythms, which have periods of about 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />.

Fatigue leads to impaired reasoning and decision making, impaired vigilance and attention, slowed mental functioning and reaction time, loss of situation awareness, and adoption of shortcuts.

Unsafe Attitudes Attitudes can be hazardous to your health-and to the plant. Anyone can possess an unsafe attitude. Although influenced by many factors, attitudes are chosen." Unsafe attitudes are derived from beliefs and assumptions about workplace hazards. Hazards are threats of harm.

Harm includes physical damage to equipment, personal injury, and even simple human error.

Unsafe attitudes blind people to the precursors to harm (exposure to danger). Notice that 20

Job Site and Human Performance the Individual Fundamentals Course Reference hazards are not confined to the physical plant; they exist in the office environment as well. The unsafe attitudes that are described below are detrimental to excellent human performance and to the physical plant and are usually driven by one's perception of risk.

Risk Perception. Human beings judge risk poorly, typically underestimating it. Why is this so?

Subconsciously, each of us "decides" what to be afraid of and how afraid we should be. Most people think of risk in terms of probability, or likelihood, without adequately considering the possible consequences or severity of the outcome. Our "risk perception" tends to be guided more by our heart than our head. As human beings we consider the factors listed below in varying degrees in assessing the risk of a situation. 15 People are less afraid of risks or situations:

• when they feel they have 'control" over the situation

• that provide some benefit(s) they want

• the more they know about and 'live' with the hazard

• they choose to take than those imposed on them

• that are 'routine' in contrast to those that are new or novel

• that come from people, places, or organizations they trust

• when they are unaware of the hazard(s)

• that are natural versus those that are man-made

• that affect others What 'feels' safe may, in fact, be dangerous. The following unsafe attitudes create danger in the work place.

Pride. An excessively high opinion of one's ability; arrogance. Being self-focused, pride tends to blind us to the value of what others can provide, hindering teamwork. People with foolish pride think their competence is being called into question when they are corrected about not adhering to expectations. The issue is human fallibility, not their competence. This attitude is evident when someone responds, "Don't tell me what to do!" Because of the limitations of human nature, error-prevention methods are used to control error. As it says in the Holy Bible, "Pride goes before destruction." (Psalms 18:16).

Heroic. An exaggerated sense of courage and boldness; the Admiral Farragut syndrome:

"Damn the torpedoes, full speed ahead." Usually, reaction is impulsive, thinking something has to be done fast, or all is lost. This perspective is characterized by an extreme focus on goal without consideration of hazards to avoid.

Fatalistic. A defeatist belief that all events are predetermined and inevitable, and nothing can be done to avert fate; "que ser6, ser6," (what will be will be) or "Let the chips fall as they may."

Summit Fever. The zeal to finish the closer one gets to a goal. Nearness to goal accomplishment can cause individuals to disregard or not see conditions or factors important to safety; for example, an automobile driver running a red light at a busy intersection.16 21

Job Site and Human Performance the Individual Fundamentals Course Reference Invulnerability. A sense of immunity to error, failure, or injury. Most people do not believe they When people hang around a grizzlys long will err in the next few moments; 'That can't enough, eventuallyj she's going to catch happen to me." Error is always a surprise when it somtebody doing something stupid.

happens. This is an outcome of the human -Tom Murph limitation to accurately estimate risk. As one -o I person put it, humans are simply "accidents photographer, waiting to happen," an expression that reflects Yellowstone NationialPark Principle No. I (see Chapter 1).

Pollyanna. People tend to presume that all is normal and perfect in their immediate surroundings. 17 Humans seek order in their environment, not disorder, to fill in gaps in perception and to see wholes instead of portions." Consequently, people unconsciously believe that everything will go as planned. This is particularly true when people perform 'routine' activities, unconsciously thinking nothing will go wrong. This belief is characterized with quotes such as "What can go wrong", or "It's routine." This attitude promotes an inaccurate perception of risk and can lead individuals to ignore unusual situations or hazards, potentially causing them to react either too late or not at all (related to complacency).' 9 Bald Tire. A belief that past performance is justification for not changing (improving) existing practices or conditions: "I've got 60,000 miles on this set of tires and haven't had a flat yet." A history of success can promote complacency. Evidence of this attitude is characterized with quotes such as, "We haven't had any problems in the past," or "We've always done it this way."

Station managers can be tempted to ignore the need to benchmark their processes and practices with other organizations or to reject recommendations for improvement if results have been good.

Awareness of such attitudes among the workforce is a first step toward actions to improve work planning, procedure development, and application of error-prevention methods.

Uneasiness and Intolerance Understanding fallibility encourages a proactive perspective toward work. Because of human I am always scared. Imaginationand fallibility, it is easy to err, and a person may not fear are among the best enigineering even know it. In light of the limitations of human toolsforpreventing tragedjy.

nature, people in any function should possess a -Dr. Henry Petroski keen sense of uneasiness toward any activity, To Egne is Human whether it involves managing, operating, To____________is_________

maintaining, or engineering. A nagging doubt that the current job situation may be hiding something endures.2 1 Uneasiness prompts a person to "expect success but anticipate failure." A sense of uneasiness will foster intolerance for error traps. Eventually, people become intolerant of working conditions that could provoke error or increase the risk to the plant. Recognizing error-likely situations and degraded or missing defenses forms a strategic foundation for improving human and plant performance.

Job-Site Vulnerabilities The job site is that location where people can "touch" physical plant equipment or alter the "paper" plant. Vulnerability becomes relevant at the job site from two perspectives. First, the physical plant is vulnerable to the mistakes and at-risk behaviors of station personnel, especially front-line workers. The risk (to the plant) is in people.2 2 Second, people are vulnerable to conditions in the work place that can provoke error. External conditions that can provoke error 22

Job Site and Human Performance the Individual Fundamentals Course Reference at the job site are of key concern for management. Such job-site conditions are known as error-likely situations.

ERROR-LIKELY SITUATION A work situation in which there is greater chance for error when performing a specific action or task in the presence of errorprecursors. 23 An error-likely situation-an error about to happen-typically exists when task-related factors exceed the capabilities of the individual (a mismatch) at the point of utouching" either the physical or paper plant.24 Notice the words action or task in the definition. The simple presence of adverse conditions cannot be error-likely unless a specific action is to occur within that set of adverse conditions. A person cannot fall off a bicycle unless he or she rides the bicycle.

Darkness is not a factor for performance until an instrument technician attempts to read a label on an instrument. Error-likely situations are also referred to as error traps.

Error - likely Situation unintentional Job Site Conditions deviation from

• task preferred behavior

• individual Degree of mismatch due to error precursors Error Precursors Unfavorable conditions embedded in the job site that create mismatches between a task and the individual are known as error precursors. Error precursors interfere with successful performance, and increase the probability for error. 2 5 Undesirable job-site conditions can be categorized into one or more of the following four categories:2 6 Task Demands. Specific mental, physical, and team requirements to perform an activity that may either exceed the capabilities or challenge

\ 1 the limitations of human nature of the individual assigned to the task; for example, excessive workload, hurrying, concurrent actions, unclear roles and responsibilities, and vague standards.

Individual Capabilities. Unique mental, physical, and emotional characteristics of a particular person that fail to match the demands of the specific task; for example, unfamiliarity with the task, unsafe attitudes, level of education, lack of knowledge, unpracticed skills, personality, inexperience, health and fitness, poor communication practices, and low self-esteem.

Work Environment. General influences of the workplace, organizational, and cultural conditions that affect individual behavior; for example, distractions, awkward equipment layout, complex tagout procedures, at-risk norms and values, work group attitudes toward various hazards, and work control processes.

23

Job Site and Human Performance the Individual Fundamentals Course Reference Human Nature. Generic traits, dispositions, and limitations that may incline individuals to err under unfavorable conditions; for example, habit, short-term memory, fatigue, stress, complacency, and mental shortcuts.

Error precursors are, by definition, prerequisite conditions for error and, therefore, exist before the error occurs. If discovered, job-site conditions can be changed to minimize the chance for error. This is more likely if people possess an intolerance for error traps. For example, knowing that drugs and drinking impair one's ability to drive an automobile safely, an individual can choose not to drive, and not to drink or take drugs, even prescription drugs. Such conditions are controllable before performing the task.

Challenge. When a mismatch is reduced by addressing the relevant error precursors, the risk for error is minimized, but a chance for error remains because of human nature. Contamination in radiologically controlled areas is controlled to minimize the risk of being contaminated.

Similar to the ALARA (as low as reasonably achievable) concept, error precursors can be minimized to reduce the chances of error. Most error precursors are outcomes of latent organizational weaknesses (see Anatomy of an Event in Chapter 1) and can be corrected by addressing the respective processes, programs, values, etc. As such conditions are minimized, the error rate should drop, resulting in a lower frequency of events. Robust multiple defenses protect the plant from isolated, trivial errors.

Common Error Precursors Conditions at the job site that can provoke error are not mysterious and obscure. Often, they are obvious. They are noticeable, if people look for them. The error precursors listed below (in order of impact) were compiled from a study of INPO's event database as well as reputable sources on human performance, ergonomics, and human factors:

1.

I ow" .

I Time Pressure (in a hurry) 11E11se.1 RMsPe I 1. Unfamiliarity with task / First time IM

2. High workload (large memory 2. Lack of knowledge (faulty mental model)

3. Simultaneous, multiple actions 3. New techniques not used before

4. Repetitive actions / Monotony 4. Imprecise communication habits

5. Irreversible actions" 5. Lack of proficiency / Inexperience

6. Interpretation requirements 6. Indistinct problem-solving skills

7. Unclear goals, roles, or responsibilities 7. Unsafe attitudes

8. Lack of or unclear standards 8. Illness or fatigue; general poor health

1. Distractions / Interruptions 1. Stress /

2. Changes / Departure from routine 2. Habit patterns

3. Confusing displays or controls 3. Assumptions

4. Work-arounds / OOSP instrumentation 4. Complacency / Overconfidence

5. Hidden system / equipment response 5. Mind set (intentions)

6. Unexpected equipment conditions 6. Inaccurate risk perception

7. Lack of alternative indication 7. Mental shortcuts or biases

8. Personality conflict 8. Limited short-term memory

'Irreversible actions are not necessarily precursors to error, but are often overlooked, leading to preventable events. It is included in this list because of its Importance.

POOS - out of service 24

Job Site and Human Performance the Individual Fundamentals Course Reference Although many conditions can provoke error, the error precursors listed in the above table appear to be the more common conditions associated with events triggered by human error.

Descriptions of the above error precursors (Common Error Precursor Descriptions), and a more extensive list of error precursors (Error Precursors) are provided at the end of this chapter.

Each station is encouraged to adapt the list to more closely reflect the conditions experienced by specific work groups. These conditions should be reviewed periodically to ensure they accurately reflect prevailing working conditions.

TWIN Analysis. Understanding error precursors provides insight into the potential for error for a specific task. TWIN is a memory aid that stands for Task demands, Work environment, Individual capabilities, and human Nature. Several stations use "Always WITH It" (Work environment, Individual capabilities, Task Demands, and Human Nature) to aid personnel with the preparation of work to head off potential error-likely situations.2 7 Remember, by themselves, error precursors do not define an error-likely situation. A human act or task must be either planned or occurring concurrent with error precursors to be considered error-likely. Several examples are provided below. For each example, notice the underlined action. TWIN analysis is ineffective without consideration of the specific action, which is usually a step in the specified procedure or work package. Recall that error is an unintended action.

1. Writing the wrong year on personal checks at the beginning of a new year Error Precursors:

I I

6 Change - new year Repetitive task - write several checks Habit - written previous year numerous times during the previous year

2. Turning the charging pump switch instead of the dilution valve switch Error

• Identical switches - both pistol-grip style Precursors:

• Adjacent - within an inch apart

• Interruption - verifying the status of several annunciator alarms just at the moment to start dilution

• Repetitive task - done several times during shift while performing a plant startup

3. Isolating the wrong flow transmitter during a calibration of several instruments while one is in test Error 6, Poorlighting_ incandescent lights casting shadows Precursors: Repetitive task- several transmitters calibrated previously

• Random placement of transmitters:- procedurally directed to calibrate in numerical sequence by component nomenclature

• Small lettering (black-on-gray) - difficult to read unless person is positioned directly in front of label plate 25

Job Site and Human Performance the Individual Fundamentals t tCourse Reference PERFORMANCE MODES Information Processing To better anticipate and prevent error, one should understand how people process information, as illustrated Mistakes arise directls from the below. The brain is designed for information transfer, but Ivan tile iid handles sometimes it fails.2 8 Error is a function of how the brain informnation, not through processes information related to the performance of an stutpidity or carelessness.

activity. When people err, there is typically a fault with one -Dr. Edwtard de Bono or more of the stages of information processing, not so Practical Thinking much a function of one's motivation, as is the case in violations. However, be cautious not to base the causes of an event on internal mental structures; it leaves managers guessing as to what to do about it. What people were thinking at the time of an event is mostly the outcome of their tools, assigned tasks, and operational and organizational environments (see Chapter 6 on Root Cause Analysis).2 9 Sensing. Visual, audible, and other means to perceive information in one's immediate vicinity (displays, signals, spoken word, or cues from the immediate environment). Recognition of information is critical to error-free performance.

Thinking. Mental activities involving decisions on what to do with information. This stage of information processing involves interaction between one's working memory and long-term memory (capabilities, knowledge, experiences, opinions, attitudes).

Acting. Physical human action (know how) to change the state of a component using controls, tools, and computers; includes verbal statements to inform or direct others. 30 Shared Attention Resources. A pool of mental resources that enables the mind to 3hard attend to information while performing one Ros or more tasks (such as driving a car and talking on a cellular telephone at the same time).3' How much attention is required to perform satisfactorily defines the mental workload for an individual, as some tasks Sensing Thinking Acting require more attention than others. 32 Knowledge, skill, and experience with a /Inforaton task decrease the demand for attention. FIow Path Attention Inattention to Detail. This is a commonly cited cause of human performance problems.

Attention can be focused, divided, or selective. If attention is focused, something has to be ignored. By focusing on one thing, other items cannot be perceived. Divided attention involves paying attention to two or more sources of information on a time-share basis, similar to using a flashlight in a dark room trying to see two different items, moving the flashlight back and forth.

Divided attention can be dangerous; for example, a driver's attention is significantly distracted while using a cell phone. Studies show that drivers are four times more likely to be in an accident if using a cell phone, even "hands-free" styles. Selective attention means an individual gives preference to distinct information such as one's name in a noisy meeting room. Humans cannot pay attention to everything all the time, which leads to the occasional error. 33 Managers demand that workers "focus on the task at hand," and then post signs that say, 'Think Safety."

26

Job Site and Human Performance the Individual X Fundamentals Course Reference Does this make sense? The likelihood of error is enhanced when someone attempts to do more than one activity in one stage of information processing, such as listening to the radio and a passenger simultaneously while driving an automobile. Trained, experienced operators can consciously attend to a maximum of two or three channels of information (such as flow, temperature, pressure) and still be effective.34 Beyond that, error is likely.

"Gut Feeling." It is common to be aware of something without being conscious of it. The subconscious level of attention continually receives information from the immediate environment. A 'gut feeling" that something is not right is a signal that the subconscious has detected something that is inconsistent with the present situation, goals, or intent. For instance, one can walk to the car in the morning to go to work without a wallet and feel something has been forgotten. This feeling is an opportunity! 3 5 Do not ignore it. Pursue what is causing the feeling. The subconscious level of attention is notifying the person that something is not quite right. Questioning attitude and situation awareness are enhanced by paying attention to these feelings.

Generic Error Modeling System (GEMS)

This model (flow chart) shows how humans select the level of information SPfltrbased processing for a particular performance ZisS1k-or I situation, work or play. Depending on Krred-n----_ K the situation as perceived by the NO individual, he or she will chose a Rulebased - - - - - - - - -

processing mode-that is, performance fe r Recognizn No mode-that seems adequate to control -rnoefl i<Svi problem the situation. As described later, the k bul1 GEMS model helps explain the three modes of error. Awareness of the Idcnifry avoilbl "performance mode" chosen for a symptom specific task will help a person anticipate the kind of errors one can /IF\

make and which error prevention Applyknownation.

techniques would be more effective.

Information processing (sensing- based I v thinking-acting) operates in one or An.eree" 1;A. .y Mlbra more of three modes: skill-based (SB), , None rule-based (RB), and knowledge-based Pmblcm4ligmode Sect problenrolution (KB). The performance mode is usually Recallmentalmodel. Applyobserved Dcvelopcofneclivcaclion.Applylo a function of the familiarity an individual to Uprobtcmuitotaion.

mocdvecl has with a specific task and the level of attention (information processing) a >

person applies to the activity. The chart illustrates the distinctions between the three modes of performance. 36 Uncertainty declines as knowledge about a situation improves (learning and practice). Consequently, familiarity (knowledge, skill, and experience) with a task will establish the level of attention or mental functions the individual chooses to perform an activity. As uncertainty increases, people tend to focus their attention to better detect critical information needed for the situation. People want to boost their understanding of a situation in order to respond correctly. 37 But, people tend to default to the 27

Job Site and Ho Human Performance the Individual Fundamentals Course Reference lowest level of mental effort they perceive necessary to adequately accomplish the task (avoidance of mental strain). As a result, information important for the situation may be missed.

Error Mode. Error modes are the prevalent ways people make mistakes, not the only way, for the particular performance mode. Error modes are generalities that aid in anticipating and managing error-likely situations aggravated by inattention, misinterpretation, and inaccurate mental models.

Skill-Based Performance Skill-based performance involves highly practiced actions in very High 0

familiar situations. They are usually executed from memory without significant conscious thought or attention (see Inaccurate illustration above). Behavior is Mental Picture governed by preprogrammed instructions developed by either training or experience and is less dependent upon external 0

° Misinterpretation

©2~

38 conditions. Many actions ina <

typical day are controlled unconsciously by human instinct, Low Inattention such as writing one's signature, a classic example of skill-based Low Familiarity (witask) High performance. Also, performing a very familiar procedure is typically performed at the skill-based level.

