ML19308B831
| ML19308B831 | |
| Person / Time | |
|---|---|
| Site: | Crane  |
| Issue date: | 03/31/1976 |
| From: | Eicher R AEROJET NUCLEAR CO. |
| To: | |
| References | |
| TASK-TF, TASK-TMR ERDA-76-45-5, SSDC-5, NUDOCS 8001170411 | |
| Download: ML19308B831 (28) | |
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E R DA-76-45-5 SSDC-5 O
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REPORTED SIGNIFICANT OBSERVATION (RSO) STUDIES SYSTEM SAFETY DEVELOPMENT CENTER A
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AEROJET NUCLEAR COMPANY 550 Second Street Idaho Falls, Idaho 83401 MARCH 1976 UNITED STATES ENERGY RESEARCH AND DEVELOPMENT ADMINISTRATION DIVISION OF SAFETY, STANDARDS, AND COMPLIANCE 800117041)
O DISCLAIMER This report was prepared as an account of work sponsored by the United States Government.
Neither the United States nor the United States Energy Research and Develop-ment Administration, nor any of their employees, nor any of their contractors, subcontractors, or their employees, makes an, warranty, expressed or implied, or assumes any legal liability or responsibility for the accuracy, com-pleteness, or usefulness of any information, apparatus, product or process disclosed, or represents that its use would not infringe privately owned rights.
O Available from:
System Safety Development Center EG&G Idaho, Inc.
P. 0. Box 1625 Idaho Falls, Idaho 83401 th
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ERDA-764E5 SSDC-5 Oc 41 REPORTED SIGNIFICANT OBSERVATION (RS0) STUDIES l
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Prepared By R. W. Eicher I
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Work Performed At AEROJET NUCLEAR COMPANY
-l IDAHO OPERATIONS OFFICE Under Contract No. E(10-1)-1375 March 1976 5
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i ACKNOWLEDGMENT i
i Special acknowledgment is due to Robert J. Nertney and Ja:k L. Clark for their helpful guidance and suggestions, and to Della T. Kellogg for her editor ial assistance.
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1 CONTENTS Page i
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Introduction.....
1 Discussion......................
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Needs Survey.....................
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j Select Method and Topic................
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l Collect and Organize Results.............
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l Cursory Analysis...................
8 Fa s t Ac ti on Cycl e...................
8 Standard Validation / Analysis.............
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Key Wording and Filing................
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l Appendix A......................
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l Appendix B......................
17 Appendix C......................
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References......................
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V REPORTED SIGNIFICANT OBSERVATION (RS0) STUDIES Introduction The Reported Significant Observation (RS0) study, as used in the field of safety, is an information-gathering technique which uses employee-participants to describe situations they have personally witnessed involving good and bad practices and safe and unsafe conditions.
This information is utilized in the risk assessment process by helping to monitor the presence of hazards and thereby facilitate their elimination and hopefully prevent their existence in future operations and designs. While capable of playing an integral part in the process, RS0 should not be expected to stand alone as the only risk assessment program element.
As used by the Air Force in their aviation psychology program and further developed by John C. Flanagan, RS0 is more commonly known as the " Critical Inc1 dent Technique". However, the words " Critical" and " Incident" had other connotations in the nuclear safety discipline, prompting early users within the Aerojet Nuclear Company to coin the more fitting title of " Reported Signi-ficant Observations". The technique experienced an initial slow start in the safety field primarily due to the fact that the majority of users were researchers A) interested in af ter-the-fact data, with the application to everyday problems and U
behavioral factors not being fully realized or appreciated.
RS0 was formally recognized as a significant hazard reduction tool during the development of the Management Qvgrsight and Risk Tree (M0RT) program for the U. S. Atomic Energy Comissionlli. The Energy Research and Development Adm%i-stration (ERDA) has, in turn, adopted MORT for its system safety program, and this has resulted in RSO being brought to the forefront as a modern and viable technique to be considered for possible application in all ERDA contractor safety programs.
The RSO flow process described in this paper is depicted graphically in Figure 1.
