ML050840496

Presentation Slides: Excellence Through Prevention

ML050840496
Person / Time
Site:	Point Beach
Issue date:	04/09/2004
From:	- No Known Affiliation
To:	Office of Nuclear Reactor Regulation
References
FOIA/PA-2004-0282
Download: ML050840496 (28)

Text

Point Beach Excellence I Through Error Prevention Point Beach U1R28 Human Performance and Communication Time Out April 9, 2004 9.

Human Performance Excellence

• Every Task

• Every Job

• Every Day

• EVENT FREE!

U1R28 Human Performance Issues

• Schedule anomalies

• Workers in energized equipment

• Mispositionings

• Worker contaminations

• Industrial safety events

• Others?

Objective ts} To proactively prevent events caused by human error (A

How does the Picture of Excellence apply?

AC EMAN t.

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Commued toNudearEx v I . /A/Il.61 1 d q I-7 Pride Safety Partnership Zero Tolerance Accountable Config. Control Ownership Predict/Prevent Teamwork Reduce Errors Participation Prioritize Learning Effective Reliable At t' - At A

. . .I I I I I I I Accident Control Event Meet Attend No Free Dose Free Schedule Training Rework

Performance Modes

• 3 Performance Modes

• Skill Base Rule Base

• Knowledge Base

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Performance Modes High Inacurat 0-%

Ce W. in Inaccurate ,

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.60 Mental Picture zl_

0co U -I Q r. v f C.)

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N-Misinterpretation CD.-

8e 0*~

t 11 1.

o Low Inattention II ,fE SO Low 'nFamiliarity (w/task) Y(000 High 1/ 17

(, c C-,s P'ar£ S 0

fega a-,'2

Skill Base Performance Mode

• Definition - Skill base performance involves:

I Highly practiced actions in a very familiar situation, and

• Usually performed from memory without significant conscious thought.

Examples t I7;9-S9

• Error Mode -Inattention

Skill Base Performan ce Modes High U,

Co Inaccurate -

.0 SU Mental Picture 0

.0 Q:co SR 0 C) a Misinterpretation .C _

M JD M -d z C (00 a) ,0 E col W-,.N Low Inattention co on O Low Familiarity (w/ task) High

Rule Base Performance Mode

• Definition - Rule base performance is

• 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

• Examples C

• Error Mode - Misinterpretation

If You Ever Catch Yourself Saying the Following Phrasi v- I SOOS

/ I Know I am Supposed

. uda h' e MY a' Mr.

I was taug to do this way..

is way really meets the intent; at's not what it really me WATCH OUT...

You are not ... in procedural compliance.

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Rule Base Performance Modes High (0 Inaccurate 0 0

cr.

4-'-

Mental Picture So 0

._ 0})

aL Misinterpretation .0)

• -C 010 n C 0

ok oMn -o Low Inattention High Low Familiarity (w/ task)

Knowledge Base Performance Mode Definition - Knowledge Based Performance Mode

• Is a response to a totally unfamiliar situation

• There exists no skill or rule recognizable to the individual.

• People transition to knowledge based situation as soon as they realize they are uncertain.

• High uncertainty increases the need for additional information.

• Examples GaI

Knowledge Base Performance Mode Error Mode - Inaccurate Mental Model

• Knowledge base activities require diagnosis and problem - solving

• Error likely if based on inaccurate information

• Most decisions are made with limited information and assumptions

Knowledge Base Performance High Modes I Inaccurate Mental Picture i"I "I Misinterpretation I

i

7. co-Low Inattention M Low ~Familiarity (wI task) Hg

Knowledge Base Performance Mode

• When do we perform in a Knowledge Base Performance Mode?

• How do you recognize you are in a knowledge base performance mode?

• What can you do to prevent errors when working in Knowledge Base Performance Mode?

.I

Knowledge Base Performance Mode

• Error Reduction Tools for use in Knowledge Base Performance Mode

• Stop when Unsure

• Challenge Information (a.k.a QV&V)

Vf;2O (,k- BYOf 0259 gi l-I

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Stop When Unsure When in doubt- STOP and resolve

Challenge Information

• The formalization of a questioning attitude and follow-up through continued challenging of information:

• Question information

• Check accuracy

• External confirmation, if unsure

• Also Known as QV&V

Performance Modes High CU Inaccurate 0 Mental Picture 0

mm I-1 CX Misinterpretation L-o 0*ax

' c6 D an O !i, E4O o a; Low Inattention Low Familiarity task)

(w/ High

Error-likely Situation An error about to happen due to error precursors.

• Task Demands

• Work Environment

• Human Nature

• Individual Capabilities S..

Al

Error Precursors BANS , .

(short list)

'li ,

_ n A v T. X _ - _

11, , nL-PWI-)s I , ))(,oo - /,r C-

• High workload (memory requirements) . Unfamiliarity with task / First time

• Time pressure (in a hurry) . Lack of knowledge (mental model)

• Simultaneous, multiple tasks . New technique not used before

• Repetitive actions / Monotony . Imprecise communication habits

• Irrecoverable actions . Lack of proficiency / Inexperience

• Interpretation requirements . Unsystematic problem-solving skills

• Unclear goals, roles, or responsibilities . "Can do" attitude for crucial task I nr 4 e of r.r l Inmlcnr ctnnrnrrIc

• Distractions / Interruptions . Stress

• Changes / Departure from routine

• Habit patterns Confusing procedure / Vague guidance

• Assumptions

• Confusing displays / controls

• Complacency / Overconfidence Work-arounds / OOS instrumentation

• Mind set (intention)

• Hidden system response

• Inaccurate risk perception

• Unexpected equipment conditions

• Mental shortcuts (biases)

• Lack of alternative indication

• Limited short-term memory

_0egWm& AM2I W,

I

Where are my zeros

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Communication is the key..

Ineffective communications often results in:

• Errors

• Poor coordination and cooperation

@Low productivity

• Undercurrents of tension l Unclear direction

o Improve communications, all employees must:

• Understand that communication is a two-way street.

• Put more emphasis on face-to-face communications.

• Ask yourself, each time you give an instruction, was the message clear.

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o Improve communica ions, all employees must:

• Understand that communication isn't over when you finish delivering the message.

• Follow up to assure the communication is essential to success.

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Bottom line...

• We MUST communicate with each other.