Examples. Skill-based activities involve those that can be done very reliably without much conscious thought. Common examples of skill-based activities include:

• manipulating valves and switches

• taking logs

• using a hammer or other hand tool

• controlling various processes manually (such as pressure and level)

• hanging a tag

• swapping strainers

• analyzing chemical composition of a sample

• performing repetitive calculations

• moving control rods

• using measure and test equipment

• attaching test jumpers

• operating a circuit breaker

• walking through a door or opening a cabinet door 28

Job Site and Human Performance the Individual Fundamentals Course Reference

• performing a commonly used procedure

• replacing parts during maintenance Error Mode. The error mode for skill-based performance is You cannotthink and inattention. Skill-based errors are primarily execution errors, hit at the samoe time.

involving slips and lapses in attention or concentration. Errors involve inadvertent slips and unintentional omissions triggered by -YogiBerra simple human variability or by not recognizing changes (note the A Foriner Mlanager, symbol on above chart) in task requirements, system response, or New York Yankees plant conditions related to the task. Under ideal conditions the chance for error is less than 1 in 10,000.39 People most often possess an accurate understanding of the task and have correct intentions. Roughly 90 percent of a person's daily activities are spent in the skill-based performance mode.40 However, only 25 percent of all errors are attributable to skill-based errors. 41 Potentially, a person can be so focused on a task that important information in the work place is not detected. 42 Another concern for skill-based tasks is that people are familiar with the task. The greater the familiarity the less likely perceived risk will match actual risk. People become comfortable with risk and eventually grow insensitive to hazards.4 3 Rule-Based Performance Rule-based behavior is based on the selection of stored rules derived from one's recognition of a work situation; it follows an IF (symptom X), THEN (situation Y) logic. The situation, although possibly familiar, is usually unanticipated. Problems discovered during a task usually require a different skill than originally planned to accomplish the task successfully.44 Many events have occurred because people did not recognize that the original task had changed, such as the transition from preventive maintenance to troubleshooting. The work situation has changed such that the previous activity (skill) no longer applies. Therefore, the big picture in rule-based performance is to improve one's interpretation of the work situation so that the appropriate response is selected and used.45 This is why procedures are prepared for situations that can be anticipated. Using the GEMS model, procedures are pre-determined solutions to possible work situations that require specific responses. Rules are necessary for those less familiar, less practiced work activities for which a particular person or group is not highly skilled. For instance, if the 'Reactor Scram" annunciator alarms, the operator then performs the pre-determined immediate actions for a reactor scram and follows the appropriate emergency procedures to guide plant stabilization and recovery. Most rules are documented in procedures or recalled from previous training, but many rules are developed from experience Errors made perforting routine,familiar (thumbrules) or accepted group practices. tasks are not itmllike accidents that occur in thte htome. Jutst as wfe general!)' assumoe that Not all activities guided by a procedure are necessarily rule-based performance. In our homes are the safest places imaginable, normal work situations, such activities are we tend to disregard the possibility oferrors commonly skill-based for the experienced in the perfornmance of routine tasks. The user. truth is, we relax our vigilance performinng

. . .familiar activities amidfail to pays close Examples. Rule-based activities involve a ion .itiehaards] we aj,ctys decisions based on an "if-then" logic. attention e .teIto hazards] an activt. is Examples includes the following: rottine.

• deciding whether to replace a ball -GerardNierenberg bearing inspected during preventive Do It Right the First Timne 29

Job Site and Human Performance the Individual Fundamentals Course Reference maintenance

• responding to a control board annunciator

• estimating the change in tank level based on a temperature change (thumbrules)

• feeling equipment on operator rounds

• performing radiological surveys

• facilitating a training seminar (choosing response to participant statements)

• using emergency operating procedures

• developing work packages and procedures Error Mode. Since rule-based activities require interpretation using an if-then logic, the prevalent error mode is misinterpretation. People may not fully understand or detect the equipment or plant conditions calling for a particular response. Errors involve deviating from an approved procedure, applying the wrong response to a work situation, or applying the correct procedure to the wrong situation.4 6 For example, blocking automatic actuation of safety injection used to be an accepted rule whenever a reactor operator perceived a reactor scram as Uuncomplicated," when, in fact, the scram was not. The chance for error increases when people make choices or decisions, especially in the field. Rule-based and knowledge-based performance modes involve making choices. With less familiarity for the activity, the chance for error increases to roughly 1 in 1,000.47 In terms of reliability, this is still very good (99.9 percent). In the nuclear industry, studies have shown that roughly 60 percent of all errors are rule-based. 4 8 Knowledge-Based Performance Knowledge-based behavior is a response to a totally unfamiliar situation (no skill or rule recognizable to the individual). The person Htntans are notorious must rely on his or her understanding and knowledge of the system, pattern matchers.

the system's present state, and the scientific principles and -Dr. James Reason fundamental theory related to the system. 49 People enter a Hutias Error knowledge-based situation when they realize they are uncertain (see the ? symbol on previous chart) about what to do. If uncertainty is high, then the need for information becomes paramount. 50 To effectively gain information about what we are doing or about to do, our attention must become more focused. 5 '

Not all hazards, dangers, and possible scenarios can be anticipated in order to develop appropriate procedures. Even training is unable to anticipate all possible situations that can be encountered. There are some situations in which no procedure guidance exists and no skill applies. Knowledge-based situations are puzzling and unusual to the individual. Knowledge of plant systems and fundamental sciences must be used to effectively tackle the problem-solving situation. In many cases, information sources contain conflicting data, too much data, or not enough data, amplifying the difficulty of problem-solving. Because uncertainty is high, knowledge-based tasks are usually stressful situations.

Examples. Knowledge-based activities involve problem-solving. Such situations require the use of fundamental knowledge of processes, systems, and so on-"thinking on your feet.'

Examples of common problem-solving situations include the following:

• troubleshooting 30

Job Site and I Human Performance the Individual N Fundamentals Course Reference

• performing an engineering evaluation

• reviewing a procedure for 'intent of change'

• resolving conflicting control board indications

• responding to an unknown plant transient

• meetings to address problems

• resolving human performance problems

• planning business strategies, goals, and objectives

• performing root cause analysis of events

• conducting trend analyses

• designing equipment modifications

• allocating resources

• changing policies and expectations Error mode. Knowledge-based activities require diagnosis and problem-solving. Decision-making is erroneous if problem-solving is based on inaccurate information. Most decisions are made with limited information and assumptions. Consequently, the prevalent error mode is an inaccurate mental model of the system, process, or of plant status. The mental picture people use to solve a problem may be based on insufficient information. Under such circumstances, the chance for error is particularly high, approximately one in two (50 percent). 52 In the nuclear industry, studies have shown that roughly 15 percent of all errors are knowledge-based. 5 3 Front-line workers (operators and technicians) spend most of their working hours in the skill-based and rule-based performance modes because of the prescriptive nature of theirjobs. On the other hand, managers, supervisors, engineers, and other 'knowledge" workers spend most of their time in rule-based and knowledge-based performance modes because of the discretionary character of their jobs. Knowledge workers spend a great deal of time solving problems and making judgments and decisions. Obviously, people in these positions need to apply error-prevention techniques to their jobs just as those who manipulate plant equipment.

Mental models. A mental model is the structured understanding of knowledge (facts or assumptions) a person has in his or her mind about how something works or operates (for example, plant systems).54 55 Mental models are used in all performance modes. In fact, mental models give humans the ability to detect skill-based slips and lapses. They aid in detecting deviations between desired and undesired system states, such as manually controlling tank water level.56 Fundamentally, a mental model is an internalized picture or map of a system or situation that organizes knowledge about:

• what a system contains

• how components work as a system

• why it works that way

• current state of a system

• fundamental laws of nature But, as a general rule mental models are inaccurate because of the limitations of human nature.

It is important to remember that knowledge-based performance involves problem-solving, and mental models should be considered explicitly, when a team works on a problem.5 7 Team members should agree with the model they intend to use to diagnose and solve a problem.

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Job Site and Human Performance the Individual Fundamentals F4 Course Reference Otherwise, misunderstandings and assumptions may occur. Frequent timeouts can help teams keep mental models up-to-date.

A person handles a complex situation by simplifying the real system into a mental image (simple one-line drawing) they can remember. An individual's mental model may reflect 1)the true state of the system, 2) a perceived state of the system, or 3) the expected state of the system, and is developed through training and experience with the system and recent interactions with the system. Be forewarned, all mental models are inaccurate in some way.-'

High-Risk Performance. Knowledge-based W trai: ourpeople in theory becauseyou performance is the riskiest performance mode ean Ye rpople everj accide that when it comes to expected error rate. 59 When can never postdate evens accident that encountering an unfamiliar situation, people may ..ight happen. The only real safet yoou make erroneous assumptions to ease their have is each operator having a theoretical mental workload. Consequently, they tend to and practical knowledge of the plant so he generate solutions using rules similar to the can react in allj' emergenicy present situation. Such solutions are often based on insufficient information. As time to -Ad US:. G. Rickoeaer A'I5lya respond to a situation decreases, the chance for USNa (deceased) error increases. The chance for error is highest when an unfamiliar situation (especially involving physical danger) strikes suddenly and requires quick reaction.60 Because of the limitations of human nature and an incomplete knowledge of the situation, error is almost inevitable. Therefore, all attempts should be made to change the work situation so that the individual (or team) can perform in either the rule-based or skill-based performance modes.

Assumptions. Knowledge-based situations can be stressful, anxious situations. Assumptions reduce the strain on the mind allowing it to think without excessive effort. Consequently, assumptions tend to occur more often, leading to trial-and-error problem-solving approaches.

Assumptions also occur as an outgrowth of unsafe attitudes and inaccurate mental models.

Statements such as "I think ...," 'We've always done it this way," or 'I believe ..." are hints that an assumption has been or is being made. Inaccurate mental models, in turn, can promote erroneous assumptions that may lead to errors. All too often, assumptions are treated as fact.

Challenging assumptions is important in improving mental models, solving problems, and optimizing team performance. Assigning a "Devil's advocate" in a critical problem-solving situation may be worthwhile toward achieving a better solution.

Assumptions must be challenged to detect unsafe attitudes and inaccurate mental models.

Assumptions can be challenged using the following process:6 '

1. Identify conclusion(s) being made by another person or yourself.

2. Ask for or identify the data that leads to the conclusion(s). 'How did you get that data?"

"What is the source of your concern?"

3. Ask for the reasoning(mental model) that connects data with conclusion. "Do you mean...?" "Can you clarify that...?" "Why do you feel that way?"

4. Infer possible beliefs or assumptions.

5. Test the assumption with the other person. "What I hear you saying is...'

Shortcuts. Mental biases are unconscious methods to reduce mental strain, reducing the need to acquire and process more information.6 2 Humans tend to seek order in an ambiguous situation and to seek patterns they recognize. Personnel should be aware of the potential for 32

Job Site and Human Performance the Individual Fundamentals Course Reference error this creates during problem-solving and decision-making such as troubleshooting and diagnostics during emergency operation. In some form or another, all humans use mental biases. Biases were discussed earlier in this chapter with respect to the limitations of human nature.

ERROR PREVENTION Errors can be prevented, caught, or mitigated. Some techniques listed below are designed to catch and recover from error, but most are designed to prevent error. This course reference refers to these as error-prevention techniques.

The fundamental aim of these techniques is to help the individual maintain 'positive control' of a task situation. Positive control means that 'what is intended to happen is what happens, and that is all that happens.' Every task is different. Consequently, the techniques described below must be adapted to the specific work situations encountered. Do not simply direct people to self-check. Aggressively managing job-site conditions and adapting error-prevention techniques and other defenses to counter specific error traps and other risks is a chief concern for event-free plant performance. But, be forewarned. Despite how rigorous people use error-prevention tools and techniques, people will still err. All that can be hoped for is to minimize the error rate, which tends to reduce the frequency of events the station suffers.

Avenues of Error Prevention Errors can be prevented or caught by machines, other people, and the individual, as described below. Engineered, administrative, and cultural controls provide opportunities for error prevention. An explanation of at-risk practices and basic error-prevention techniques follows.

Machines. Equipment can be ergonomically designed to catch anticipated errors. For instance, computer software can be designed to ask if the user really wants to delete an electronic file after it has been selected for deletion. This challenge gives the user an opportunity to think again if that is the right thing to do. Engineered controls, such as forcing functions, can be designed into equipment to physically block inappropriate human action, such as interlocks. For example, try inserting a 31Y2 inch diskette into a computer disk drive in any way other than the correct way. It will not work. The machine jogs one's attention by asking a question or creating an interlock.

Other People. Co-workers and supervisors are willing resources to help prevent or catch errors especially if the workforce understands the limitations of human nature. Administrative controls, such as peer-checking, challenge, concurrent verification, and independent verification, require other people. However, just because two people are used to prevent errors, it will not be successful every time. People are fallible. Team errors can occur. An open environment in which peers feel comfortable to correct or coach each other is an important success factor for effective teamwork. To facilitate this, people should take initiative and ask others to check them. More detail on team errors is provided at the end of this chapter.

Individuals. Lastly, the individual can catch his or her own error before or after it occurs. Other administrative controls, such as self-checking techniques and use of quality procedures, help individuals reduce errors. However, operating experience shows that procedure use and adherence is still people-dependent, and mistakes still happen. Since preventing and catching errors depends solely on the individual, it is the least reliable of the three ways of catching errors, because humans are fallible. Therefore, do not routinely rely on the individual as the only approach to reducing the number of plant events. To improve the rigor with which people use error-prevention techniques, cultural controls should be explicitly considered. People must 33

Job Site and Human Performance the Individual X Fundamentals Course Reference believe they can err, they must value error-free work, and they must have a sense of uneasiness and a questioning attitude as they perform their activities. Such a culture evolves through an aggressive leadership that understands the values, beliefs, and attitudes they want.

At-Risk Practices At-risk behaviors are actions that involve shortcuts, violations of error-prevention expectations, or simple actions intended to improve efficient performance of a task, usually at some expense of safety. At-risk practices involve a move from safety toward danger. These acts have a higher probability, or potential, of a bad outcome. This does not mean such actions are "dangerous," or that they should not ever be performed. However, the worker and management should be aware of at-risk practices that occur, under what circumstances, and on which systems. At-risk behavior usually involves taking the path of least effort and is rarely penalized with a plant event, a personal injury, or even correction from peers or a supervisor. Instead it is consistently reinforced with convenience, comfort, time savings, and, in rare cases, with fun.63 Some examples of at-risk behaviors are:

• performing two-handed control board manipulations

• performing a task using two or more procedures

• hurrying through an activity

• following procedures cookbook-style (blind compliance)

• removing several danger tags quickly without annotating removal on the clearance sheet when removed

• reading an unrelated document while controlling an unstable system in manual

• having one person perform actions at critical steps without peer checking or performing concurrent verification

• not following a procedure as required when a task is perceived to be 'routine"

• attempting to lift too much weight to reduce the number of trips

• trying to listen to someone on the telephone and someone else standing nearby (multitasking)

• signing off several steps of a procedure before performing the actions

• working in an adverse physical environment without adequate protection (such as working on energized equipment near standing water-progress would be slowed to cleanup the water or to get a rubber floor mat).

Single-error vulnerability is an important element when considering at-risk actions in a task.

Single-error vulnerabilities exist when one mistake or slip will lead to personal injury or damage to equipment. People and equipment are at risk, when only one mistake leads to injury or damage. For instance, if one should trip or slip while walking near the edge of a cliff, a fall is certain. If walking several feet from the edge, a trip or slip is not fatal. Similarly, if a technician is using an uninsulated screwdriver while making adjustments on an instrument in tight quarters, grounding the device is a certainty with a slip of the hand. At-risk actions should NOT be permitted when single-error vulnerabilities exist.

Persistent use of at-risk behaviors builds over-confidence and trust in personal skills and ability.

This is dangerous, since people foolishly presume they will not err. Without correction, at-risk 34

Job Site and m Human Performance the Individual Fundamentals Course Reference behaviors can become automatic (skill-based), such as rolling through stop signs at residential intersections. Over the long-term, people will begin to under-estimate the risk of hazards and the possibility of error at the job site and will consider danger (or error) more remote.6 4 People will become so use to the practice that, under the right circumstances, an event occurs.

Managers and supervisors must provide specific feedback when at-risk behavior is observed.

People are more likely to avoid at-risk behavior if they know it is unacceptable. Also, peer coaching is becoming a more popular expectation for the workforce at excellent performing stations. Preferably, peers correct peers. Otherwise, without coaching and correction, uneasiness toward equipment manipulations or intolerance of error traps will wane.

High quality procedures minimize at-risk behavior. Poorly conceived written procedures, including work packages, prompt users to be creative in accomplishing the intent of the procedure.6 5 When weak work planning and scheduling exists, workers are tempted to adopt at-risk behaviors to get the job done. Problems such as poor access to the work site and insufficient or inadequate tools or equipment may provoke at-risk actions or even violations (See Job Site Conditions and Organization Defined sections in Chapter 3.).

Error-Prevention Techniques (and Their Bases)

Error-prevention techniques are defensive measures aimed at preventing and catching active errors. These functions are implied in the Anatomy of an Event as the causal link between

'flawed defenses" and the "initiating action." To optimize their effectiveness at preventing, catching, or mitigating error, error-prevention techniques should be adapted to the specific job or task. These are commonly referred to as human performance "expectations." Error-prevention expectations and their standards should be consistently documented, interpreted, and applied across the station.

A survey of all plants in the U.S. commercial nuclear industry was conducted (fall 2002) asking each plant what practices defined their principal set of error-prevention tools; Of 65 operating stations, 1 the following top eight techniques, in order of popularity (number of plants using the technique), were identified:

• Self-checking (63)

• Peer-checking (60)

• Three-point communication (54)

• Procedure Use and Adherence (50)

• Pre-job Briefings (39)

• Stop when Unsure (37)

• Questioning Attitude (37)

• Placekeeping (27)

A variety of techniques were identified. Techniques, such as independent verification and concurrent verification, are so common, and in many cases proceduralized, that many stations did not identify them as a core error-prevention technique. The top eight techniques listed above, along with several others that are popularly used and known to be effective, are described below. The basic technique along with its bases in human nature are included in the description.

'Salem and Hope Creek are considered as one station.

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Job Site and Human Performance the Individual ^Fundamentals e ICourseReference Self-Checking. Attention varies. In most activities, some steps are more important than others. This technique boosts attention at important points in an activity before a specific act is executed. Important steps involve touching plant equipment to change its status or may What?

simply involve revising a document important for plant safety and reliability, such as technical procedures and critical drawings. In some plants these steps are determined by the component involved, which can initiate a plant transient or activate an engineered safety Deie system if handled incorrectly. Such components are known as critical components" or 'vital points." In such cases, self-checking is expected. Once attention is , When?

focused, the individual takes a moment to think about the intended action and its expected ---------

outcome. If visual or physical contact is broken, then self-checking should occur again. Where?

Flaws with self-checking include situations the user may not recognize when to use the technique, what to pay attention to, or even where to pay attention (See illustration at right.). A worker once stated, 'We are so good at self-checking, we can do it in our sleep." The physical act does not necessarily mean the mind is attending to the task. If attention is not correctly focused, error is likely. During a game of baseball, an infielder's attention can vary dramatically between pitches. However, attention becomes focused at the beginning of the pitcher's windup (when), toward the opposing batter (where),

and finally, on the ball (what). Some stations have specified situations that require self-checking. But self-checking can be used any time when the performer recognizes the importance of the act about to be performed. Workers should be specific with self-checking practices. Know the more important actions-that is, the critical steps-in a task before performing it. An effective prejob briefing that highlights critical steps of an activity aids such preparation. Error is always a specific action, not a generality. Therefore, self-checking must be specifically applied. Since, error involves an unintentional breakdown of information processing, improving attention at the critical junctions will help prevent or catch an error.