Figures 2-5 show examples of introductory material and forms used in the question-4 naire approach to RS0 studies.
The other approach, interviewing, would use similar material except, of course, it would be related orally to the participants in the study and could be widely varied.
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i REPORTED 5!GNIFICANT OBSERVAT E S FLOW PROCESS
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-MValfdate'
-! Key Word Inden!
IP Interview Train conduct Safety Organization Interviewerfs)
Interviews and Involved Feedback Organiratton Managers'-
e Perform Analysts a
l' b'50'7 I
Perform Select Collect Organtre Analysis for g
Needs R50 Results Data Iraninent T
surv=v Method HazaNs Action M File 8
Questionnaire ' nuestinnenire
)uestionnaires t,
i Distribute N
Design i
Safety Org. and g
Involved Org.---
8 Fast Action -'
Outck Validation / +-------d Data Only Feedback Analysis 1P ItSO Data Stores With-I in Librarv system 4
W Access by Designers, Managers, etc.
Figure 1 O
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, To: 850 Participants -.
We are interested in obtaining information relating to desian of your facility and We've tried to anticipate some of the Questions you might have regarding this more specifically to the way that the plant and equiarent " fit' the h@an operator.
he would like to call on your emperience to date in operating, maintaining, and working around the facility to obtain information regarding t'w man-machtne inter-Q. Why are you asking us?
faces.
A.
The answer to that is very simple. You're the experts. You're professional As one aspect of the study of this subject we would like to obtain narrative people and p_u are doing the work. It's been dewenstrated tier and again accounts of actual operating events which indicate particularly good design at the that the peopTe who are doing the job are the ones who know w* hat's going on.
man-machine Interface and other events which indicate that design is not to good.
Does this have anything to do with checking up on individual people?
Q.
On the following pages we will ask for specific examples of operational events which you have personally observed that can be associated with particularly effec-A.
Absolutely not! You'll note that we don't ask you to put your names on the tive or ineffective design from the point of view of the operator (engineer) who reports andW ask you not to put anybody else's name in your examples, has to make the hardware system work or perform matntenance on it, he're interested only 1 Mow the system works and what branch and d? vision management can do to help 3 n g professional goal of conducting the i
[ach o$ your emanples should be a brief factual account of something that:
safest possible operation.
1.
Mappened at a particular part of the complex at a particular time that you Q.
I've never seen anything like this befnre. Is this somethly new and experimental?
personally nbserved.
2.
Was the result of design that you judge to be particu' *, effective from the A.
This is not an emperimental method. It's been used a great deal. in app 11-potet of view of the operater (or ineffective) cations ranging from aircraf t piloting to teaching met %15 at col'eges and universities.
3.
Resulted in a positive consequence or avoided a potential problem (or resulted I've noticed that two of the questionnaire sheets are blue and two are pink.
in a prohlm situation or a situation that was potentially a problem).
Q.
You may, if you like, choose events from which the consequences were trivial at I
the time but which could represent more serious consecuences under different A.
We're asking you for four examples, conditions.
W (1) mest recent example of a' job or operating situation in which you feel The descriptions which you write should M include the names of the specific Edesfgn at the man-eischine toterf ace was particularly good, g
personnel involved.
(2) another example of a job or operettnq situation in which yoa feel the design at the man-machine interface was particularly good.
A usable description riust!
1.
Clearly set the time and situation at the time of the event.
(3) Most receat example of a job er operating situation in which you feel Edesign at the man-machine 1sterface could be taproved.
2.
Specifically identify the media involved in the event (operating instruc-tion, panel layout, mechanical design of specific components etc.).
(4) Another example of a job or operating situation 'n which you feel the design at the man-machine interf ace could be improved.
3.
Precisely record the way that operations or maintenance personnel reacted to the media (turned cor. troller wrong way, overshot control point im-If you look at the top of the sheets you'll see that the blue sheets are for proper assenbly or disassembly, misinterpreted instrument indications.
ood jobs. The pink sheets apply to jobs or operating siCaTions in which you ce the design could te improved.
