ML050840496
| 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
I Point Beach Excellence 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
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/A/Il.61 Pride Safety Partnership Zero Tolerance Accountable Config. Control Ownership Predict/Prevent Teamwork Reduce Errors Participation Prioritize Learning Effective Reliable At t'
At A
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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 W.
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N-Inaccurate 1".I Mental Picture Misinterpretation t
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High 1/
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,fE SO Low Inattention Low II
'nFamiliarity (w/
task) Y(000
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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 I
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- Error Mode -Inattention
Skill Base Performan ce Modes High U,
Co SU
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0 SR a
Low Inaccurate Mental Picture Misinterpretation co
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C)
.C _
(00 M JD M -d z C a),0 E col W-,.N co on O Inattention 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
/
I Know I am Supposed da u
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...
v-I SOOS You are not...
in procedural compliance.
p-
Rule Base Performance Modes High (0
0 4-'-cr.
0 So aL Low Inaccurate 0
Mental Picture Misinterpretation 0} )
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- -C 010 o -
n C 0
ok Mn o Inattention Low Familiarity (w/ task)
High
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 I
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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 Modes I
High Inaccurate Mental Picture Misinterpretation co-Low Inattention M
Low
~Familiarity (wI task)
Hg i"I "I
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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)
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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 0
0 mm I-1 L-o Low Inaccurate Mental Picture Misinterpretation CX 0*ax o a; E4O
' c6 D an O !i, Inattention Low Familiarity (w/
task)
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 (short list)
BANS n
A v T.
X 11, nL-PWI-)s I
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'li,
C-High workload (memory requirements)
Time pressure (in a hurry)
Simultaneous, multiple tasks Repetitive actions / Monotony Irrecoverable actions Interpretation requirements Unclear goals, roles, or responsibilities I nr4 e of r.r l Inmlcnr ctnnrnrrIc Unfamiliarity with task / First time Lack of knowledge (mental model)
New technique not used before Imprecise communication habits Lack of proficiency / Inexperience Unsystematic problem-solving skills "Can do" attitude for crucial task Distractions / Interruptions Changes / Departure from routine Confusing procedure / Vague guidance Confusing displays / controls Work-arounds / OOS instrumentation Hidden system response Unexpected equipment conditions Lack of alternative indication Stress Habit patterns Assumptions Complacency / Overconfidence Mind set (intention)
Inaccurate risk perception Mental shortcuts (biases)
Limited short-term memory
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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.
I }
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.