Therefore, the self-checking technique, or any error-prevention practice for that matter, should be precise in its application.

Peer Checking. Peer-checking allows another individual to observe or check the work of a performer to ensure correct performance of a specific manipulation or set of actions. Peer-checking involves having a second knowledgeable individual verify that the action planned by the performer is appropriate before execution and occurs according to plan. The purpose of peer-checking is to prevent error. Peer-checking is merely two persons (performer and checker) self-checking in parallel on the same action. This technique takes advantage of a fresh set of eyes not trapped by the performer's task-related mind-set. The checker may "see" hazards or potential consequences the performer does not see. Peer-checking augments self-checking, but does not replace it for the performer. Peer-checking is not intended to oversee an entire activity or job.

36

Job Site and Human Performance the Individual Fundamentals Course Reference In most cases, workers ask for a peer-check. In It's our (injq responsibility to catch, other cases, a peer-check can occur without being examite, and prevenit not oinly our own requested. This is becoming known as a "challenge." If a person detects that an action by errors but those that others take too.

another person may be unsafe, or at risk, especially -Gerard Nierenberg if a safety system is being bypassed, he or she may Do It Right the First Timne question the performer to verify the intent and desired outcome before the action is taken. Scuba divers call this the "buddy system." The opportunity to challenge is enhanced if performers verbalize their actions in advance. The challenge is a teamwork technique and should not be interpreted as mistrust of one's competence or qualification. Finally, in a high-reliability organization, workers and supervisors request peer checks when they feel the potential consequences warrant it. Special cases of peer-checking can be designed for specific activities. For instance, another qualified individual can be assigned to verify an action does not produce a plant transient and confirms or verifies that the equipment is left in the required position.

Usually, peer-checking is reserved for selected, important, or nonreversible actions on equipment deem 'risk-significant' with respect to plant safety or reliability, personal safety, or radiological safety. But peer-checking can be over-used. Using peer-checking too often can diminish the perceived need for self-checking, a principal error-prevention tool. Peer-checking

'all' actions may result in an increase in errors, because peer-checking may become rote (engaged physically, absent mentally). It becomes an inefficient use of a worker's time, when applied to simple, low-risk activities. Finally, asking for a peer-check during extremely busy periods can distract the peer, who may be preoccupied with an equally important task. Asking for a peer-check during emergency or off-normal situations may make matters worse. In these cases, self-checking is the technique of choice. The following example was observed during a recent plant evaluation:

The reactor operator (RO) potentially distracted the balance-of-plant reactor operator (BOP). The RO asked for a peer check on starting the heater drain pump, while the BOP was manually controlling feedwater. The BOP had to stop and divert his attention from an important task. Rather than decline the request and ask someone else to help, the BOP maintained his hands on the feedwater station controls, while he confirmed the selection of the RO, and he did not adjust feedwater when the peer check was performed.

Although peer-checking is usually more reliable than self-checking, there are exceptions to every rule. The practice adopted for such situations is obviously management's prerogative, but the potential of creating other error traps should be considered when setting such an expectation. -

Peer-checking and concurrent verification should not be used interchangeably. Although the physical act of verification is the same, concurrent verification is a documented, formal, rigorous check of another's action and is usually directed by a procedure. A potential hazard associated with either method is that the peer may not be fully aware of the context of the action. The selected method may be successful for the action, but the action may not be correct for the plant or equipment situation.

Peer-checking is performed by two individuals. One acts as the performer, and the second person, peer, acts as the checker. Peer-checking is performed as follows:

Three-Part Communication Practices. The aim of communication is to exchange information, achieving mutual understanding between two or more individuals. Verbal communication involving speaking and listening can occur face-to-face, by telephone, portable radio, or public 37

Job Site and Human Performance the Individual Fundamentals Course Reference address systems. Written communication occurs by procedures, labels, signs, logs, pass-down/turnover logs, e-mail messages, personal notes, and so on. The face-to-face exchange of information is the most frequently used form of communication. It is usually not recorded, and possesses the greatest risk of misunderstanding. Information related to plant status is of primary importance for plant safety and reliability. Routinely, areasfor improvement involving communication weaknesses are identified during INPO evaluations of operator performance during shift activities and simulator training. However, hallway conversations can be just as risky in that both individuals are often in a hurry on their way to an appointment.

To ensure understanding of near-term changes of physical plant equipment during critical activities, face-to-face, telephone, or radio communication requires at least three verbal transmissions. Mutual understanding is the goal. The person responsible for the communication is the originator, or sender, verifying the receiver understands the message as intended. The sender gets the attention of the intended receiver and speaks the message, the receiver repeats the message in a paraphrased form, and the sender acknowledges the receiver understands the message. Appropriate feedback is used to verify understanding of each transmission. This is commonly referred to as 'three-part communication." For instance, the following standard practice could be used:

Face-to-Face Technique Explanatory Comments

1. Sender states the message. > Sender position himself or herself in front of the intended receiver.

> The first name of receiver is used to get his or her attention.

> Caution: Three-way communication does not start with a question; it always starts with a direction.

2. Receiver acknowledges sender. > Receiver paraphrases the message in his or her own words.

> The receiver asks questions to verify his or her understanding of the message.

3. Sender acknowledges the receiver's > If receiver understands the sender response. correctly, then the sender responds with

'That is correct."

> If the receiver does not understand the message as intended, the sender responds with 'That is wrong," (or words to that effect) and restates the original message.

4. If corrected, the receiver acknowledges the corrected message paraphrasing the message in his or her own words.

When the only distinguishing difference between two component designators is a single letter, then the phonetic alphabet form of the letter should be substituted for the distinguishing character. The table below lists substitute words. For example, 2UL-18L and UV-18F would be stated 'two U L eighteen LIMA" and "two U L eighteen FOXTROT."

38

Job Site and I Human Performance the Individual 1% Fundamentals Course Reference Letter Word Letter Word Letter Word Letter Word A Alpha H Hotel 0 Oscar V Victor B Bravo I India P Papa W Whiskey C Charlie J Juliet Q Quebec X X-ray D Delta K Kilo R Romeo Y Yankee E I Echo I L Lima I Sierra I Z I Zulu F Foxtrot M Mike T Tango G Gulf N November U Uniform Some key words can be used to convey specific meanings, when communicating operational information critical to plant or personnel safety. For instance, "STOP" should be used to immediately terminate any action or activity before harm is realized. 'CORRECT" means sender has confirmed understanding of the receiver. "WRONG" conveys clearly a lack of understanding of the meaning of the intended message. Other words can be reserved for special meanings related to the organization's activities. However, all personnel must be trained in the meaning and use of such operational words.

Verbal communication can either be effective or efficient. Efficient communication is more concerned with the speed of transmission of the message and less with understanding.

However, effective communication requires verification that all parties understand the message.

Errors can occur with either the sender or the receiver. Sending errors include:

• Wrong message is sent or message is unclear.

• Message is inconsistent with other information; creates confusion. Content may conflict with non-verbal cues of the sender or with the context of the activity. For example, specific values are stated when operators report the state of critical parameters during off-normal plant situations.

• Message is unsuitable for the receiver. Sender fails to consider the receiver's work situation, role, knowledge, or terminology (such as an operator talking to an engineer).

• Message is not transmitted adequately (such as not loudly enough or by imprecise enunciation of words).

• Message is not sent.

• Message is transmitted to the wrong person or place. This error is more prevalent when the communication is not face-to-face, such as telephone, e-mail, or radio.

• Message is transmitted at the wrong time, either too early or too late to be useful to the receiver.

• Sender fails to verify receiver accepted and understood the message.

Just as the customer is responsible for verifying the accuracy of a pizza delivery order over the telephone, so is the sender responsible for the accuracy and understanding of the message received by the receiver. Errors by the receiver include:

39

Job Site and Human Performance the Individual X Fundamentals Course Reference

• Message (written) is not found or used. This is similar to the first error. Also, the message may be disregarded.

• Message is not sought. Receiver does not seek information necessary to perform a task.

• Message is misunderstood.

• Receiver does not check with sender to verify understanding.

The will to communicate is an attitude, a conviction. In all disasters around the world that were analyzed, information was available before or during the tragedy that could have prevented the outcome. In every case, either the information was not acted on, or it was not sought out, or it was not passed on, or it did not get through. 66 Communication is, perhaps, the most effective defense in the prevention of errors and events. The will to communicate and the means to communicate must prevail in the organization. People must believe communication of either facts or feelings is a desirable behavior and will be reinforced. Assertive communication is essential to effective execution of some error-prevention methods (such as peer-checking, concurrent verification, teamwork, problem-solving, conservative decision-making), feedback, self-assessments, coaching, prejob briefings, etc. In today's society, it's easy to keep quiet, not wanting to draw attention to oneself. However, when the safety of the plant or people are at risk, speak up! Excessive professional courtesy for one's superior can lead to team errors (see Team Errors at the end of this chapter.).

Any level or function of an organization can impede the flow of information. Obstacles to communication, whether formal or informal, must be rooted out to maintain all communication channels open, up, down, or across the organization. Consequently, every individual of the organization is responsible to request needed information, verify he or she accurately understand it, pass it on to those who need or could use the information, or act on it.

Procedure Use and Adherence. The need to use and adhere to procedures is well understood and accepted in the nuclear industry. Effective procedure performance is fundamental to safe operation of the plant. Procedures are used to ensure activities are performed correctly, safely, consistently, and in accordance with licensing requirements.

However, lack of clear direction from management often leads to errors by the worker and is frequently identified as a cause of plant events or equipment problems. Technical procedures are written to direct desired behavior for the various complex and technical work that is performed in the station. Procedures incorporate the policies, operating experience, effective practices, and management decisions about how a task is to be performed. Procedures are intended to direct people's behavior in a proper sequence and to minimize the choices users have to make. Experience has shown that procedures may not contain sufficient information for the user. With turnover of the workforce, younger workers take the place of more experienced personnel. When workers are forced to interpret a procedure's use and applicability, the chance for error is increased. The quality of the procedure is paramount, especially if the task involves risk-significant systems or components.

Expectations for procedure use specify the minimum required reference to the procedure during the performance of a task, such as continuous use (in-hand), reference use, and information use. Procedure adherence means following the intent and direction provided in the procedure regardless of the level of use. Some procedures are used so often, that the individual becomes skilled with the procedure. These are no longer rule-based tasks, but skilled tasks. One's proficiency with a procedure (frequency of use and how recently it has been used), and the risk associated with the task are the primary factors used to determine the level of use.

Three levels of procedure use frequently encountered in the industry are defined as follows:

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Job Site and Human Performance the Individual 'j Fundamentals Course Reference

• Continuous Use. The procedure is in hand and followed step-by-step; each step is completed prior to commencing following step. The expected response(s) of an action is understood before the action is taken, and responses to actions are verified before proceeding with the next step. In most cases the activity will have an immediate, adverse impact on plant or personnel safety if performed incorrectly-that is, an error is not recoverable before suffering undesirable consequences. Also, 'Continuous Use" should be required if the activity is either complex (beyond 'skill-of-the-craft") or infrequently performed by the person assigned.

• Reference Use. Segments of the procedure can be carried out by memory and does not necessarily have to be in hand, but is followed step-by-step. 'Reference Use" is appropriate if incorrect performance will NOT have an immediate adverse impact on plant or personnel safety, being recoverable. The procedure or work package is reviewed periodically during performance of the task to verify all steps are being completed as written, and all segments have been performed. Also, 'Reference Use" is allowable if the task is relatively simple (within skill of the craft) or is performed frequently enough by the person assigned such that proficiency has been maintained. "Reference Use" procedures should be available to users at the job site.

• Information Use. The procedure can be carried out by memory, section-by-section, allowing resequencing of steps within the section; also known as "periodic" use.

Incorrect performance has no impact on plant or personnel safety. Such tasks are simple to carry out regardless of the person assigned. Administrative procedures usually are designated "Information Use."

Working copies of procedures are used in the field when record keeping is required at multiple or remote work locations. These procedures should be stamped "Working Copy" to distinguish them'from other copies. Reference copies of procedures require no recording of data, signatures, or initials. Typically, reference copies are used, while another individual completes a working copy in the field based on first-hand knowledge of the outcome of each step. First-hand knowledge exists when one observes or performs an action, or one receives a direct report from an individual who performed the action. If working copies of procedures are contaminated, a photocopy may be made, or data, signatures, and initials can be transferred to another copy of the procedure. A photocopy is preferable, since it is less likely to involve errors.

Occasionally, procedure non-use becomes the accepted norm, especially if management has tacitly accepted the practice. Procedure quality suffers if adherence is not held to high standards. Over time the station workforce experiences turnover, and plant equipment is modified. If procedures are unused, or used in a casual manner, needed changes to the procedure may not be identified. Worse, an inexperienced user may follow an outdated procedure verbatim and trigger an event. Obviously, formal policies and resulting expectations

'on the use and adherence of procedures should be established.

Certain words have special meanings in procedures and should be defined clearly. Typically, "shall" denotes a requirement, usually a regulatory requirement or commitment. The words

.will" and "must" should be interpreted as "shall." "Should" denotes a management expectation with no link to regulatory requirements; the individual is to perform the action unless there is a good reason not to. uMay' implies an allowable or permissible action (not a requirement or recommendation), if conditions warrant it; "shall" and "should" do not apply. "Ensure" or "verify" direct the user to establish the stated condition or status if not already established. "Check" directs the user to determine the status or existing condition, but does not allow changing that status or condition without explicit approval from responsible authority.

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Job Site and I Human Performance the Individual P; Fundamentals Course Reference Procedures are developed with two assumptions: all required equipment is operating correctly, and the necessary plant conditions have been established. Consequently, a given procedure may not work every time. Users must be alert to plant situations to identify when procedures cannot be performed as written for the plant conditions. Not only should procedures match plant conditions, but procedures also should be developed to match the skills and knowledge of the people who will use them. Processes related to procedure development and revision can encourage use and adherence by the following:67

• Clearly delineating key decision points or critical steps in a procedure

• Keeping procedures simple at a level of detail that matches user knowledge and ability

• Minimizing mental and physical workload (burden)) as well as personal risk of injury to the user

• Reducing in-field interpretations or decision-making not guided by the procedure

• Using a language and terminology that is clear to the user

• Eliminating inconsistencies internal to the procedure and between procedures (such as mutually exclusive actions and actions incompatible with equipment or plant state)

• Improving familiarity with key procedures by training individuals to a skill-based level

• Enhancing usability by adhering to established human factors principles in both procedures and work instructions (such as salience of information, referencing, branching, graphics, tables, organization, and presentation style)

• Eliminating drawing and technical errors Individuals can improve their personal effectiveness using procedures by:

• Improving their knowledge of procedure bases

• Verifying the procedure to be used in the field is the most up-to-date version of the document by checking its revision number and date against an authorized list of effective procedures

• Rereading the previous two or three steps of a procedure before proceeding with a task after being distracted, interrupted, or delayed

• Practicing transitions between procedures

• Using placekeeping methods rigorously Procedures are not perfect. All will have some flaws. Some flaws can possibly impact plant and person. "Thinking compliance" must be used-a questioning attitude while using a procedure. If a procedure cannot be performed as directed by the approved document, then:

• Stop the job.

• Place the system, equipment, and components in a safe condition.

• Contact the supervisor and recommend corrective action, if able.

• Resolve the problem.

Various guidelines regarding procedure development are not included in this document, since many other useful references have been published on this important topic. However, the reader is encouraged to refer to EPRI technical reports or to benchmark this issue at other 42

Job Site and Human Performance the Individual Fundamentals Course Reference organizations. EPRI's Procedure Usability Measurement Process (PUMP) can be used to determine a procedure's usability.6 8 Stop When Unsure. When confronted with a situation that creates a question, a person is in uncharted (unfamiliar) territory-a knowledge-based performance situation. Given the chances for error are particularly high in a knowledge-based situation (1 in 2 to 1 in 10), the best course of action, when unsure, is to stop and get another 'mind' on the problem (also known as "timeout"). For collaboration to occur, people must recognize when they are in knowledge-based situations. Whenever a question is encountered and what to do about it is uncertain, stop and get help. Get help from those who possess the expertise, not necessarily from those of higher rank.6 9 One plant instituted a policy that "You cannot answer your own question." 7 0 The aim is to make the best decision by promoting collaboration and group problem-solving.

Also, when that 'gut feeling" is telling you that something is not right, stop. This also applies when one experiences, "What am I doing here?" or 'I'm here, but can't remember what I am supposed to do." Don't be embarrassed, stop and collaborate!

Prejob Briefing. There are two primary purposes of the prejob briefing: 1) to prepare workers for what is to be accomplished, and 2) to sensitize them to what is to be avoided. Most prejob briefings do not adequately address what to avoid. Error prevention is not adequately addressed, even when the first-line supervisor reminds the work crew, "Make sure you self-check!"

A task preview should occur before the prejob briefing. This involves giving the worker time to review the task before participating in the prejob briefing. This provides the individual with a concept of the task, what the task is trying to accomplish, and what to avoid, especially if the task was addressed during work planning or the walkdown. See SAFER in Chapter 5 for a description of a task preview technique.

Knowing the critical steps before conducting an activity can save the plant from unnecessary trips and transients. Workers are forewarned when their attention must be piqued, and they will more readily recognize where and what to self-check. Self-checking is more effective when a good pre-job briefing has taken place.

Prejob briefings should be a dialogue among the participants, rather than a monologue by the first-line supervisor or a lead technician. A genuine dialogue will uncover subtle conditions that could lead to error. Intelligent conversations between the team members will help recognize assumptions, error traps, and misunderstandings that could lead to an event.

Prejob briefings should be conducted for routine as well as infrequently performed or complex tasks. Routine tasks are usually simple and/or repetitive. Experience shows that many events occur during 'routine' activities. Given human nature, there really is no such thing as "routine."

Questioning Attitude. A questioning attitude encourages foresight to precede actions, to make sure planning, judgment, and decision-making are appropriate for the situation. A questioning attitude fosters awareness of uncertainty and hazards. Recognizing hazards or error-likely situations while on the job is greatly dependent on this attitude. It is similar to defensive driving.

Uneasiness toward human fallibility, especially when performing physical work on plant equipment, is important to a healthy questioning attitude. Also, intolerance for uncertainty, error traps, and degraded defenses is effective only with a questioning attitude. A reluctance to fear the worst is aggravated by human nature, since humans tend to accentuate the positive. A healthy questioning attitude must overcome the temptation to rationalize away "gut feelings" of something not right.