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4 state clearly the consequences or poterttai consequences (difficulty in voor cooperation and assistance in this effort are greatly appreciated.
matntaining operating conditions. loss of time, difficulty in under-standing what's going on loss of product etc.).
We would Itke to have you take time to think over your examples and write them down as you have time. They will be collected by branch supervisfon and trans-mitted to us for analysts.
Figures 2 and 3.
These two pages serve as an example of the introductory material which would accompany the question-naires. These are oriented toward operability / maintainability, a good topic for the first RSO study. They would be appropriately changed to address special considerations for indivMual facilities or target groups. It may be desir-able to include examples of completed questionnaires in the introductory material if it is felt that this can be done without biasing the participants.
From your experience, think of the most rece*t situation in which you observed From your esperience, think of the most recent situation in meich you observed a job or operating situation for whWit was easy to operate or maintain plant a job or operating sitaatton for wnWit was M easy to operate or maintain equipment in an effective, error-free manner.
plant equipment in an effective, error. free manner.
1.
When and where did this happen (approximate date and place)?
1.
WMn and where did this happen (approminate date and place)?
2.
What equipment and/or what type of job was involved?
2.
What equipment and/or what type of job was involved?
3.
Briefly describe the situation at the time (process or machine running, process or machine shut down, abnormal operating conditions. etc.).
3.
Briefly describe the situation at the time (process or machine running.
process or machine shut down, abnormal operating conditions, etc.).
4 Exactly what occurred? (Use other side if necessary.)
4.
Emactly what occurred? (Use other side tf necessary.)
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5.
Why do you classify this as being an especially easy operatfonal or matatenance job?
5.
Why do you classify this as being an especially difficult operettonal or maintenance job?
6.
What might have been expected from less effective plant design or procedures f n this sisuatf on (e.g., more difficult to perform. more chance for error.
6.
What might have been espected from more effective plant design or procedures more chance of equipment damage, etc.)?
in this situation (e.g.. easier to perform. less chance of error less chance of equipment damage, etc.)?
Fiqure 4 Figure 5 These are examples of one possible format of the " good" and " bad" sheets used in the questionnaire method. If addi-tional questionnaires are used, the first sentence on both examples is changed to:
"From your experience, think of another situation..." for each subsequent questionnaire.
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RS0 FLOW PROCESS (Refer to Figure 1)
Discussion Every organization finds itself subject to varying degrees of scrutiny by the public, consumer action groups, sponsors, customers for contract work, government agencies, and others.
If this is a particular concern to your organization, serious consideration should be given to the manner in which RSO study results will be generally handled and made available to individuals other than those involved in the hazard analysis process.
The material is sensitive, making it best suited to use internally, and it may be necessary to take precautions to assure that the material is never taken out of the context of the risk assessment system. As a minimum, if an RSO program is to be instituted, the organization should be prepared to act quickly and effectively on identified hazards.
The resNnsibility for initiating an RSO study lies within the safety organization.
If the volume of studies is high and the size of the organization permits, a permanent group may be established to handle RS0's, even though it will not be a full-time activity. Othemise, ad hoc task groups could be created for indi-vidual studies. The need for good analytical work and a general understanding A}
of multi-discipline functions should be kept in mind when selecting RS0 group members.
In order to prevent an overburden and to allow for development of new experiences, it may be best not to apply the RSO technique to the same organiza-expressed an interest in continuous sampling with monthly meetings (gyps h tion more frequently than about every six months.
However, some gr l.
Since the widespread responsibilities of most safety organizations have resulted in a general concern over safety resource allocations, it is worthwhile to address here the manpower impact of introducing an RS0 program.
For a safety organization which already allocates manpower to a risk assessment system, the impact of RSO's will be minimal; the reason being that individuals involved in risk assessment will recognize the RSO as a tool to help them gather a segment of the information they require for a total hazard analysis.
Without that segment, a significant amount and type of data will be missing and the hazard analysis cannot be consi-dered complete. Most safety professionals agree that for every accident reported under the usual organization reporting requirements, there are hundreds of "near-misses" that go unreported. The RSO helps in that regard by furnishing quantity data on observed near-misses.
Besides quantity, the type of information included in RS0's is difficult to j
' gather by any other method. When appraisers or observers enter an ongoing activity, they will usually witness an artificially high level (due to their presence) of performance and good behavior. RS0 information, on the other hand, is provided by the workers themselves, without fear of punitive action, and is typified by its candidness and specificity concerning hazardous situations.
Thus, the RS0 work load within the safety organization will be primarily asso-i ciated with the analysis of study results.
For an organization with a formal
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risk assessment system, the incorporation of these valuable data should evolve as a natural extension of the hazard analysis process....
The manpower impact external to the safety organization is also minimal, since it is spread evenly over a large number of participants.
Each participant can furnish his or her response, as time permits, within the framework of the study and the individual's job.
If the interview method is used, the work load will be significantly increased for the safety organization, since the participants' time will have to be matched hour-for-hour by the interviewer's time.
This added manpower may be partially offset by a possible reduced amount of later data analysis / validation, due to the ability of a skilled interviewer to properly' screen participant's responses on the spot; however, validation will still represent a major area of effort.
The impact of initiating an RSO program will be more significant for an organization that has no formal risk assessment system.
It is not within the scope of this paper to discuss the merits of having a risk assessment system.
It can only be stated that if an organization has reached the conclusion that it is time to establish such a system, then the RSO program should be considered as an integral part of that system, but not as a risk assessment entity in itself.
Needs Survey Having established an RSO group, whether ad hoc or permanent, the next step is to perform a needs survey to determine the scope and extent of " free play" for the RSO study. The needs survey may take on several forms.
The line organiza-
' tion can be formally " pulsed" by asking in writing for target areas which managers or supervisors feel are in need of hazard analyses.
Audits and appraisals are another good source of target areas.
Accident investigation reports will frequently contain recommendations involving a need for hazard analysis.
(However, a caution here is that a study conducted immediately af ter a major incident will have biased results.
Participants will make their responses in light of the incident. A sufficient waiting period may be in order before initiating the study.)
Other inputs for a needs survey might be:
accident / injury statistics; routine area surveys; problem priority lists; risk projections; employee suggestions; previous special studies (such as RS0's, research projects, etc.); national trend statistics (from NSC, OSHA, and others); and other monitoring techniques, including routine hazard reviews, error sampling, and quality assurance reports.
Using any one or a combination of these will constitute a needs survey.
The RSO group or its leader will have to determine the suitability of the available inputs.
If the available information is sufficient and satisfactory, then sound judgment must be used to select:
- 1) the study's scope - a specific topic; a general discipline; or " free play"; and 2) the target group - one particular facility; a single discipline (all welders, all electricians, all machinists, etc.); or a multi-discipline, across-the-board approach.
Select Method and Topic In choosing between the interview and questionnaire methods, the primary consi-deration, besides the manpower problem mentioned previously, is the validity of the study results.
This consideration has two aspects, biasing and anonymity.
The interview method seems to have the edge in being less likely to bias the participant.
The reason for this is that a skilled interviewer can sense those opinions that cause individuals to react dif ferently to the same question.
If the part cipant has misinterpreted a question or is trying to voice some personal, i
- O non-safety problem, the interviewer has the freedom to change his line of ques-tioning in order to redirect the participant back on track. The questionnaire, unfortunately, has no variability once it is distributed, and there will always be a certain number of invalid results in each study. This can be minimized only through experience in careful wording of the written questions and any examples or introductory remarks included in the questionnaire package.
However, similar care is' required in the selection and training of interviewers.
Unsuitable results might be obtained, for example, from an electrical safety engineer used as an interviewer in a general RS0 study, if the engineer is biased toward uncovering electrical safety problems. The skilled interviewer will be able to detect and correct misinterpretation without leading the participant to a predetermined answer. Also, as the required number of interviewers increases, training becomes more important to assure uniformity among interviewers.