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Job Site and Human Performance the Individual Fundamentals Course Reference Foresight is the level of attention given to understanding the significance and nature of near-term actions before proceeding with an action. In other words, the individual looks ahead for the presence of hazards before changing the state of equipment. Each individual should think not only about 'my actions," but also about 'equipment response." If one is conscious of only a given action and not to the plant or system at large, the individual is mindlessly following the procedure, which is known as 'cookbooking." Similarly, use of "thumb rules" leads to the application of familiar solutions to familiar problems. The routine use of thumb rules can promote an 'unthinking' response to perceived 'simple" problems.

A questioning attitude is enhanced by a good prejob briefing that explicitly includes a dialogue on hazards, critical parameters, and error traps and their potential consequences. Using an "If-Then" logic or "What if...," questions can help improve people's foresight and situation awareness. A questioning attitude should also lead to the practice of using multiple, alternative indications (facts). Indications of critical parameters are verified against independent, alternative indications to improve comprehension of the actual state of equipment. Knowing the critical parameters that readily indicate the effect of an action aids in responding to offnormal situations correctly. Therefore, agreement on critical parameters important for plant safety or job success should be reached before an activity is begun.

Placekeeping. Placekeeping involves reliably marking steps in a procedure that have been completed or that are not applicable (skipped). Placekeeping is particularly important for plant status and configuration control as well as reassembly of equipment after maintenance, or any situation when the consequences of skipping, repeating, or partially completing a step would result in adverse consequences. The method should help the user maintain positive control of steps completed and those yet to be performed. It is especially useful if the user is interrupted or delayed, such as at turnover and shift change, allowing the user to go to the last step performed. The technique may differ for each procedure depending on factors such as the layout and logic of the procedure and the importance of the task with respect to safety and reliability. 7 2 Navigating a procedure, especially a detailed one involving branching and multiple decision points, can place the physical plant in jeopardy if steps are omitted or performed in' an incorrect sequence. As workers perform a task, their attention constantly shifts from the procedure to the controls, to indicators, to physical equipment, to other people, and so on. Therefore, placekeeping becomes an important error-prevention technique.

The following practices are examples from the industry that enhance placekeeping:

• Performing page checks to verify no pages are missing prior to use

• Blacking out procedure steps that are unot applicable"

• Rereading the previous two or three steps performed after being distracted

• Proceduralizing peer checks for the risk-significant steps

• Providing sign-offs for each step (signatures or initials), documenting completion

• Circling a step denoting 'in progress" and slashing through the circle to indicate completion of the step

• Annotating completion of a page in the bottom margin of the procedure

• Identifying which page is the last in a procedure by printing "LAST PAGE."

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Job Site arlA Human Performance the Individual IC Fundamentals Course Reference Procedure steps are usually signed off as completed by the person performing the step. In some cases a second person is allowed to sign off a step as completed only when in direct contact with the performer. When a second person is required, the second individual should sign for" the performer, such as "JCS for TMM."

Some placekeeping/signoff practices should NOT be used such as the following:

• Using check marks instead of initials or signatures for continuous use procedures, unless the procedure specifically allows it

• Ditto marks (")

• One set of initials followed with a line through remaining signoff blanks

• Signing off a step as completed before it is Several other error-prevention practices are used across the industry. Other techniques that could be used include the following:

Concurrent Verification. Concurrent verification (CV) (also known as 'double' verification) is the act of having a second qualified individual verify the correctness of an action and the expected result before and during the action. CV aims to prevent errors. It is used when an action or manipulation, if performed in error, could result in an immediate threat to safe and reliable plant operation (for example, throttling a valve, installing a jumper, lifting an electrical lead, or operating a switch or breaker), personal safety, or result in a significant transient. This error-prevention technique is usually reserved for predetermined actions of a critical nature that are usually directed by a procedure. It is important to identify those situations that could result in an immediate threat to safe and reliable plant operation and designate the use of CV for such actions. Individuals performing a CV review intended actions and expected responses before the act is performed. CV is generally documented formally. The operations perspective of the process is described in detail in section VI of INPO 01-002, Guidelines for the Conduct of Operations at Nuclear Power Stations (Component Configuration Control).

Persons performing a CV should be qualified with the CV technique, and qualified technically for the job.

A supervisors can decide to use CV, if the nature of the work warrants it based on the following conditions:

• Complexity of the action(s)

• Chance of missing the step / section exists due to excessive redundancy

• Human factors or ergonomic constraints such as difficult access, poor labeling, limited visibility, etc.

• Limited ability to test or verify status before restoration or repositioning

• Limited experience or proficiency of individual involved Self-checking is always performed during CV, but CV can be confused with other two-person techniques. Peer-checking accomplishes the same function as CV, but peer-checking can be requested by anyone at any time for any action for which a greater degree of human reliability is desired. Also, keep in mind that CV is not independent verification. Whenever the principal individual performs an action in the physical presence of the checker, the acts are not independent. People in the presence of others are always influenced despite their best efforts.

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Job Site and Human Performance the Individual in Fundamentals Course Reference However, two objective self-checks should occur, one by each person, while minimizing the influence (leading) of the performer on the checker.

Independent Verification. Independent verification (IV) is an additional verification of product quality or system state by a second qualified individual, operating independently after the original performance, to verify a specified condition exists. Peer-checking and concurrent verification are designed to catch errors before they are made. IV on the other hand, catches errors after they have been made. Consequently, IV is used when an immediate consequence to the plant or equipment is unlikely should an action be performed incorrectly. It is an act of checking a component's or document's status independent of the actions that established the existing state. Qualified has the same meaning as explained earlier for CV. The operations perspective of the process is described in detail in section VI INPO 01-002, Guidelines for the Conduct of Operations at Nuclear Power Stations (Component Configuration Control).

Independence requires separation in time and space between the individuals involved to ensure freedom of thought. True independence cannot be established if one individual is looking over the shoulder of the other, even from a distance. An advantage of rigorous independent verification is higher assurance of actual component condition. A disadvantage is the additional time, exposure, and costs necessary to maintain rigorous independence of verifications.

Important management aspects of the technique include identifying which components require verification, defining situations that require independent verification, defining methods for performing the independent verification, and training personnel in the use and bases of the methods. Methods must ensure that all personnel perform IV in the same fundamental manner.

Methods will likely vary depending on the type of component, such as air-operated valves, manual-locked valves, fuses, circuit breakers, and others. Not all components require verification, because the possibility of error may be remote or the effect of an error may not be significant to safe and reliable plant operation. In some cases, it would be unreasonable to use IV if it would require undoing what the first person did, such as for work on locked valves and installation of fuses. Such situations may actually require concurrent verification. Therefore, it is important to designate systems and components to be verified and the appropriate verification method for the situation.

Problem-Solving. Problem-solving is a classic indication that the individual or group is in a knowledge-based situation. There is unfamiliarity with the issue, it has been characterized as a problem that must be solved, and individuals dealing with the issue may lack fundamental knowledge of the situation. Everyone eventually experiences situations that do not match what is desired, and the path to achieve the desired goal is vague or unknown. Consequently, the chance for error increases dramatically in a knowledge-based work situation. Without guidance, human beings do not usually solve problems rigorously, methodically, or painstakingly. People need a disciplined approach to problem-solving and become so well practiced with the approach that they will maintain it during stressful situations. Without practice, people will default to what they are comfortable with-that is,trial-and-error.

This is commonly the case during problem-solving meetings. Frequently, meetings are conducted to solve problems that cannot be handled as well individually. Errors can be made during meetings, mostly because of inaccurate mental models and misinterpretation of information. Open communication is key to overcoming these hindrances. The accuracy of various mental models being used to deal with problems must be verified by those participating.

This is particularly difficult, since most mental models are tacit, existing below the level of awareness. This could lead to more assumptions being made, especially if factual information is not readily available.73 46

Job Site and Human Performance the Individual X Fundamentals Course Reference Any obstacle that can hinder the free flow of communication must be identified before the problem-solving task is performed. Inaccurate mental models will persist if a dialogue of factual information is inhibited. In addition to the problem-solving task, participants must be keenly aware of ongoing group processes, such as conflict resolution, brainstorming, social loafing, groupthink, personality conflicts, and so on (See Team Errors near the conclusion of this chapter.). Groupthink, in particular, must be guarded against, because it can result in poor decisions with disastrous outcomes. Individuals may censor themselves to maintain cohesiveness with the group. Consequently, the group may possess inaccurate perceptions about hazards, pitfalls, and even error-likely situations.

A fundamental problem-solving technique includes many or all of the following elements: 74

• Define the problem-that is, the gap between actual and desired conditions.

• State the goal(s) clearly. Prioritize them if more than one.

• Establish an accurate mental model of the system. Gather as much information relevant to the problem as time permits (Some data may be missed.).

• Identify alternatives that could accomplish the goal(s).

• Decide on a course of action that achieves goal(s), considering risks and costs.

Consider guidelines for conservative decision-making.

• Plan by considering several solutions or courses of action.

• Predict potential outcomes and side effects ("what if?").

• Execute the plan.

• Review the outcomes and adapt (any of above steps).

Sometimes problem-solving occurs during stressful situations. To be better prepared for such situations, consider the following suggestions to improve problem-solving performance:

• Start problem-solving meetings with a review of the agenda, critical decisions to be made, the potential consequences of a bad decision and how a bad decision can be avoided.

• Use data, not assumptions, as facts.

• Assign the role of devil's advocate to someone to challenge assumptions, decisions, and so on, using direct questions (See the technique for challenging assumptions described in Knowledge-Based Performance of this chapter). Beware leaps in logic.

Encourage people to identify facts that support their assertions. This encourages reflection and deeper reasoning.

• Strengthen people's ability to work cooperatively with others. Practice using team conflict management and communication skills. Do not let personality conflicts or emotions influence decisions. Frustration should be recognized as a cue to ask more questions.

• Be cautious of problem-solving dominated by one individual. It is difficult to see your own mistakes, and others may not be given the opportunity to share their ideas or challenge that person's reasoning.

• Enhance people's fundamental knowledge of scientific principles and mental models of the plant hardware and human systems. Use system/component knowledge and 47

Job Site and Human Performance the Individual gFundamentals Course Reference fundamental principles of physical sciences associated with plant systems and components in unfamiliar situations.

• Adopt a methodical problem-solving technique such that people do not default to trial-and-error methods during stressful circumstances.

• Practice using the methodical diagnostic and problem-solving techniques with simulated, unfamiliar situations under various levels of time pressure. Develop and practice lateral thinking skills-that is, solving problems with no explicit directions on how to proceed.

• Buy time by delaying the deadline to respond. This reduces time pressure, allowing the thinking process to proceed more slowly, improving the chances for success.

• Promote generation of ideas using group techniques such as brainstorming and the nominal group technique.

Conservative Decision-Making. Conservative decision-making is a rule-based and knowledge-based performance strategy that places the safety needs of the physical plant, in particular the reactor core, above the near-term production goals of the organization. Most often, these choices are rule-based in that the decision to make is usually clear. However, choices may not always be absolutely clear, as is in situations one is uncertain what to do. The conservative decision will remain illusive until the operational problem has been deliberately and methodically thought out. Even then, the decision must be considered suspect. If an individual recognizes a manipulation error, he or she must "think" before reacting. Simply reversing an act that was done in error, for instance, reconnecting a terminal lead after it has been removed, may do more damage than good.

Short-term decisions are those made without a formal engineering analysis. In these situations, the following guidance can be used:

• Stay within a safe operating envelope.

• Use all available information.

• Avoid hasty decisions or hurried actions.

• Use all available people who can provide additional insight. At a minimum, the control room team should be used for operational decisions.

• Develop contingency actions if time allows.

• Minimize uncertainty, and do not proceed when uncertain.

• Do not allow economics to preempt safety (production).

Long-term decisions enjoy the luxury of time allowing the support of formal analysis. Such decisions should be guided by the following principles:

• Use all available information.

• Use all available qualified personnel including offsite support if necessary.

• Maintain plant parameters within a safe operating envelop.

• Minimize as much uncertainty as possible. Rely on data, and challenge assumptions.

• Verify changes to safe operating parameters are fixed, understood, and trusted by the worker.

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Job Site and Human Performance the Individual Fundamentals Course Reference

• Develop contingency actions to place plant structures, systems, or components in safe conditions if limits are exceeded.

• Involve upper management in the decision-making, taking advantage of worker input.

• Consider the cumulative risk of all decisions made (for situations involving more than one decision).

• Consider long-term consequences of minimizing loss of revenue (trust of regulator, public, and staff).

Decisions are reviewed after the fact to publicly reinforce conservative decisions, privately coach or counsel personnel who make non-conservative decisions, and incorporate lessons learned.

As the industry becomes more competitive, operators must not let pressure to keep the plant running affect conservative decisions needed to operate the plant safely, particularly regarding the reactor core. A corollary of this is that operators must not feel a sense of haste. Haste can lead to nonconservative action. Conservative acts demand support and positive recognition by managers and should not be criticized. Regrets about conservative decisions should not be made public. Individuals, despite their positions, should not criticize team decisions to be conservative. Incentive programs and reinforcement must be consistent with this policy.

Additional information on conservative decision-making can be found in Operational Decision Making (a Professionalism series document); Significant Operating Experience Report (SOER) 94-01, "Nonconservative Decisions and Equipment Performance Problems Result in a Reactor Scram, Two Safety Injections, and Water-Solid Conditions"; SOER 96-01, "Control Room Supervision, Operational Decision-Making, and Teamwork"; and INPO 01-002, Guidelines for the Conduct of Operations of Nuclear Power Stations.

Flagging. Several events have been attributed to an individual starting an activity on one component, taking a break or otherwise distracted from the component, and performing manipulations on the wrong component. Wrong unit, wrong train events were at one time a frequent occurrence. These kinds of errors have decreased dramatically with improved labeling, color-coding, and procedures to guide the user. However, to further enhance the probability of working only on the correct equipment, some stations have implemented "flagging" that either denotes the correct component to work on or highlights those "not" to touch during an activity. Exelon stations developed this technique and have a great deal of experience and success using the practice.

Operating Experience. A key to effectively using operating experience is for the right information to be communicated to the right people in time to make a difference. It is unreasonable to expect workers to recall lessons learned from training that was provided months or, perhaps, years earlier. Hence, the station should make effective use of the operating experience information tools (for example, Nuclear Networke and the INPO Website) and have a systematic way of providing "just-in-time" relevant operating experience information to workers. The "Prevent Events" section in INPO operating experience documents provides insight that may be pertinent to a person's role and the technical elements of the task.

Operating experience that is properly reflected in procedures should lessen the severity and number of recurring problems. Other documents such as standing orders, lesson plans, and the work planning process may also be used to incorporate operating experience information.

People have an innate or natural tendency to think "it can't happen here," or "that won't happen to me." Humans underestimate risk and overestimate their ability to maintain control. None of 49

Job Site and Human Performance the Individual X . Fundamentals Course Reference us think we will make a mistake. This sense of invulnerability is a unsafe attitude. Do not underestimate the difficulty of using and internalizing operating experience. Prudent use of operating experience must be a relentless pursuit of leadership. Lessons learned can be reinforced during various training forums and through day-to-day activities such as, prejob briefing, job-site coaching and reinforcement by supervisors, and engineering decisions. What expectations have been established for the routine use of operating experience information?

Do managers and supervisors use operating experience as an input for their own field monitoring activities? Is access to operating experience information in support of work preparations and prejob briefings convenient ("just-in-time)? Is appropriate operating experience used to highlight potential consequences of an evolution or task? How are post-job reviews used to capture lessons learned from in-house experience? Questions such as these provide insight into the effective dissemination of operating experience information.

Supervisory Monitoring. Supervisory presence in the work place can be an effective defense against error. Errors are less likely when supervisors are in the field. Supervising field activities provides the technician or operator another set of eyes to detect and recover from error, as well as 'see" conditions that could provoke error. Through work preparation, pre-job briefings, field observations, coaching, reinforcing, and counseling, worker performance is enhanced, and the physical plant is challenged less from error, at-risk practices, and violations.

Supervisors should, and are expected to, exercise their authority to protect the plant and personnel. Maintaining high standards of performance minimizes complacency, and focusing on professional, caring relationships with individual workers promotes healthy communication about work-place conditions that pose obstacles to error-free performance. Knowledge of critical tasks, critical parameters, critical steps, and vital points will aid their oversight. Because of their unique, uninvolved role, they are typically able to see potential barriers to completing assigned tasks and can take appropriate measures to remove them from the activity.

Supervisors, when they detect at-risk practices or behaviors that do not satisfy expectations and standards of performance, can take the opportunity to coach, reinforce, and counsel as needed.

In the field supervisors can solicit feedback. Communications with subordinates should promote a spirit of cooperation, mutual respect, honesty, and fairness. This environment encourages workers to willingly bring up issues and share what is hindering their ability to accomplish assigned tasks.

Entergy Operations established a utility-wide standard for 'contact time" for in-field monitoring.

Contact Time is defined as 'the cumulative amount of time spent in the company of employees, observing and coaching their behaviors." 75 Internal studies revealed that each station's error rates dropped with a corresponding increase in contact time.

TEAM ERRORS Why do events happen when there are two or more people working on a task? Doesn't a second set of eyes provide an additional defense against error? How can anything go wrong?

Just because two or more people are performing a task does not ensure that it will be done correctly. In team situations, workers may not be fully attentive to the task, or may be otherwise influenced co-workers. Several socially related factors influence the dynamics among individuals on a team. Team errors are shortcomings in performance that can be triggered by the social interaction among group members. For instance, data at one nuclear station shows that operations' configuration control issues, which usually involve concurrent or independent verification, are particularly subject to the dangers of 'social loafing." 76 50

Job Site and Human Performanee the Individual Fundamentals Course Reference Social Loafing. 77 Because individuals are usually not held personally accountable for a group's performance, some individuals in a group may not actively participate. As the saying goes, "there is safety in numbers." People refrain from becoming involved believing that they can avoid accountability, or "loaf," in team, or "social," activities.

Team errors are stimulated by, but are not limited to, one or more of the following situations:

• Halo Effect - This results from blind trust in the competence of specific individuals because of their experience or position in an organization. Consequently, other personnel drop their guard against error by the competent individual, and vigilance to check the respected person's actions weakens or ceases altogether.

• Pilot/Co-pilot - A subordinate person (co-pilot) is reluctant to challenge the opinions, decisions, or actions of a senior person (pilot). Subordinates may express "excessive professional courtesy" when interacting with senior managers, unwittingly accepting something the boss says without critically thinking about it or challenging the person's actions or conclusions. 8

• Free Riding - If one person takes the lead in a group activity, others may tend to 'tag along' without actively scrutinizing the intent and actions of the person doing the work.