Anonymity is important to the individual who fears punitive action against himself or others as a result of information that he reveals. The RSO technique is based on the premise that these individuals will be less inhibited with RS0's, since they will usually be describing "near-miss" situations in which no one was injured and no property was damaged. The questionnaire method further ensures anonymity by not requiring names.
The results can even be returned in sealed envelopes to the RS0 group. The openness associated with anonymity can help reveal employee attitude and morale information that is difficult to obtain by other methods.
The interviewer can only offer oral assurances that the participant's material will remain anonymous. However, this should prove ta be less of a problem after the first study has been conducted and employees are able to see that n
no punitive actions are taken.
Besides the manpower concern in selecting an RSO method, another factor may be the type of human resources available to the organization. An expertise may already exist within the organization for either skilled interviewers or ques-tionnaire designers. Without this expertise, consideration may be given to contracting with outside consultants in the field. Whichever method is selected, upper management knowledge and backing of the study is necessary.
The whole program must start with senior management and labor representatives making a commitment and then a joint campaign to educate and enlist the working level people in this program.
If the questionnaire approach is used, for example, the questionnaires should be introduced at the upper management level and passed on with appropriate instruc-tions to supervisors for eventual distribution to the target group. The sealed results would be returned through the supervisors to the RS0 group. This display of management backing will enforce the desired participant attention to the study, with the added benefit of having the safety organization remain anonymous to the participants.
The topic for an RSO study should not be so general that participants are not sure of what is desired. Operability / maintainability is a good topic for a facility's first study for two reasons.
First, participants being introduced to RS0's find hardware and equipment easier to talk about than less tangible subjects. Second, it is a good idea to eliminate facility operation and main-tenance problems before addressing problems related to procedures, standards, etc.
q Figures 2-5 are examples of introductory material and questionnaires for a study y J on operability / maintainability.
Examples of responses to this study topic are v
given in Appendix A. -
Collect and Organize Results The piecemeal method of conducting interviews makes it possible to perform a cursory hazard analysis of incoming data as it becomes available, rather than waiting until the interview series is completed.
Usually, the interviewer (s) would be capable of making this type of judgment as individual interviews are completed. Otherwise, a copy of the results should be sent to the RSO group following each interview, if the series will not be completed for some time.
This quick analysis will permit identification of imminent hazards so that necessary action can be taken.
For the questionnaire method, there may be situations which lend themselves to batch collection of the results. An organization may find it beneficial to use time normally assigned to a periodic safety meeting for the completion of questionnaires by participants (a signifi-cant cost / benefit factor). A typical session might require four questionnaires for each participant - two examples of observed " bad" situations and two " good" situations. The total time involved per participant may vary from 30 to 60 minutes, depending upon ease of recall of observed cases.
Some organizations may find it desirable to not place a limit on the number of questionnaires used.
The batch results from the session would be transmitted through the appropriate supervisor to the RSO group.
The collected data should be organized in a manner that lends itself to later analysis and followup actions.
Each organization will have its own preferences as to arranging the material by facility, disci-pline, or subject matter.
Cursory Analysis One of the immediate benefits of an RSO study is the uncovering of imminent hazards that other monitoring systems have failed to detect.
If the RSO analysis group is furnished with a clear definition of what the organization considers an " imminent hazard", then the study results can be easily skimmed through to pull out such cases.
Copies are made of these cases and are sent on a fast action cycle to Safety and to the involved line organization (s) for a quick validation / analysis and followup action, if required.
The complete study results package remains intact and is routed through the standard validation /
analysis process.
Fast Action Cycle When the safety organization and the involved line organization receive RSO data for fast action, their first concern is validation.
They must quickly determine whether the situation, as described in the RSO, actually exists or could have existed.
In a few serious cases, it may be necessary to shut down the operation until the RSO can be validated. Generally, the line organization would be responsible for making this determination while Safety would confirm their finding.
If it is found that an imminent hazard situation does exist or could recur, the case should be analyzed for the best course of remedial action.
Safety should offer advice on ways to eliminate the hazard or on taking other corrective actions needed. The line organization should see that the action is taken and should receive feedback as to the success of eliminating the hazard.
Standard Validation / Analysis i
All data produced by the study must be validated to sg..e extent.
This can be accomplished through personal knowledge of the situation, discussion with the responsible supervisor, or confirmation by the local safety representative.
If a piece of data turns out to be invalid, it should not be included with valid data to be analyzed, key worded, and filed. However, for safety purposes, it is a good idea to determine the cause for data being invalid.
If a partici-pant misunderstood an observed situation, he should be informed of the pertinent details so that he is not left with the impression that the RSO study was unres-ponsive to his contribution, nor should he be left with an improper concern about a nonproblem situation.
If the study was conducted anonymously, feedback to participants can be accomplished through such means as periodic safety meetings, toolbo). talks, plant newspaper, bulletins, board notices, etc. A participant may use the RSO to get attention for a nonsafety or personal complaint.
These, too, may deserve further investigation since their effect on attitude and morale can have later safety implications. Attitude and morale problems can also serve as indicators of possible topics of concern that may develop further at labor negotiations.
Valid data should be carefully analyzed for patterns, systemic problems, hidden problems, and positive features. Time should not be expended to synthesize possible accidents / incidents using various combinations of RSO cases. However, if the organization is concerned over a postulated accident of severe consequences, it may be worthwhile to examine RSO results for mechanisms which could lead to that particular occurrence. Such mechanisms may be necessary links in the
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causal-flow chain leading to the undesired incident, or they may be situational events that have an indirect yet relevant effect on the major chain events (see Appendix C).
If the validation process was done properly, identification will have been made of patterns caused artificially by the use of leading questions or by conducting the RSO study too soon after a major incident has occurred.
The analysis of legitimate patterns can indicate areas in need of more attention and effort from the safety resources.
Likewise, systemic problems are indicated when a "fix" applied to an RSO case will solve only that specific situation, and will not prevent recurrence of a similar situation.
Improvements would then be in order for the general manage-ment system or its implementation. Hidden problems are frequently found in participants' descriptions of supposedly " good" situations (see Appendix A).
Many of these are simply cases where something went wrong and an individual was observed taking the right corrective action. Taken in this light, these cases can be analyzed with the " bad" RSO cases.
It is possible to correlate these cases with national industry experience, as has been done in Appendix B.
RS0's that describe actually good situations are of value for determining program features that:
- 1) should not be suspended or reduced in effort;
- 2) could be applied in other ongoing operations; and 3) should be considered for future operations and designs.
All actions taken as a result of RS0 data analysis are the responsibility of the line organization, although the division of work (in the validation / analysis process) between this group and Safety may vary considerably from one organiza-tion to another. A definite feedback route needs to be established so that the impact of remedial actions can be monitored.
This also provides a measure of I
success of the R50 technique.
O Key Wording and Filing It is recommended that to make the study data more usable and readily accessed, all RSO cases be key word indexed.
If the organizatiori is not experienced with key wording, one approach is to distribute copies of the first RS0 study to safety personnel representing various disciplines, in order to have them indicate those words in each case which are important to them in their work.
This will provide the RS0 group with an idea of the areas of interest that need to be considered for future key wording. The kuy words must be functional to the users; otherwise, the index is just a useless exercise.
In addition to the list of key words, the index might include the location of the observation, as well as the study number and ;ase number within that study.
The index should be updated after each st;dy.
The volume of cases makes this task adaptable to a basic computer >rogram.
Each safety reference /resourc< area within the organization is supplied with copies of all RSO studies, ireluding the updated index.
Easy access by managers and designers is required to fulfill the objective of preventing mistakes in future operations while reinforcing positive aspects that have proven benefits.
Consideration should be given to proper command documents being issued, which require the query of RS0 files during all hazards analyses, risk assessments, and other evaluations in need of a thorough literature search, before committing a design to manufacture, fabrication, or construction.
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APPENDIX A v
On the following pages are a sampling of four responses to RS0 studies on operability /maintainabili ty.
For the first two cases (A and B), the participants were asked to describe a situation involving a " good" design, while the second pair (C and D) were to have involved a " bad" design.