"The other person is 'thinking' about the task." Or, they may feel, "it's not my job."

• Groupthink- This is a reluctance to share contradictory information about a problem for the sake of maintaining the harmony of the work group. This is detrimental to critical problem-solving. Highly cohesive, tight-nit groups are particularly susceptible to this kind of team error. Usually, this is worsened by one or more dominant team members who possess considerable influence on the group's thinking (pilot/co-pilot or halo effect). Consequently, critical information known within the group may remain hidden from other team members. Groupthink can also result from too much "professional courtesy"-subordinates passing on only "good news" or "sugar-coating" bad news so as to not displease their bosses or higher level managers.

• Risky Shift - There is tendency to gamble with decisions more as a group than if each group member was making the decision individually.79 Accountability is diffused in a group. If two or more people agree together that they know a "better way" to do something, they will likely take the risk and disregard established procedure or policy.

This has been referred to as a "herd mentality." In the worst case, this is how riots get started.

Competence vs. Control.80 Humans are fallible, and even the best people can make the worst mistakes.81 Regardless of who a person is and what position he or she holds in an organization, that person can err. Therefore, controls (defenses and error-prevention techniques) are adopted to prevent, catch, or mitigate the outcomes of error. The purpose of these controls is to make the process (or task) go smoothly, properly, and according to high standards.8 2 Remember, positive control means that 'what is intended to happen is what happens, and that is all that happens.' Some people may be insulted when others check their work. When people are directed to check or review another person's performance, the competence of the performer is not being called into question as some may think. Controls are necessary because of human fallibility, not incompetence. The fact that a person is assigned a task means he or she is considered competent, or qualified, to perform the activity. Human nature is the problem, and 'controls" are needed to reduce the chances for error.

Antidotes to Team Errors. The following strategies can be used to reduce the occurrence of team errors:

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Job Site and Human Performance the Individual Fundamentals Course Reference

• Train on team errors and their causes.

• Practice questioning attitude/situation awareness.

• Designate a devil's advocate.

• Maintain independence in thought from other team members.

• Challenge actions and decisions of others.

• Call "time outs" to help the team achieve a shared understanding of plant or product status.

• Perform a thorough and independent task preview. (See Chapter 5 for a description of task preview.)

• Participate in formal team development training 52

Job Site and Human Performance the Individual lIE Fundamentals Course Reference ERROR PRECURSORS (long list)

The conditions listed below were derived from an in-depth study of INPO's event data base and several highly regarded technical references on the topic of error. Many references refer to error precursors as behavior-shaping factors or performance-shaping factors. The bolded error precursors are more prevalent and are listed in order of impact. Other error precursors are not listed in any particular order.

Task Demands Individual Capabilities Time pressure (in a hurry) Unfamiliarity with task I First time High workload (memory requirements) Lack of knowledge (faulty mental model)

S Simultaneous, multiple tasks New technique not used before Repetitive actions I Monotony Imprecise communication habits Irreversible actsm Lack of proficiency I Inexperience 0 Interpretation requirements Indistinct problem-solving skills S Unclear goals, roles, or responsibilities 'Unsafe' attitudes for critical task Lack of or unclear standards Illness I fatigue (general health)

Confusing procedure / Vague guidance Unawareness of critical parameters Excessive communication requirements Inappropriate values S

Delays; idle time Major life event: medical financial, and emotional Complexity / High information flow Poor manual dexterity Long-term monitoring Low self-esteem; moody Excessive time on task Questionable ethics (bends the rules)

Sense of control I Learned helplessness Personality type Work Environment Human Nature Distractions / Interruptions Stress (limits attention)

Changes / Departure from routine Habit patterns Confusing displays / controls Assumptions (inaccurate mental picture)

Work-arounds / OSSO Instrumentation Complacency I Overconfidence Hidden system response Mind-set Unexpected equipment conditions Inaccurate risk perception (Pollyanna)

Lack of alternative Indication Mental shortcuts (biases)

Personality conflicts Limited short-term memory Back shift or recent shift change Pollyanna effect Excessive group cohesiveness / peer pressure Limited perspective (bounded rationality)

Production overemphasis Avoidance of mental strain Adverse physical climate (habitability) First day back from vacation / days off No accounting of performance. Sugar cycle (after a meal)

Conflicting conventions; stereotypes Fatigue (sleep deprivation and biorhythms)

Poor equipment layout; poor access Tunnel vision (lack of big picture)

Fear of consequences of error Something is not right (gut feeling)

Mistrust among work groups Pattern-matching bias Meaningless rules Social deference (excessive professional courtesy Nuisance alarms Easily bored Unavailable parts or tools Close-in-time cause-effect correlation 53

Job Site and Human Performance the Individual U- Fundamentals Course Reference

• Acceptability of 'cookbooking' practices

• Difficulty seeing own errors

• 'Rule book culture

• Frequency and similarity biases

• Equipment sensitivity (inadvertent actions)

• Availability bias

• Lack of clear strategic vision or goals

• Imprecise physical actions

• Identical and adjacent displays or controls

• Limited attention span

• Out-of-service warning systems 0 Spatial disorientation

• Lack of procedure place-keeping Physical reflex

• Anxiety (involving uncertainty) l Irreversible actions are not necessarily precursors to error, but are often overlooked, leading to preventable events. It is included in this list because of its importance.

° OOS - out of service 54

Job Site and Human Performance the Individual Fundamentals Course Reference COMMON ERROR PRECURSOR DESCRIPTIONS The first eight error precursors from the table on the previous pages are described below.

These tend to be the more commonly encountered conditions that provoke errors. The error precursors for each category are arranged in order of influence.

3."";& S *,

Time pressure Urgency or excessive pace required to perform action or task (in a hurry) Manifested by shortcuts, being in a hurry, and an unwillingness to accept additional work or to help others No spare time High workload Mental demands on individual to maintain high levels of (high memory requirements) concentration; for example, scanning, interpreting, deciding, while requiring recall of excessive amounts of information (either from training or earlier in the task)

Simultaneous, multiple tasks Performance of two or more activities, either mentally or physically, that may result in divided attention, mental overload, or reduced vigilance on one or the other task Repetitive actions / Inadequate level of mental activity resulting from performance Monotony of repeated actions; boring Insufficient information exchange at the job site to help individual reach and maintain an acceptable level of alertness Irrecoverable acts Action that, once taken, cannot be recovered without some significant delay No obvious means of reversing an action Interpretation requirements Situations requiring 'in-field" diagnosis, potentially leading to misunderstanding or application of wrong rule or procedure Unclear goals, roles, & Unclear work objectives or expectations responsibilities Uncertainty about the duties an individual is responsible for in a task that involve other individuals Duties that are incompatible with other individuals Lack of or unclear standards Ambiguity or misunderstanding about acceptable behaviors or results; if unspecified, standards default to those of the front-line worker (good or bad) 55

Job Site and Human Performande the Individual Adz Fundamentals Course Reference 0 0 - 3- S 0 Distractions / Interruptions Conditions of either the task or work environment requiring the individual to stop and restart a task sequence, diverting attention to and from the task at hand Changes / Departure Departure from a well-established routine from routine Unfamiliar or unforeseen task or job site conditions that potentially disturb an individual's understanding of a task or equipment status Confusing displays I Characteristics of installed displays and controls that could controls possibly confuse or exceed working memory capability of an individual Examples:

• missing or vague content (insufficient or irrelevant)

• lack of indication of specific process parameter

• illogical organization and/or layout

• insufficient identification of displayed process information

• controls placed close together without obvious ways to discriminate conflicts between indications Work-arounds / Uncorrected equipment deficiency or programmatic defect Out-of-Service requiring compensatory or non-standard action to comply with instrumentation a requirement; long-term materiel condition problems that place a burden on the individual Hidden system response System response invisible to individual after manipulation Lack of information conveyed to individual that previous action had any influence on the equipment or system Unexpected equipment System or equipment status not normally encountered condition creating an unfamiliar situation for the individual Lack of alternative Inability to compare or confirm information about system or indication equipment state because of the absence of instrumentation Personality conflict Incompatibility between two or more individuals working together on a task causing a distraction from the task because of preoccupation with personal differences 56

Job Site and Human Performance the Individual IC Fundamentals Course Reference Unfamiliarity with task / Unawareness of task expectations or performance standards First time First time to perform a task (not performed previously; a significant procedure change)

Lack of knowledge Unawareness of factual information necessary for successful (mental model) completion of task; lack of practical knowledge about the performance of a task New technique not used Lack of knowledge or skill with a specific work method required before to perform a task Imprecise communication Communication habits or means that do not enhance accurate habits understanding by all members involved in an exchange of information Lack of proficiency / Degradation of knowledge or skill with a task because of Inexperience infrequent performance of the activity Indistinct problem-solving Unsystematic response to unfamiliar situations; inability to skills develop strategies to resolve problem scenarios without excessive use of trial-and-error or reliance on previously successful solutions Unable to cope with changing plant conditions "Unsafe" attitude for Personal belief in prevailing importance of accomplishing the critical tasks task (production) without consciously considering associated hazards Perception of invulnerability while performing a particular task Pride; heroic; fatalistic; summit fever; Pollyanna; bald tire Illness I Fatigue Degradation of a person's physical or mental abilities caused by a sickness, disease, or debilitating injury Lack of adequate physical rest to support acceptable mental alertness and function 57

Job Site and Human Performance the Individual Fundamentals Course Reference MM-  ! IiBy -so

- - - II

_:A.,_

I k, A ,_

n Stress Mlnd s response to the perception OT a tnreat to one s heautn, safety, self-esteem, or livelihood if task is not performed to standard Responses may involve anxiety, degradation in attention, reduction in working memory, poor decision-making, transition from accurate to fast Degree of stress reaction dependent on individual's experience with task Habit patterns Ingrained or automated pattern of actions attributable to repetitive nature of a well-practiced task Inclination formed for particular train/unit because of similarity to past situations or recent work experience Assumptions Suppositions made without verification of facts, usually based on perception of recent experience; provoked by inaccurate mental model Believed to be fact Stimulated by inability of human mind to perceive all facts pertinent to a decision Complacency I A uPollyanna" effect leading to a presumption that all is well in Overconfidence the world and that everything is ordered as expected Self-satisfaction or overconfidence, with a situation unaware of actual hazards or dangers; particularly evident after 7-9 years on the job Underestimating the difficulty or complexity of a task based upon past experiences Mind-set Tendency to "see" only what the mind is tuned to see (intention); preconceived idea Information that does fit a mind-set may not be noticed and vice versa; may miss information that is not expected or may see something that is not really there; contributes to difficulty in detecting one's own error (s)

Inaccurate risk perception Personal appraisal of hazards and uncertainty based on either incomplete information or assumptions Unrecognized or inaccurate understanding of a potential consequence or danger Degree of risk-taking behavior based on individual's perception of possibility of error and understanding of consequences; more prevalent in males 58

Job Site and E-3< Human Performance the Individual aITN Fundamentals Course Reference

- . I*1 - -- - -N Mental shortcuts (biases) Tendency to look for or see patterns in unfamiliar situations; application of thumbrules or "habits of mind" (heuristics) to explain unfamiliar situations:

• confirmation bias

• frequency bias

• similarity bias

• availability bias Limited short-term memory Forgetfulness; inability to accurately attend to more than 2 or 3 channels of information (or 5 to 9 bits of data) simultaneously The mind's "workbench" for problem-solving and decision-making; the temporary, attention-demanding storeroom we use to remember new information 59

Job Site and Human Performance the Individual K Fundamentals Course Reference REFERENCES 1Dorner. The Logic of Failure. 1996; pp.185-186.

2 Senders & Moray. Human Error Cause, Prediction, and Reduction. 1991; pp.44, 67.

3 Reason. Human Error. 1990; pp.38-39.

4 Wickens. Engineering Psychology and Human Performance. 1992; pp.277-281.

5 Swain & Guttman. Handbook of Human Reliability Analysis with Emphasis on Nuclear Power Plant Applications (NUREG/CR-1278).1983.

6 Wickens. Engineering Psychology and Human Performance. 1992; pp.211-222.

7 Spettell & Liebert. 'Training for Safety in Automated Person-machine Systems," American Psychologist.

May 1996.

8Wickens. Engineering Psychology and Human Performance. 1992; pp.20-21.

9Weick and Sutcliffe. Managing the Unexpected. 2001; pp.33-41.

10 Russel. The Brain Book. 1979; pp.211-215.

"1Reason. Human Error. 1990; pp.38-39.

12 Turner and Pidgeon. Man-Made Disasters. 1997; pp.109-115.

13 Hursh. 'Fatigue and Alertness Management using FASTPM." Presentation at nuclear industry annual workshop on Human Performance/Root Cause/Trending in Baltimore, MD, June 6, 2001. Dr. Steven Hursh is a professor at Johns Hopkins University School of Medicine. FAST TM (Fatigue Avoidance Scheduling Tool) isa software program aimed at minimizing personnel fatigue.

14 Keller. Attitude is Everything. 1999; pp.14-16.

1'5Ropeik and Gray. Risk: A Practical Guide for Deciding What's Really Safe and What's Really Dangerous in the World Around You. 2002; pp.15-18.

16 Krakauer, Into Thin Air, 1997. This is the story of how 12 climbers died during an ascent of Mount Everest in 1996.

17 Yates. Risk-Taking Behavior. 1992; p.52.

18 Dorner. The Logic of Failure. 1996; p.

10 9.

19 Tumer and Pidgeon. Man-Made Disasters. 1997; p.34.

20 Yates. Risk-Taking Behavior. 1995; p.52.

21 Weick and Sutcliffe. Managing the Unexpected. 2001; p.94.

22 INPO. 'in-Reactor Fuel-damaging Events, A Chronology (INPO 91-008)." 1991.

23 Swain and Guttman. Handbook of Human ReliabilityAnalysis with Emphasis on Nuclear Power Plant Application, Final Report (NUREG/CR-1 278). 1983.

24 Center for Chemical Process Safety. Guidelines for Preventing Human Error in Process Safety, American Institute of Chemical Engineers. 1994; pp.12-15.

25 Health and Safety Commission. "Advisory Committee on the Safety of Nuclear Installations Study Group on Human Factors, Second Report: Human Reliability Assessment - A Critical Overview.' Her Majesty's Stationery Office. 1991; p.33.

26 Gilbert. Human Competence, Engineering Worthy Performance. 1996; pp.82-89.

27 Limerick Generating Station, 2000.

60

Job Site and 4 Human Performance the Individual o . Fundamentals Course Reference 28 Restak. Brainscapes. 1995; p.60.

29 Dekker. The Field Guide to Human Error Investigations. 2002; pp.47-50.

30 Wickens. Engineering Psychology and Human Performance. 1992; pp.17-20.

31 Marrietta Daily Journal. 'Scientists: People cannot drive safely, talk at same time." July 30, 2001.

32 Wickens. Engineering Psychology and Human Performance. 1992; p.69.

33 Wickens. Engineering Psychology and Human Performance. 1992; pp.386-391.

34 Spettell & Liebert. "Training for Safety in Automated Person-machine Systems," American Psychologist.

May 1996.

35 Weick and Sutcliffe. Managing the Unexpected. 2001; p.41 .

36 Reason. Managing the Risks of OrganizationalAccidents. 1998; pp.68-70.

37 Turner and Pidgeon. Man-Made Disasters. 1997; pp.124-126.

38 Reason. Human Error. 1990; p.56.

39 Health and Safety Commission. 'Advisory Committee on the Safety of Nuclear Installations Study Group on Human Factors, Second Report: Human Reliability Assessment - A Critical Overview." Her Majesty's Stationery Office. 1991; p.9.

40 Catoe, J. 'Hypnotherapy." Atlanta Journal and Constitution. November 22, 1998.

41 Performance Improvement International. An internal study of errors across the nuclear industry revealed that 25 percent of errors were skill-based, 60 percent were rule-based, and 15 percent were knowledge-based. 2000.

42 Health and Safety Commission. Advisory Committee on the Safety of Nuclear Installations Study Group on Human Factors, Second Report: Human Reliability Assessment - A Critical Overview. Her Majesty's Stationery Office. 1991; p.7.

43 Geller. The Psychology of Safety. 1998; p.61.

44 Center for Chemical Process Safety. Guidelines for Preventing Human Error in Process Safety, American Institute of Chemical Engineers. 1994; pp.78-80.

45 Reason. Managing the Risks of Organizational Accidents. 1998; p.7 0 .

46 Reason. Human Error. 1990; pp.74-86.

47 Swain & Guttman. Handbook of Human Reliability Analysis with Emphasis on Nuclear Power Plant Applications (NUREG/CR-1278). 1983.

48 Performance Improvement International. An internal study of errors across the nuclear industry revealed that 25 percent of errors were skill-based, 60 percent were rule-based, and 15 percent were knowledge-based. 2000.

49 Reason. Human Error. 1990; pp.53-55.

50 Turner and Pidgeon. Man-Made Disasters. 1997; pp.124-126.

51 Wickens. Engineering Psychology and Human Performance. 1992; p.20.

52 According to a conversation with Dr. James Reason, professor of psychology at the University of Manchester in the United Kingdom, the chances for error in a knowledge-based situation are roughly a toss-up, 'If you're good." Otherwise, the chances for success get worse. February 1997.

53 Performance Improvement International. An internal study of errors across the nuclear industry revealed that 25 percent of errors were skill-based, 60 percent were rule-based, and 15 percent were knowledge-based. 2000.

61

Job Site and iw Human Performance the Individual Fundamentals Course Reference 54 Domer. The Logic of Failure. 1996; pp.71-79.

55 Reason. Human Error. 1990; pp.61-66, 86-89.

56 Howlett. The Industrial Operator's Handbook. 1995; p.45.

57 Dorner. The Logic of Failure. 1996; p.42.

58 Baxter, G. & Bass, E. 'Human Error Revisited: Some Lessons for Situational Awareness." Fourth Symposium On Human Interaction with Complex Systems. March 22-24, 1998; pp.81-87.

59 Swain & Guttman. Handbook of Human ReliabilityAnalysis with Emphasis on Nuclear Power Plant Applications (NUREG/CR-1278). 1983.