Case A actually does describe a good design, which would be worth con-sidering for new facilities in which inter-room communications might be cri tical.
Case B, while intending to describe a good situation, reveals an under-lying problem of poor tool design, which may have caused delays or damage in the past and could do so in the future.
Case C describes a " bad" situation, as requested. This case shows that design problems are not limited to complex equipment or processes, but can also be found in the more basic and common elements of a facility.
Case D involves a situation which probably would not result in personal injury, although property damage appears likely. Even if there were no property damage, there could certainly be delays, downtime, loss of product, or lowered efficiency.
If this were true, the case serves as an example
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that RS0's can have programmatic as well as safety benefits.
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(A)
From your experience, think of the most recent situation in which you observed a job or operatinq situation for which it was easy to operate or maintain plant equipment in an effective, error-free manner.
1.
When and whera did this happen (approximate date and place)?
June 1967. A-Bailding Process Room and Coutttol Room.
2.
What equipment and/or what type of job was involved?
Building pitone system.
3.
Briefly describe the situation at the time (process or machine running, process or machine shut down, abnormal operatir.g conditions, etc.).
Acceptance testing of nese ptocess macit.ine required constante commartication bekiecen Process Room, Conttol Room, and lititity Room.
4.
Exactly what occurred ?
(Use other side if necessary.)
0.C. pitones teete plugged in and tiie patcIt panck set up so titat tliste tais tittec-tary communication.
5.
Why do you classify this as being an especially easy operational or maintenance job?
In tite time it takes to plug in a socket, tittce-atty communication nts set up.
6.
What might have been expected from less effective plant design or procedures in this situation (e.g., more difficult to perform, more chance for error, more chance of equipment damage, etc.)?
Wititaat tite pItone setup tee teould liave Itad to resort.to otlier mearts of communicating testic{t migitt not liave been as fast or as accettate as a direet pitone system.
(B) l From your experience, think of the most recent situation in which you observed a job or operatinq situation for which it was easy to operate or maintain plant
's equipment in an effective, error-free manner.
1.
When and where did this happen (approximate date and place)?
Attgttst
- 67 ctt tite A-Bitildistg Ptocess room.
2.
What equipment and/or what type of job was involved?
Ifodttle renovat tool.
3.
Briefly describe the situation at the time (process or machine running, process or machine shut down, abnormal operating conditions, etc.).
V1ocess tais slutt dotat for removal of modttles.
4.
Exactly what occurred?
(Use other side if necessary.)
m
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v' Tool fitnetioned as designed and modttles wete removed from theit positicuts tcLth little at no delatj and leitit no chance of dropping tite pieces.
5.
Why do you classify this as being an especially easy operational or maintenance job?
!.fany of cltr tools are too heavtj to itse or ineffeetive for tile job tlict]
are designed to do.
This is not the case tcLth this tool (2 tools).
6.
What might have been expected from less effective plant design or procedures in this situation (e.g., more difficult to perform, more chance for error, more chance of equipment damage, etc.)?
}
Ifote time constuned dttting the operation tcLth possible damage to the modates.
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(C)
From your experience, think of the most recent situation in which you observed a job or operating situation for which it was not easy to operate or naintain plant equipment in an effective, error-free manner.
1.
When and where did this happen (approximate date and place)?
9/22/75.
On patit behecen Building 7 and Building i2.
2.
What equipment and/or what type of job was involved?
Tico-teltected cart.
Ifaving Itcavy fiting cabinets and desh from one buildb1g to anotlter.
3.
Briefly describe the situation at the time (process or machine running, process or machine shut down, abnormal operating conditions, etc.).
Rocks and sanken pa, tit.
4.
Exactly what occurred? (Use other side if necessary.)
hopped tidngs off cart.
5.
Why do you classify this as being an especially difficult operational or maintenc: ice job?
Need some Idnd of liard pa. tit behecen buddings.
6.
What might have been expected from more effectie picnt 6> sign or procedures in this situation (e.g., easier to perform, less chance of eNor, less chance of equipment damage, etc.)?
l Keep catt leuci and not damage contestts.