60 Turner and Pidgeon. Man-Made Disasters. 1997; pp.33-34.

61 Senge. The Fifth Discipline Fieldbook. 1994; pp.245-246 62 Senge. The Fifth Discipline Fieldbook. 1994; pp.86-95.

63 Geller. The Psychology of Safety. 1998; pp.41-43.

64 Turner & Pidgeon. Man-Made Disasters. 1997; p.34 .

65 Reason. Managing the Risks of OrganizationalAccidents. 1998; pp.49-51.

66 Allison. Global Disasters. 1990; p.40-45.

67 EPRI. Phase 2 Development of Procedure Usability Measurement Process (PUMP) Method," Report (TR-110175).1998; pp.7-8.

68 EPRI, "Phase 2 Development of Procedure Usability Measurement Process (PUMP) Method," Report TR-110175.1998.

69 Weick and Sutcliffe. Managing the Unexpected. 2001; p.109.

70 Duane Arnold, 2000.

71 Turner & Pidgeon, Man-Made Disasters. 1997; pp.85-89.

72 EPRI, 'Phase 2 Development of Procedure Usability Measurement Process (PUMP) Method," Report TR-110175.1998.

73 Senge, P. The Fifth Discipline Fieldbook. 1994; p.245 74 Domer, The Logic of Failure. 1996; pp.43-47.

75 Entergy. "Human Performance Program" (PL-1 62), Nuclear Management Manual. 2002.

76 Coovert & Smit, "Are Two Heads Better Than One?" Braidwood Nuclear Station. 1999.

77 Latane, "Many heads make light the work: The causes and consequences of social loafing." Journal of Personality and Social Psychology. 1979.

78 Hopkins. Preventing Human Error, A Practical Guide to Quality - Safety - Effectiveness. 2000; p. 44-45.

79 Yates. Risk-Taking Behavior. 1992; pp.168-173.

80 Hollnagel. Cognitive Reliability and ErrorAnalysis Method. 1998; pp. 154-155.

81 INPO. Excellence in Human Performance. 1997; p.3.

82 Drucker. Management: Tasks, Responsibilities, Practices. 1974; p.218.

62

Leadership Human Performance Fundamentals CourseReference CHAPTER 4 LEADERSHIP LEADER DEFINED 93 LEADER'S ALIGNMENT ROLE 93 Competing Purposes: Production and Prevention 94 Vision: Event-Free Operation Through 95 Excellent Human Performance KEY LEADERSHIP PRACTICES 96 Facilitate Open Communication 97 Promote Teamwork 101 Reinforce Expectations 102 Eliminate Latent Organizational Weaknesses 106 Value Prevention of Errors 107 ATTACHMENTS Coaching and Counseling ('M' Model) 110 Site Leadership Team Gap Analysis Tool 111 REFERENCES 117 Excellence in Human Performance 91

Co I-CD C)

CD g BHuman Factor CD Eria ntal Work-aroundst & Hou eeping Turover 11 os Inconvenences RWPs Challenge Question ng Atttd C -U.

Clearance Walkdown / ritical Parameters 3-Part Communicato I er Knowledge Procedure/Work EquJpme E Skill, &Proficiency Package Quality & Conditlo Prejob Just4In-time / rocedure Use Conservative Managemet Briefing Operating / Adherence Decision-Making Monitorln Personal Morale Lockout/I Tool Quality Inoeacfr Experience Motives Tagout & AvailabilityEroTap / Self-Checking Placeeeeplng Problem-sovn Task Preview g - Methodohgc Forelgn Beliefs f~otr-Dut~y __ Double (dual) Supervison Xxcluslon UnessyAftttude Verification 0 CD WOKPeer-Checking Execution)

~JOB-SITE ..~ ... - p WORKER RecognIzIng Team 0 I

... -.. . . .  :. I .. I,,

CONDITIONS ~euestioning!

Q "Attitude*-

BEHAVIO R Stop When C1D_

Or I .L . 11 - L '& .............. . as Uncetai I

Wakowns CD QC Hold Points HP Surveys Independent Forcing Task Quallficaton Verification Functions Task Assignment Personal Interlck Performance Protective Equipment FME Alas C',

Training Procedure ORGAN IZATION CD C,,-

PLANT a

Reinforcement Meetings PROCESSES Goals & Priorities Approvals & VALUES RE SULTS Role Safety Strategic Protection Moes Philosophy HU Plans Systems Design & Configuration Control Equipment Reliability 0 Staffing OE Work Simple I Effective Problem.

Clear Planning Processes Solving Root Cause Problem E i Containment Analysis Reporting Allocation Expectations Self-Assessment Accountability Independent Oversight Scheduling I Change Benchmarking Soclalization Performance 0 &

Sequencing Mgmt. Labor Corrective Action Indicator Communicationroram Practices & Pian Management Practices

CD

Leadership m Human Performance Fundamentals Course Reference LEADER DEFINED Management systems and engineered controls are not fully effective on their own to ensure safety. A culture must exist in which hazards, error-likely situations and flawed defenses are readily recognized, communicated, and resolved before work proceeds. Fostering the will to communicate at all levels of the organization despite personal fears is one of the most challenging tasks of station management. Consequently, leadership is the management activity that will most likely move a station to the next level of human performance.'

A leader is any individual who takes personal responsibility for his or her performance as well s it!: evern probleut soseeone sotewtbere as the plant's performance and attempts to sees it coming. But thosepeople ted to be influence the improvement of organizational low rank, invisible, unauthorized, processes and values. Improving human reluctantto speak tip, and mayl not even performance demands that people value know theyr knowv something that is prevention (safety) and perceive it as crucial to consequential.

the long-term success of both the station and -Weick and Sui themselves. Workers, supervisors, and -Inaing the utclJexe managers must believe they can prevent human Managing the Unexpected error and its consequences. Values, beliefs, and corresponding practices-the culture-reaches into all parts of the organization. The values and beliefs people possess are strong factors in the choices they make when they encounter unanticipated situations or when direction is vague or absent. Influencing these factors such that people possess the will to communicate despite personal consequences is the central theme of leadership in human performance improvement.

To promote effective communication, healthy relationships among plant personnel are imperative. Fundamentally, such relationships are characterized by respect, honesty, and fairness. Also, if workers are to make safe choices in the field, they must have a clear vision of the station's values with respect to safety. Is the business case for human performance improvement clear? Do production pressures preempt safe work practices? Do people value the prevention of errors? Are error-prevention behaviors reinforced? Are the recognition plan and accountability policy consistent with safety and prevention values? Is feedback to management important to eliminate process deficiencies? By establishing and maintaining healthy, as well as professional, relationships with individual workers, managers can stay aware of the values, beliefs, and practices of the organization. Focusing on the station's shared values, beliefs, and practices-culture-is the most effective way to maximize the organization's resistance to events. 2 LEADER'S ALIGNMENT ROLE Human performance occurs within the context of the organization. Human performance is the system of processes, values, behaviors, and their ultimate results that determine plant performance. The organization is the engine that drives the performance system (see the Performance Model) directing and influencing human performance in the field (See Chapter 3).

This perspective contrasts with the more traditional notion that human performance is simply a worker issue. Managers, staff, supervisors, and workers must work as a team to accomplish the station's missions to generate electricity safely and reliably-event-free.

However, when workers, managers, and supervisors do not understand their roles or when expectations are unclear, human performance suffers. Therefore, the leader's role is to align 93

Leadership Human Performance X Fundamentals Course Reference organizational processes and values to optimize individual performance at the job site (behavior and results). Success at the job site and in the plant is a chief aim of organizational processes and values and is best achieved by strengthening defenses as illustrated in the Performance Model in Chapter 3.3 Production and prevention practices will always compete. Leaders (not simply 'managers")

must work to keep the physical plant and personnel safe. Well-informed leadership at all levels of a station organization will ensure that the vision, beliefs, and values do not conflict with the station's mission, goals, and processes. Consistency and alignment is imperative to promote desired production and prevention behaviors, all to generate the desired results for the long term.

Competing Purposes: Production and Prevention Two types of behaviors are required to generate electricity safely and reliably.

Production Behaviors. Traditionally, managers have emphasized the production effort.

Production behaviors are those actions or activities aimed toward generating electricity.

Management-centered structures (mission, goals, work processes, schedules, and procedures) are needed to achieve production goals. The outcomes of production are self-evident, such as completing jobs on schedule, running equipment, generating electricity, minimizing expenses, and satisfying the customer. Such feedback-most of it positive-informs people how they are doing.

Prevention Behaviors. Prevention behaviors, such as self-checking, peer-checking, reviews and approvals, and procedure use, are applied as a work situation requires to minimize the risk of error. Production activities slow down long enough to allow people to think, while executing prevention tactics, before proceeding with an activity in order to prevent errors and events.

Excellence in Human Performance (1997) was written to provide the industry with a set of principle-based prevention behaviors. If used correctly, nothing (bad) happens! Plant events are minimized, and the long-term success of the station is enhanced.

I-Goals.,-)  ;, .1:Beliefs<

• *,. - -*Reslts Studies have shown that the initial stages of a disaster usually began with the degradation of the organization's beliefs about hazards in the workplace.4 This observation is consistent with long-term success. Complacency builds up, and prevention practices weaken as people forget about what can go wrong. Lacking constant emphasis and reinforcement, prevention can be perceived as less important than production People, including mangers, may come to think 94

Leadership Human Performance Fundamentals Course Reference that prevention activities are optional when they conflict with the accomplishment of production objectives.

Without leadership intervention, production practices will overcome those aimed toward prevention. Production behaviors will take precedence over prevention behaviors unless there is a strong safety culture-the central focus of leadership. Healthy relationships between managers and workers are necessary to promote a sense of wariness toward error and an intolerance toward error-likely situations. Wariness and intolerance are attitudes, generally derived from one's beliefs about hazards in the plant. Hence, the need for leadership.

Together, prevention and production behaviors are necessary for long-term success. But sometimes managers err when they assume people will be safe. Safety and prevention behaviors do not just happen. They are value-driven, and people may not choose the conservative approach because of the stronger production influences in the short term. To help understand the need for leadership, the differences between production and prevention behaviors are listed in the table below:

S-. _. TS

. s I.=*

. will accomplish the station's mission o will avoid challenges to the mission

. will achieve desired results . will protect desired results

. are process driven . are values driven

• are easy to measure

• are hard to measure

• are frequently reinforcing

• are perceived as burdensome

. provide natural feedback . provide little or no feedback

. can be perceived as mandatory

• can be perceived as optional

• involve the mind (logic)

• involve the heart (emotion)

. require management practices . require leadership practices A robust safety culture requires aggressive leadership emphasizing healthy relationships that promote open communication, trust, teamwork, and continuous improvement. Continuous improvement needs ongoing leadership attention to improve the plant's resistance to events triggered by human error (defense-in-depth). 6 Those in positions of responsibility must see themselves as leaders as well as managers to create an atmosphere of open communication.

Therefore, leadership is a defense. Interactions involving quality coaching and counseling will promote clear values and improve performance. An illustration explaining the relationship between coaching and counseling is provided at the conclusion of this chapter.

Vision: Event-Free Operation Through Excellent Human Performance To achieve event-free plant performance, station management creates a defense-in-depth philosophy that functions at all levels of the organization. Therefore, managers in their leadership role establish healthy relationships that promote the following conditions and practices sitewide:

1. Leaders demonstrate a commitment to improving human performance by establishing, communicating, and reinforcing clear expectations for professional behavior, continuous improvement, appropriate policies, efficient and effective processes, and common values.

2. Organizational processes and values include a defense-in-depth philosophy that considers human fallibility. These processes are also designed to function efficiently and to support safe operation.

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Leadership Human Performance

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3. Training and leadership forums are used to improve human and station performance, including the sharing of operating experience and beneficial techniques to reduce errors and eliminate events. All employees reinforce desired individual behaviors at every opportunity including subordinate and peer coaching. Reward and discipline practices are linked to professional behaviors.

4. Individuals at all levels demonstrate an intolerance of error-likely situations and flawed defenses, routinely consider how their actions can affect the plant, and take the initiative to communicate concerns. Individuals also demonstrate accountability for thorough task preparation, process execution, use of error prevention techniques, and contingency planning.

5. Individuals at every level seek to continuously improve their performance, equipment performance, the work environment, and organizational processes by aggressively communicating opportunities for improvement. Managers and supervisors promote a continuous improvement culture by being highly responsive to employee input and by involving employees in developing actions to improve processes and techniques.

Improvements are pursued through benchmarking, training, and innovation.

6. Managers and supervisors assess and trend human performance through in-field observations, formal assessments, and performance data analyses. Results are used to develop corrective actions, to improve training, and are shared with all personnel.

7. A culture exists, involving respect, fairness, and honesty that places a high value on healthy relationships among individuals and among groups. This is evident in the work quality, the conduct of business, and the way communication occurs.

These statements are not intended to supplant the principles of Excellence in Human Performance but to enable their application, which depends heavily on leadership. Leadership is not optional. Consequently, sustaining prevention behaviors for the long-term success of the, plant requires application of several key leadership practices. A "gap" analysis survey tool is provided as an attachment to this chapter that may be used to facilitate the senior leadership team's alignment on human performance issues.

KEY LEADERSHIP PRACTICES

1. Facilitate open communication.

2. Promote teamwork.

3. Reinforce desired behaviors.

4. Eliminate latent organizational weaknesses.

5. Value prevention of errors.

These practices, when used consistently, optimize worker behavior at the job site by aligning organizational processes and values to support desired behaviors. But, effective alignment depends on the presence of healthy relationships. That is, a culture based on respect, fairness, 96

Leadership Human Performance Fundamentals Course Reference and honesty among individuals and groups. It takes teamwork to achieve excellence, and effective teamwork demands trust. Mismatches in the expectations associated with the

.psychological contracts between management and the workforce hinders improvement in human and station performance.

Front-line workers have traditionally been perceived as the largest contributors of risk that management has to control. However, individuals at all organizational levels should be regarded as critical resources in identifying opportunities for improving human as well as plant performance. This includes managers seeing themselves as an integral part of the system, part of the team. Workers should perceive themselves as an integral part of the station organization as well, providing feedback to supervision and management on opportunities for improvement.

Everyone has the opportunity to be a leader when it comes to preventing human error and plant events. In this sense, leadership is considered more a set of behaviors than a position.

Facilitate Open Communication Communication is the most effective defense against events. An organization must have, without fear, the will to communicate in order to sustain long-term safe and reliable operations. 7 Obstacles to communication must be eliminated immediately. Leaders make communication happen instead of assuming it happens. The organizational atmosphere must promote open, candid conversations among individuals.

Leaders, no matter what positions they hold, Managers, askfor whatyou need to hear, not actively encourage others to identify error- for whatyou want to hear. Subordinates, tell likely situations and respective our boss whatvneedthey to hear, not what organizational weaknesses. o Healthy personal relationships occur only y they want to hear.

when workers are actively engaged in -Roger Boisjol' improving plant performance. An Aforton-Thltokol ChiefEngineer atmosphere of teamwork and collaboration Space Shuttle Challenger will motivate individuals to improve the effectiveness of the organization. A safe atmosphere is cultivated when people treat each other with honesty, fairness, and respect-that is, when they establish healthy relationships.

Eventually, people become more willing to be held accountable and seek assistance by admitting to and learning from mistakes. Listed in order of importance, the more effective ways to promote productivity in people's jobs involve the following top 10 situations: 8

1. Knowing what is expected from me

2. Having the equipment and resources to do the job correctly

3. Giving me the opportunity to do my best every day

4. Receiving recognition and reinforcement for my efforts during the last week (while the performance is fresh in the worker's minds) (See 'Effective Reinforcement Techniques" later in this chapter.)

5. Perceiving that the boss cares about me as a person aA psychological contract is an unwritten set of expectations between managers and workers in an organization that is in effect at all times. Organizational expectations are related to rewards and incentives such as salary, wages, working hours, benefits, and privileges that go with the job and involve a person's sense of dignity and worth. For more information see Edgar Shein, Organizational Psychology, 1994.

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6. Having a mentor or someone who helps with personal development

7. Discussing my progress within the last six months (quarterly is common.)

8. Knowing that my opinions count

9. Making me feel my job is important

10. Knowing that the people I work with are committed to quality work These are consistent with the job-site conditions that are most influential on quality work: task-related information, resources, and incentives (see Chapter 3).

Communication Plan. A communication plan guides manager and supervisor verbal and written interactions (formal and informal) with line workers so that a consistent message about safety is passed on. It identifies multiple forums, media, and opportunities for managers and supervisors to engage the workforce. The plan supports understanding of the organization's mission, vision, values, priorities, and expectations. One plant has developed a methodical process for developing communications. Forums such as formal meetings, maintenance shops, classrooms, job sites in the plant, and even hallways provide opportunities to send messages. In addition to production improvement, forums should exist that allow dialogue on safety and cultural issues. Media such as station newspapers, weekly bulletins, e-mail messages, closed-circuit television, and posters can be used to communicate in a written form.

Managers must also be sensitive to informal interactions in which a careless, unthinking word or action may send an unintended message.10 Leaders set the example with their communication practices.

Generally, a communication plan should accomplish the following:

• Clarify the purpose and goals of the plan.

• Identify target audiences (work groups). Generally, it is more effective to focus on positive role models than on those who habitually resist and complain.

• Summarize the key messages to (or not to) communicate.

• Identify settings in which managers, supervisors, and workers interact, such as outage meetings, training, observations, and prejob briefings.

• Specify what is paid attention to, measured, or controlled for each target audience, setting, or situation.

• Suggest guidance for controlling Human manager's emotional reaction to Error 4 incidents and conflicts.

Inconsistencies between espoused More flawed defenses Individual counseled values and unguarded reactions can & error precursors and/or disciplined adversely affect the widely held values and beliefs of the workforce. 4 Blame W A Just Environment. An organization atent organizatonal Cycle Reduced tnjst cannot consistently learn from error/failure weaknesses persist and punish professional individuals at the same time. If a workforce believes errors will be punished, then information related to Management less Less errors in the plant, if not self-revealing, will aware of Jobsio e communication likely remain unknown. To an erring conditions 98

Leadership Human Performance Fundamentals Course Reference employee, knowing how one's manager will react to error is important to one's willingness to report the problem."' In a just environment, the likelihood that a problem will be reported will increase. People want to be treated fairly, honestly, and with respect, and they want the same for others. High-performing organizations do not punish employees who make mistakes while trying to do the right thing.'2 These organizations view error as an opportunity to learn.

When an event happens, the organization is culpable, not simply the individual. As illustrated, the "blame cycle" is urged on by the belief that human error occurs because people are not properly motivated.1 3 In reality, no matter how motivated an individual is, human error will continue to occur, though at a slower rate. No amount of punishment, counseling, or training-in fact, nothing-will change a person's future fallibility. Events will continue as long as root cause analyses are stopped prematurely, before the real causes are identified. The true causes (typically organizational weaknesses) will not be discovered (will remain latent or hidden), and errors and events will persist.

Most errors do not result in events because of defenses-in-depth. The severity of an event is always a function of the type and Serious number of defenses that failed, not the Accdent error itself (as illustrated by the severity pyramid at right). However, the error that or triggers a serious accident is often the n error that has been happening for years at the nonconsequential level. People have, more often than not, been disciplined for "honest" mistakes. Error is not a choice. Nonconsequenta6 Discipline or punishment does not influence future fallibility, but it should be used as a tool for behavior change if the person acted purposely, knowingly, or recklessly. In high-performing organizations, punishment is not used for restitution. Dr. James Reason, a former psychologist at the University of Manchester in the United Kingdom, provides a "culpability decision tree" that helps managers determine a person's guilt regarding a recent mistake made.' 4 A "culpability decision tree" can be developed using station-specific criteria by following Dr. Reason's description in the referenced publication.

When potential discipline is considered, the substitution test provides a means of determining culpability (see endnote on Diablo Canyon's policy).'5 For a given set of circumstances in which an individual erred, perhaps triggering an event, mentally substitute several of the person's peers into the same situation. If most of them could have done the same thing, then the individual passes the substitution test-it is a 'blameless" error. However, if the individual has a history of error or unsafe acts, then the person probably does not have the aptitude for the job, or there may be extenuating circumstances.

Accountability. Accountability is a necessary characteristic for the long-term success of any organization. The American Heritage Dictionary defines accountability as "answerable for performance; liable for being called into account for actions."

The perceived threat of punishment is a major obstacle to gathering information about human performance. People in the nuclear power industry are professionals and are generally proactive with their work situations as implied by the accountability ladder illustration (below).

However, the severity of an event has traditionally been used as a criterion for determining whether punishment or discipline is necessary. To err or not to err is not a choice.'6 While 99

Leadership -mi Human Performance Fundamentals Course Reference consequences greatly impact one's emotional Things Happen response to an event, disciplinary decision-making BECAUSE OF should be guided by the error-the behavior-that You triggered the event, not by the consequences.1 7 Using consequences to establish accountability Make It Happen diminishes trust and ultimately communication. Also, a "zero tolerance" policy toward human error creates F ou.

frustration and solves nothing. Improvement is more effective when people learn from errors (nonconsequential events) rather than trying to Own It" "motivate" employees to refrain from error.'

Learning is promoted if the "system" is held Acknowledge accountable. Calert Cliffs accomplishes this with Reality

'200% Accountability," in which accountability is dH shared among all parties to a task, and people are aware of their dependence on each other, working together to accomplish the task event-free. 19 Excuses When an event is initiated by an honest mistake, the Blame hers entire system that supports the performance in question should be evaluated (see "Systems A:_

Thinking" in Chapter 1). Events triggered by human error are symptomatic of a system failure. Instead of Things Happen asking how the individual failed the organization, the TO You question "How did the organization fail the individual?" would be more appropriate. In addition to the individual, what or who could have prevented the event? What flaws or oversights in work processes, policies, or procedures contributed, promoted, or allowed the error and event to occur? Because the majority of the causes of events originate in the system of controls, processes, and values established by the management team, the former should be management's first reaction to events.

Coaching. According to the dictionary, to coach is to 'tutor, train, give hints to, prime with facts.'

Fundamentally, coaching is a method to help unlock another person's potential to maximize his or her own performance, to self learn.2 0 Teaching is not coaching. Effective coaching helps people become aware of their need for change and to take personal responsibility for taking appropriate steps to change. Consequently, coaching is an essential tool for organizational change. Coaches create awareness and responsibility, best, through effective questioning and sequencing. With the other person's interest in mind, effective questions start broad (open-ended) and increasingly focus on detail (close-ended). The following mnemonic, GROW, helps guide this sequence of questions:2 1

• Goal - the short- and long-term objectives, what is to be accomplished (results), during the particular encounter between coach and individual being coached

• Reality - exploration of current results, practices, behavior, attitudes, beliefs, motives etc.

• Options - alternatives, strategies, or courses of action to change performance in light of the goals; best developed by individual

• What - actions to take when, by whom, how well, and the willingness to change 100

Leadership -d Human Performance

.4 Fundamentals Course Reference Questions asked in the above sequence help create awareness and responsibility. Coaching will be more effective if the above sequence is used iteratively. For instance, while discussing "Whats," verify they are consistent with the "Goals."

Promote Teamwork Team skills are needed to identify and eliminate error-likely situations and to reinforce defenses.

Humans experience difficulty detecting their own errors, especially when working alone.

Teamwork improves the ability of individual team members to collectively prevent human performance problems. This is particularly important when a team or crew is confronted with an unfamiliar problem (knowledge-based). Since people are fallible in their thinking, teamwork can make individual thinking and reasoning visible to the other members of the team. Dialogue among team members allows each one to challenge assumptions and to detect team errors.

But without trust, open dialogue suffers, and team errors multiply. Team errors were addressed in Chapter 2.

Errors can be caught three ways: machines, others, and oneself. Human factors and ergonomic designs are built into the physical plant to catch errors that have been anticipated.

An individual can catch most errors, but not at the degree of reliability desired. Consequently, other people become necessary to help "see" error-likely situations and to defend against error in team activities.

Peers and supervisors are used through independent verification, concurrent verification, peer-checking, challenge, and devil's advocate, among others. As described earlier, independent verification is a technique to find errors that have already happened. Concurrent verification attempts to prevent an error from occurring in the first place. Challenge is an unsolicited peer check. A devil's advocate aids team decision-making and problem-solving activities by challenging assumptions and mindsets of other team members.

The U.S. aviation industry's extensive studies on crew resource management, a study of teamwork on commercial air carriers, identified characteristics vital to the success of pilot performance on the flight deck. Many of these characteristics were adapted into INPO's High Performance Teamwork Development course, as follows:

Inquiry. Inquiry involves asking a series of questions to understand what is happening with the plant. Here it is important to distinguish between fact and assumption. Statements such as "I think" or "I believe" are hints that an assumption has been made. Assumptions can be challenged using the following process: 22

1. Identify conclusion(s) being made by another person or yourself.

2. Ask for or identify the data that leads to the conclusion(s).

3. Ask for the reasoning (mental model) that connects data with the conclusion.

4. Infer possible beliefs or assumptions.

5. Test the assumption with the other person.

Assumptions must be challenged to detect unsafe attitudes and inaccurate mental models regarding the task. See Chapter 1 on how inaccurate mental models promote erroneous assumptions that may lead to errors.

Advocacy. Expressing a concern, position, or solution-making certain others understand what an individual knows-is perhaps the most important team practice. The individual is 101

Leadership Human Performance

-^ Fundamentals Course Reference assertive for the plant's sake. People must not be timid when communicating their concerns.

Without advocacy and clear communication practices, team errors continue unchecked.

Leadership. Leaders take the initiative to influence the behavior of others, especially when it comes to the physical plant. The individual demonstrates leadership by taking responsibility for not only his or her own behavior, but also for team performance as it alters the state of the plant through its activities. Challenge and peer-coaching are outgrowths of this characteristic of teamwork.

Conflict Management. Resolving differences of opinion and getting all information on the table to reach the best solution are critical elements to successful team performance. Understanding the personalities of a work team is particularly important to solving problems, especially if people take a devil's advocate approach.

Critique Performance. Learning from experience, identifying what works well, and pinpointing what areas need improvement are important for continuous improvement. Without feedback from workers, management cannot optimize the processes to support the workforce in the field.

Critiquing performance can occur periodically during a task to make sure everyone is aware of current job-site conditions. Post-job reviews are particularly important and are helpful in identifying not only errors that occurred, but also process-related flaws that did not adequately support work in the field.

Tone. Tone is an important success factor for effective team performance. Tone is important for boosting the situation awareness of individuals and work teams. Setting the tone is a leadership practice that conveys the demand for wariness and communication among team members. The combination of wariness, good situation awareness, and open communication leads to an effective questioning attitude. This way, unplanned situations or unusual conditions are more often recognized and resolved without incident.

Reinforce Expectations Peter Drucker, a well-known authority on management, states:

'...the fundamental reality for every worker, from sweeper to executive vice president, is the eight hours or so he (or she) spends on the job. In our society of organizations, it is the job through which the great majority has access to achievement, to fulfillment, and to community."

For achievement to occur, the worker has to take responsibility for the job. People will take responsibility if their jobs are well designed and their bosses 1) see what they do and 2) know who they are.24 Learning and having the personal satisfaction of doing a job well occurs if a person is to take that responsibility. In turn, jobs and reinforcement must be well planned for learning and satisfaction to occur. Planning is necessary-a manager responsibility.

There is a direct cause-and-effect relationship between a manager's actions and an employee's behavior, and behavior is motivated by its consequences. Therefore, managers can take specific actions to improve performance for the long term by managing the consequences that follow behavior, especially after effective execution of error-prevention tools. 2 5 Consequences, not training, directives, or threats, reinforce behavior. For the principles of reinforcement to work, clear expectations and standards must exist, the work force knows them, and managers accurately model them.

Expectations. Expectations for error-prevention and other defensive practices require thoughtfulness and accuracy. Expectations explicitly define acceptable and unacceptable behaviors, norms, and practices, along with circumstances that necessitate each expectation. If 102

Leadership Aimj Human Performance Fundamentals Course Reference it is a well-designed job, expectations establish high standards for the conduct of station activities and controls to achieve uniform adherence to those standards. Many expectations are consolidated in 'Conduct of ..." administrative procedures as well as being contained in goals and objectives, policies and directives, procedures, action plans, and training programs.

Good expectations follow the ABC format: antecedent or cue, behavior or action to occur, and consequences for the behavior. With the involvement of front-line workers, managers can identify at-risk behaviors that are unacceptable and prevention behaviors that workers would readily accept, reinforce, and correct. Prevention behaviors are best defined in terms of the following:

• Action that is observable by others

• Person(s) to apply the behavior (or group)

• Situation in which the prevention behavior is to be performed. 2 6 The action or behavior should be defined so that two or more observers of the same action would agree whether the behavior occurred. Good expectations can be characterized as specific (concise definition), observable (countable or recordable), objective (no interpretation required), and doable (in the respective work place).2 7 In some safety-critical situations, expectations explicitly define what is unacceptable. These are corrected when observed. To coach expectations effectively, managers and supervisors should be able to model any expectation. To ensure expectations do not become obsolete, they should be compared with best industry practices on a periodic basis (benchmarking).

People tend to seek/do things they like and avoid things they do not like.28 This is a fundamental principle of human behavior. Positive consequences must be associated with job-site behaviors if people are to continue using them. Positively reinforce individuals who obtain value-added results using preferred behaviors, not those who cut corners to get jobs done on schedule and under budget. As noted above, expectations should provide the cue for the new behavior. This gets the new behavior going. Consequences either keep the behavior going or extinguish it in the long term. What people decide to do while at work, above and beyond minimum requirements, depends on consequences. Therefore, leaders should take time to understand and learn how to use reinforcement-consequences-to promote targeted behaviors; that is, expectations.

All behavior that is occurring in the station right now is the result of consequences that are also occurring right now. In a manner of speaking, the organization is perfectly attuned to get the performance it is getting, right now. All behavior is reinforced. If at-risk behavior is common, it is because management has not made a difference with consequences. Behavior has four basic consequences. 2 9 The following model describes the effect consequences have on behavior:

Consequences that Increase O Behav INCREASES

_ k.

lvio~r>4 Aii . _ BEHAVIOR Consequences that Decrease DECREASES Behavior 5 w,.

O.s I 103

Leadership Human Performance Fundamentals Course Reference The following consequences can be used to get the desired performance by targeting specific behaviors:

Positive Reinforcement - "Get something you want" enhances the probability the preferred behavior will recur and maximizes performance. This optimizes use of discretionary effort by the individual.

Negative Reinforcement - "Avoid something you don't want" enhances the probability the preferred behavior will recur, but only to meet the minimum standard.

Note: Consequences that cause behavior to either increase or continue at a high standard are known as "reinforcers."

Punishment - "Get something you don't want" reduces the probability undesired behavior will recur if unwanted consequences are consistently coupled with the behavior. Punishment may also involve "losing something you don't want to lose," a penalty. Sometimes this is necessary to get the new expectation started for an individual. However, it should not be used for the long term.

Extinction - 'Don't get something you want" reduces the probability undesired behavior recurs, since nothing happens when that behavior occurs. Usually, the behavior eventually disappears after several repeated attempts.

Activators take the form of procedure steps, training, incentives, reminders from supervisors or peers, administrative policies, and expectations. Activators are stronger if they a) specify the behavior, b) specify whom, c) occur at the point of attack, and d) imply the consequences. 3 0 Similarly, consequences in terms of reinforcers need to be determined. Expectations need positive reinforcers, while unacceptable behaviors need penalties-disincentives-or the elimination of positive reinforcers that motivate the undesirable behavior. Punishments and penalties also need to be eliminated for expected practices. Positive reinforcers are more effective if they are positive-for the individual, immediate with respect to the behavior, and certain. Penalties are stronger if the consequence is negative, immediate, and certain for the individual concerned. 31 For specific expectations important for safety-critical activities, develop a rewards and reinforcement plan at least for the general population and ideally for each individual. Such a plan is described below. Reinforcement is something that should happen every day. However, from time to time, celebrations and reward ceremonies are conducted to recognize results.

Remember, celebrations reward results, and reinforcement rewards behaviors. Be certain to single out the behaviors or actions that were key to achieving the results.

Rewards and Reinforcement Plan. This plan strengthens desired job-site performance and is best used in conjunction with systematic measures and feedback to the individual or group. 32 Similar to how preventive maintenance is planned and scheduled for plant equipment, rewards and reinforcement for employees are planned and scheduled. To be effective, rewards and reinforcement demand time. A rewards and reinforcement plan is defined by the following considerations: 3 3

1. Pinpoint desired results for selected task(s)-key outcomes.

2. Target specific behaviors to obtain results-expectations.

3. Identify specific opportunities to apply reinforcers (positive reinforcers, mostly).

(Specified "at-risk" behaviors are targeted with particular penalties.)

4. Develop measures of results (quantity, quality, cost, timeliness).

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Leadership Human Performance Fundamentals Course Reference

5. Provide feedback about past behavior that will help an individual change (specific, sincere, immediate, personal). This is known as coaching.

6. Celebrate results (highlight preferred behaviors that achieved results).

Reinforcers matched to the individual's motivations (personal needs for affiliation, achievement, security, or power) are the most effective.

Effective Reinforcement Techniques. Rewards and reinforcers for front-line workers come from three sources: the work, their peers, and the boss.34 It is uncommon for workers to compliment or even correct their peers. So do not count heavily on peer reinforcement except from role models. Aside from the personal satisfaction people may get from their work, employees simply want to know that their bosses "saw what you did and know who you are." 35 This is important. Personal, or social, reinforcers are the most powerful, the easiest, and the most cost-effective means of reinforcing behavior. Managers and supervisors must know how to reinforce expectations. The following strategies go a long way toward improving performance without time-consuming programmatic changes being made: 3 6

1. Provide feedback specifically and frequently.

2. Verbally reinforce preferred behavior specifically and frequently (personal).

3. Remove obstacles or give workers a strategy for going around obstacles.

4. Let workers know the work priorities.

5. Remove negative consequences for preferred behavior.

6. Remove positive reinforcers and rewards for at-risk behavior.

7. Use penalties only with consistent undesirable behavior (progressive discipline).

8. Accommodate those with personal, non-work-related problems, if practicable. Otherwise, assign the job to someone else without such distractions.

Common Mistakes with Rewards and Reinforcement. Avoid the following mistakes:3 7

1. delayed reinforcement - Reinforcement's power to influence behavior is robbed if the act(s) is not fresh in the mind of the performer.

2. infrequent reinforcement - If desired behavior is ignored, the individual may believe it is unimportant.

3. generic rewards - Recognition is most effective if it specifically recognizes the achievement of the individual vice the group. If awarded en masse, people will not remember what behaviors helped accomplish the goal. Reward, as well as reinforcement, must be personal.

4. unearned reinforcement or reward - Cynicism becomes rampant if people are reinforced for being lucky or rewarded for meaningless accomplishments.

5. impersonal reinforcement - Reinforcers, whether tangible or social, must match the individual's preferences. For example, some people dislike public praise.

In summary, plan positive reinforcement to sustain the use of prevention behaviors (expectations), and develop appropriate sanctions or disincentives (with worker input) to discourage unacceptable behavior (including targeted at-risk behaviors). Remember, this is a change. Preparation, management, and follow-through are necessary.

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Leadership Human Performance PM Fundamentals Course Reference Eliminate Latent Organizational Weaknesses Strategically, if problems with processes and values can be identified and resolved proactively, many events may be prevented. Eliminating the causes of flawed defenses and error precursors (see Anatomy of an Event) helps minimize both the error rate (frequency) and the severity of events.

Error is a symptom. All organizations possess hidden weaknesses in their processes and culture that will eventually, under the right circumstances, result in an event. As explained earlier in this chapter, communication is an important means to success. Identification and resolution of the hidden causes of performance problems in the field cannot occur without it.

Communication is a requirement for a learning culture. A learning culture promotes continuous improvement in human performance by improving organizational processes, shared values, and job-site conditions. A learning culture is based on the premise that the causes of recurring performance problems and minor, nonconsequential events are the same as those of significant events. In an odd way, error is a good thing, when there are no negative consequences. It occurs often enough to expose the weaknesses in defenses, organizational processes, and the culture.

Worker Feedback. The workforce is the best source of information about the weaknesses in the organization. It is important that those not in positions of management or supervision realize the influence they have on station performance. Who is better than workers to provide the feedback managers need to optimize processes that support work in the field? Front-line workers are the beneficiaries of what the work organization provides them. They know its shortcomings. Also, it takes courage to report personal mistakes-to be self-critical. Finding and eliminating latent organizational weaknesses improves dramatically when worker feedback and communication are encouraged. Along with training in human performance fundamentals, improving the workforce's questioning attitude will improve its sensitivity to problems at the job site that went unrecognized before. Leadership seeks this feedback and provides a vital link between the job site and the organization that is needed for continuous improvement. This is why the self-identification ratio is an important measure of human performance improvement. In another way, this is a measure of leader effectiveness. Therefore, effective self-assessment and corrective action programs characterize a strong learning culture.

Methods. Can organizational weaknesses be identified and corrected before they cause an event? Yes. 3 3 Self-assessment and corrective action processes offer tangible, effective methods for achieving high levels of resistance against events. Self-assessment methodologies help with the proactive identification of weaknesses that can lead to error and events, while corrective action programs promote resolution of problems.

Excellence in Human Performance (1997) lists three ways of identifying organizational weaknesses:

• Solicit and act on feedback from workers about problems that may lead to error (such as postjob reviews, problem reporting programs, and voluntary reporting (confidential) methods).

• Determine the fundamental cause(s) of performance problems (such as root cause analysis).

• Monitor trends in plant and human performance (such as performance indicators, leading indicators, common cause analyses, and performance monitoring reports).

106

Leadership )o Human Performance Fundamentals Course Reference However, since the publication of that document (1997), additional methods have surfaced that have proactive value in identifying organizational weakness. Other methods include the following:

• self-assessments

• observation of work in the field

• surveys and questionnaires

• process mapping

• task analysis (see Chapter 6)

• benchmarking To be effective, these methods must identify how the organization shapes job-site conditions (recall the Performance Model). Knowing how a process or value influences worker behavior will offer insight into how to improve the particular process or value. Generalities are unacceptable; specifics are needed. Self-assessment and corrective action programs have to be tuned to do this. However, identifying and eliminating organizational weaknesses cannot simply be relegated to these programs. These are leadership challenges. Keeping the organization focused on continuous improvement (learning culture) while meeting ever-challenging production goals is a daunting task. Instead of waiting for periodic self-assessments or for errors and events triggered by error to reveal organizational weaknesses, leaders must clearly show the value of preventing the next event from any path. Prevention is much less expensive than recovery.

Value Prevention of Errors By valuing error prevention, the number of "shots on goals" will be reduced. High standards communicate Lopng-termi survivalin the wilderness the value of error reduction. By clinging to high depends on having the right attitude.

standards regardless of the perceived importance, -Scott AcMillion adherence to expectations will be more consistent. Mlark of the Grizzly People's beliefs and attitudes toward hazards and True Stories of Recent BearAttacks error traps tend to drive adherence to high standards. and tfle HardLessons Learned But attitudes are hard to manage. Personal factors such as motives and attitudes are resistant to change. However, positive attitudes are more widespread when workers attempt to achieve a goal rather than try to avoid failure.

Consequently, positive attitudes about error prevention depend greatly on what is rewarded and which behaviors are reinforced. Also, it is easier to change behavior when positive attitudes exist. To develop positive attitudes, the focus must be on behavior. Positive values and attitudes will follow behavior if those behaviors (expectations) consistently result in personal success. It is not necessary for values and attitudes to precede behavior, but it is preferable.

The emphasis is on behavior-acts or actions by individuals that can be observed, what people say and do, as opposed to what they think, feel, or believe. Ultimately, the aim of leadership is to instill error-prevention values and practices into the fabric of all performance, regardless of the task's priority. Getting dressed each day helps explain this concept. Regardless of how hurried people are, they do not leave home without putting on their clothes. 39 People value wearing clothing over the priorities of the day. Fundamentally, prevention practices are value-driven, which benefit the station in the long run. The primary tool to develop error-prevention values is positive reinforcement of safe practices.

107

Leadership Human Performance Fundamentals Course Reference Manager Behaviors That Influence Values. The only effective way to communicate values is to act in accordance with them and reinforce them. 40 According to experts in organizational culture and leadership, the following behaviors convey the values of the organization, in order of strength of influence:41

1. what managers pay attention to, measure, and control

2. reactions to critical incidents or crisis

3. allocation of resources

4. deliberate attempts to coach or role model

5. criteria for allocation of rewards and punishment

6. criteria for selection, advancement, and termination If those in positions of responsibility react appropriately, with integrity and consistent with stated values, people will change their behavior. When management's responses are in harmony with the importance of safety and reliability, then front-line workers will more likely choose error-prevention behaviors and avoid at-risk actions.

Studies of 'high-reliability organizations" have shown that leadership is a key ingredient to long-term success. Leaders promote event-free operation by advocating the value of error-free behavior and encouraging a healthy belief in human fallibility. High reliability organizations tend to exhibit the following characteristics: 42

• The Will to Communicate. The most important factor in the prevention of events and for continuous improvement in human performance is communication. In all major disasters worldwide, someone knew something that could have prevented the outcome. 4 3 'Obstacles in communication" have been noted as a cause in more than 80 percent of all aviation accidents.44 A constant flow of information about hazards (error traps and flawed defenses) must exist throughout the organization.

• Wariness for and Intolerance of Error Traps. The greatest risk to plant safety and reliability is human. Personnel in high-reliability organizations are keenly aware of their limitations; and because of human fallibility, they are sensitive to job-site conditions that provoke error. Consequently, they are intolerant of error traps, recognizing the absence of defenses and the potential consequences of their actions. Healthy attitudes such as these help offset the human tendency toward complacency.

• Vigilant Situation Awareness. Situation awareness is the mental activity of developing and maintaining an accurate mental model of the plant state and task situation based on knowledge of critical parameters, observations of system or equipment condition, work environment, team members, and recall of basic knowledge of the plant. Situation awareness improves one's foresight-understanding the significance and nature of one's actions before proceeding with a specific action. Setting a tone of wariness and intolerance, especially during the prejob briefing, improves one's questioning attitude and sensitivity to potential hazards and error traps.

• Rigorous Use of Error-Prevention Tools. To identify and defend against error-likely situations at the job site, techniques to prevent, catch, and recover from errors are rigorously used at every organizational level and in all station functions. Such practices make personnel continually conscious of hazards, especially error traps and industrial safety dangers in their work places. An understanding of the limitations of human 108

Leadership Human Performance Fundamentals Course Reference performance and how they apply to work situations improve people's abilities to apply error-prevention tools.

• The Value of Relationships. Without a foundation built on respect, honesty, and fairness, interpersonal and interdepartmental relationships will suffer and so will open communication. Anger, embarrassment, and resentment choke off communication between people, and cooperation suffers. To allow the organization to move to the next level of human performance and plant performance adversarial relationships must be turned around.

Notice the similarity between the above characteristics and the description of safety culture by the International Atomic Energy Agency (IAEA). 45 IAEA states that "the response of all those who strive for excellence in affecting nuclear safety" is characterized by 1) a questioning attitude, 2) a rigorous and prudent approach, and 3) communication.

109

I-0k CD 0 CU CD I 'ar1 z

High) C) z0 Minimum acceptable / C.)

level of performance us z0 0 On m

in z

a)

'a / M G) r, I ;i . - ...iJ., . I' !'. ' " I ounseling: :Caching-, ) 0.

, .. h .I - I I CD Low

- I I omo.

Low Individual Performance High Coaching - to tutor, train, give hints; to prime with facts. Any time an Individual Is at or above the minimum acceptable level of performance, we can coach them to higher levels of performance. The coaching slope One indicates, absent other factors, higher performance is a direct result of more coaching (slope indicates the total amount of coaching provided in the aggregate). Once performance gets to a given maximum level, an Individual is considered for assignments with greater responsibility (or promoted if ability exists).

Counseling - a process of listening, giving advice or Instruction; judgment with the Intent of Influencing a person's attitude or behavior. Counseling 0 C is performed anytime a person's performance is below the minimum acceptable level of performance. Depending upon the amount below this point warrants o _

the Increased counseling (and other actions deemed appropriate by policy such as decision making leave of absence). Depending on the sustained below C X~

par performance, Individuals are moved to less challenging jobs or, in extreme cases, actions such as termination are taken.

8D CE

-nD--

Leadership Human Performance Fundamentals Course Reference Site Leadership Team Gap Analysis Tool Purpose This tool was developed to assist the site leadership team (SLT) in performing an organizational gap analysis of human performance. The attributes used in this tool were derived from a variety of references* and include key clements commonly observed in top performing organizations.

Method This analysis tool is intended to guide members of the SLT through a series of statements for which each member provides an independent rating. Responses on this internal analysis should be based on the current understanding and opinion of each member and should not require reference to performancc reports or other perfomnance indicators. Clarifying comments should be encouraged for identified problem areas.

Rating categories

• Strength: This attribute is an obvious strength; no changes necessary.

• Satisfactory: This attribute appears satisfactory, no further actions anticipated.

• Worrisome: Although functional, this attribute has troublesome symptoms; several aspects need attention.

• Problem: This attribute may be inhibiting station performance improvement; intervention should be considered.

Interpretation Each attribute should be summarized for the organization and sorted by the number of respondents rating the attribute as a problem. For example, if 10 of 12 SLT members rated 'Effective communication'as a problem, the organization could then focus discussions on clearly defining this problem and discuss actions that the SLT should take to address the issue. Some organizations may choose to make responses anonymous and others may choose to identify specific departments. Facilitated discussions of organizational problems can help gain alignment and establish a common understanding of important issues facing the organization.

Suggestions for follow-up Resulting actions by the SLT to the collective analysis of these attributes could include actions such as the following:

• The SLT could conduct facilitated discussions focused on the worrisome or problem areas identified. These discussions should include a clear definition of barriers or impediments to improvement and a consensus agreement on corrective actions for the SLT.

• Benchmarking to industry top performers could be considered in identified problem areas.

• Self-assessment activities could be focused on developing a clear understanding of the problem. Follow-up interactions could include engaging station staff to help establish proposed solutions.

• Focused assistance visits from outside organizations should also be considered.

111

Leadership Human Performance Fundamentals Course Reference References INPO, Excellence in Human Performance, September 1997 INPO, Performance Objectives and Criteria for Operating Nuclear Electric Generating Stations (INPO 97-002)

IAEA, Safety Culture, Safety Series No. 75-INSAG-4 Review of INPO Plant Evaluation and WANO Peer Review report insights associated with organizational strengths and weaknesses INPO, Executive Review Group meeting input, November 2000 112

Leadership Human Performance 3K Fundamentals Course Reference

1. Leaders demonstrate a commitment to improving human performance by establishing, communicating, and reinforcing clear expectations for professional behavior, continuous improvement, appropriate policies, efficient and effective processes, and common values.

Attribute Strength Satisfactory Worrisome Problem

a. Senior management demonstrates commitment

b. The strategy for improving human performance is understood

c. Human performance goals are defined & measurable

d. Individuals can describe the vision and mission, in their own words, of human performance improvement initiatives.

e. Expectations clear

f. Managers demonstrate commitment and model expected behaviors

g. Vertical & horizontal alignment of station priorities

h. Appropriate resources to reduce human performance-related events (balanced procedures, supervision, knowledge)

i. Desired behaviors are reinforced Comments ('Worrisome' or'Problem' areas):

2. Organizational processes and values include a defense-in-depth philosophy that considers human fallibility.

These processes are also designed to function efficiently and to support safe operation.

Attribute Strength Satisfactory Worrisome Problem

a. Performance goals are balanced with safety and production

b. Department operating plans aligned with the business plan

c. Work Management Processes

d. Procedures are accurate

e. Procedures are updated in a timely manner

f. Key initiatives and equipment upgrades are successful

g. Effective change management Comments ('Worrisome' or'Problem' areas):

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3. Training and leadership forums are used to improve human and station performance, including the sharing of operating experience and beneficial techniques to reduce errors and eliminate events. All employees reinforce desired individual behaviors at every opportunity including subordinate and peer coaching. Reward and discipline practices are linked to professional behaviors.

Attribute Strength Satisfactory Worrisome Problem

a. Training is valued, useful, and reinforces expected behaviors

b. Universal ownership of training

c. Workforce is knowledgeable and confident (all levels)

d. Professional development encouraged

e. Personnel welcome and appreciate coaching

f. Error avoidance is recognized

g. Incentives not based solely on production

h. Successes celebrated (individual & unit)

i. Operating experience is valued and solicited Comments ('Worrisome' or 'Problem' areas):

4. Individuals at all levels demonstrate an intolerance of error-likely situations and flawed defenses, routinely consider how their actions can affect the plant, and take the initiative to communicate concerns. Individuals also demonstrate accountability for thorough task preparation, process execution, use of error prevention techniques, and contingency planning.

Attribute Strength Satisfactory Worrisome Problem

a. Awareness of top station issues

b. Individual awareness -understand consequences of mistakes

c. Consistent focus on error-prevention (eliminate error-likely situations)

d. Problems are anticipated

e. Accountability - applied up front

f. Clear individual roles and responsibilities

g. Workforce feels empowered

h. Self starters - voluntarism high

i. Procedures are followed 114

Leadership Human Performance Fundamentals Course Reference Comments ('Worrisome' or 'Problem' areas):

5. Individuals at every level seek to continuously improve their performance, equipment performance, the work environment, and organizational processes by aggressively communicating opportunities for improvement.

Managers and supervisors promote a continuous improvement culture by being highly responsive to employee input and by involving employees in developing actions to improve processes and techniques.

Improvements are pursued through benchmarking, training, and innovation.

Attribute Strength Satisfactory Worrisome Problem

a. Commitment to improve (publicly asserted)

b. Individuals search for and eliminate organizational weaknesses

c. Most improvement issues are self-identified

d. Most problems are self-identified

e. Workforce is engaged

f. Ownership, pride, & satisfaction (dedication) A=

g. Employee contribution encouraged

h. Low problem reporting threshold

i. Everyone is considered a problem solver

j. Materiel condition of plant and work areas

k. Feedback is solicited (encouraged) 1.Timely resolution of grievances

m. Productive and prompt feedback provided

n. Benchmarking is valued and effective Comments ('Worrisome' or'Problem' areas):

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6. Managers and supervisors assess and trend human performance through in-field observations, formal assessments, and performance data analyses. Results are used to develop corrective actions, to improve training, and are shared with all personnel.

Attribute Strength Satisfactory Worrisome Problem

a. Intervention occurs when expectations are not met

b. Effective root cause determinations X ___]____

c. Management presence in field is apparent and welcomed _

d. Useful performance indicators and trends available

e. Self-assessments are driven from within

f. Timely feedback Comments ('Worrisome' or'Problem' areas):

7. A culture exists, involving respect, fairness, and honesty that places a high value on healthy relationships among individuals and among groups. This is evident in the work quality, the conduct of business, and the way communication occurs.

Attribute Strength Satisfactory Worrisome Problem

a. Mutual respect demonstrated

b. Effective communications

c. Open communications-both directions - frequent and precise

d. Good teamwork is fostered and apparent

e. Good conflict management (achieve best solution)

f. Low absenteeism

g. Professional work environment

h. Individual responsiveness to management Comments ('Worrisome' or'Problem' areas):

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Leadership Human Performance

-j Fundamentals Course Reference REFERENCES 1 Ramsey & Modarres. Commercial Nuclear Power, Assuring Safety for the Future. 1998; pp.220-221.

2 Helmreich & Merritt. Culture at Work in Aviation and Medicine. 1998; p.133-139.

3 Drucker. Management: Tasks, Responsibilities, Practices. 1974; p.528.

4 Turner and Pidgeon. Man-Made Disasters. 1997; pp.85-89.

5 Kotter. Leading Change. 1996; pp.25-30.

6 Reason, Managing the Risks of OrganizationalAccidents. 1998; p.191-196.

7 Allinson. Global Disasters. 1990; p.41.

8 University of Michigan.

9 Oconee Nuclear Station. Site Level Communication Process. March 2000. In addition to describing the process, it provides a worksheet to aid the user by asking key questions regarding objectives, audience, message, strategy, and so on.

10 Entergy Operations, Inc. Equipment Reliability Achievement Anchor, Communication, Interaction and Expectations Plan. 2001. This sample communication plan lists examples that are representative of actions and behaviors expected toward equipment performance. It is meant to be all-inclusive and creativity to communicate effectively with employees is expected.

" Marx. 'The Link Between Employee Mishap Culpability and Aviation Safety." 1998; p.30.

12 Pool. "When Failure is Not an Option," Technology Review Magazine, July 1997; p.45 .

13 Reason, Managing the Risks of OrganizationalAccidents. 1998; p.127-129.

14 Reason. Managing the Risks of OrganizationalAccidents. 1998; p.208.

15 Diablo Canyon Nuclear Power Plant instituted a revised Personnel Accountability Policy that includes a tool to assess an individual's 'culpability' in a human performance situation. It was developed using Dr.

James Reason's guidelines. This tool is intended primarily for use by first-line supervisors to help determine the level or severity of disciplinary actions in response to events or near misses caused by human error. 2000.

16 Dekker. The Field Guide to Human Error Investigations. 2002; p.11.

17 Marx. 'The Link Between Employee Mishap Culpability and Aviation Safety." 1998; p.18.

18 Marx. "The Link Between Employee Mishap Culpability and Aviation Safety." 1998; p.26. Although David Marx is an expert in this field, he does not reference the research that supports his assertion.

19 Calvert Cliffs. Standards of Conduct Handbook. 2001.

20 Whitmore. Coaching for Performance, A Practical Guide for Growing Your Own Skills. 1994; p.5.

21 Whitmore. Coaching for Performance, A Practical Guide for Growing Your Own Skills. 1994; p.38-40.

22 Senge. The Fifth Discipline Fieldbook. 1994; p.245-246.

23 Drucker. Management: Tasks, Responsibilities, Practices. 1974; p.267.

24 Allen & Snyder. I Saw What You Did, and I Know Who You Are, Giving and Receiving Recognition.

1990.

25 Foumies. Why Employees Don't Do What They're Supposed to Do, and What to Do About It. 1999; p.xv.

26 Hersey & Blanchard. Management of Organizational Behavior. 1993; p.162.

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Leadership Human Performance

_go Fundamentals Course Reference 27 Geller. The Psychology of Safety. 1998; pp.118-119.

28 Daniels. Bringing Out the Best in People. 1994; p.25.

29 Daniels. Performance Management. 1989; p.29 30 Geller. The Psychology of Safety. 1998; p.133.

31 Daniels, Bringing Out the Best in People. 1994; pp.65-66.

32 Geller. The Psychology of Safety. 1998; p.217.

33 Daniels. Performance Management. 1989; p.21 7 .

34 Fournies. Why Employees Don't Do What They're Supposed to Do, and What To Do About It. 1999; p.50.

35 Allen & Snyder. I Saw What You Did, and I Know Who You Are, Giving and Receiving Recognition.

1990.

36 Foumies. Why Employees Don't Do What They're Supposed to Do, and what to do about it. 1999; p.133.

37 Kam. "Positive Reinforcement Improves Organizational Performance," The Public Manager magazine.

(date of issue unknown) 38 Reason. Managing the Risks of OrganizationalAccidents. 1998; p.23 7 .

39 Geller. The Psychology of Safety. 1998; pp.34-35.

40 Larkin and Larkin. "Reaching and Changing Frontline Employees," Harvard Business Review on Effective Communication. 1999; p.147.

41 Schein. Organizational Culture and Leadership. 1992; p. 231 42 LaPorte, Roberts, Rochlin, & Schulman. "High Reliability Organizations: The Research Challenge."

Working Paper, University of California at Berkeley, Institute of Government Studies. 1987. A general description of high reliability organizations is available in James Reason's book, Managing the Risks of OrganizationalAccidents, pp.213-218. A description of this information as it relates to nuclear power plant operation is described in "Identification and Assessment of Organisational Factors Related to the Safety of Nuclear Power Plants," February 1999; Committee on the Safety of Nuclear Installations under the auspices of the Organization for Economic Cooperation and Development, Nuclear Energy Agency, pp.24-25.

43 Allinson. Global Disasters. 1990; p.40.

44 John Nance, Speech at 1998 Plant Managers Workshop. Atlanta, GA.

45 IAEA. Safety Culture (75-INSAG-4).1991; p.1 3 .

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