1 (D)
From your experience, think of the most recent situation in which you observed a job or operating situation for which it was not easy to operate or maintain plant equipment in an effective, error-free manner.
1.
When and where did this happen (approximate date and place)?
Whenever tecathst is cool or cold.
At Building 207, Room C.
2.
What equipment and/or what type of job was involved?
Cooling toteet pump Itousc.
3.
Briefly describe the situation at the time (process or machine running, process or nachine shut down, abnormal operating conditions, etc.).
Tteo noof vents rtuuting, also Itcatets.
4.
Exactly what occurred? (Use other side if necessary.)
'~'
Tteo roof vents rtuuting cooled the room to a po. int teltere piping froze up.
s 5.
Why do you classify this as being an especially difficult operational or maintenance job?
There should be more variation in the floto of ait out of.the budding.
One vent on is of ten too much but yet.some f tote is needed.
6.
What might have been expected from more effective plant design or procedures in this situation (e.g., easier to perform, less chance of error, less chance of equipment damage, etc.)?
At a set tenperatitte one or both r.cof vents could shttt doten and at a set Itigit terpcRatute one or both could come on atttomaticatty.
Or thete could be steltches to conttet a var.iable speed exhaust fan in roof vencs.
nJ APPENDIX B RS0's can be correlated to data stores external to the organization as well as internal. The value of comparison is that it may reinforce an indication of trends and patterns, allowing for one of two conclusions to be drawn:
1.
if RSO data agree well with other data stores, this would tend to support the commitment of safety resources to those areas indicated as being high' hazard in both the RS0 and other sources; OR, 2.
RSO data may appear to not correlate well with other statistics.
Assuming that tne RS0 data base is suf ficiently large and that the validation process eliminated any biasing, then the data conflict may be due to a basic difference in either the type of operation (including plant and equipment) or the program / procedures (including resource allocation).
It is also possible that the source of
-'y comparison is in error.
Even if the RS0 data differ favorably j
from other data, it is still necessary to determine the reason for the difference.
Knowing the cause of a desirable pattern will allow it to be reinforced; understanding the faults behind a poor pattern will permit corrective actions to be taken.
The total data base of 1300 RSO cases at Aerojet Nuclear Company was compared with OSHA 1974 statistics to evaluate the correlation of electrical problems.
It was found that 25% of the 32,000 OSHA violations in 1974 were electrical problems. The Company's own OSHA-type inspection revealed electrical violations as 25% of the total, too. A precise correlation of 25% of the RS0's was also found to be electrically related. This finding would appear to support a signi-ficant safety resource commitment to the electrical discipline, proportionate to other discipline requirements as determined by the organization's monitoring and risk assessment systems.
Further analysis would be necessary to determine proper resource allocation to specific subgroups within the electrical area.
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v APPENDIX C Since RSO studies w 'e initiated at Aerojet Nuclear Company over seven years ago, there have be-about a half-dozen incidents which occurred subsequent to the collection c: closely-related RS0 data.
It should be noted that RS0 studies were being evaluated as a monitoring technique during this period; therefore, a rigorous analysis and corrective action process had not yet been implemented. Otherwise, these six cases probably would have been prevented.
In each case, the relevant problems revealed by RSO studies prior to the event were judged to be " relevant" because:
Each represented a situation specifically revealed in the accident a.
investigation, or b.
Each represented a general problem which was closely related to the specifics of the actual event.
This is not to suggest that RS0 material can or should be combined to predict
-~s future events.
Rather, these incidents and their related RSO material demon-wj strate that:
1.
There are numerous "causes" or mechanisms which lead to the main event.
2.
RS0 participants are excellent at pointing out problems that, sooner or later, can contribute to undesired events.
3.
By fixing only a few of the RSO type items, the incident causal chain could have been broken.
4.
Review agents, designers, and procedure writers should be aware of the R30 material in order to avoid repeating past mistakes and/or placing new systems in an accident provocative situation.
Following are two incidents of the six cases mentioned.
Remember that all of the problem items were reported prior to the incident, and they were not uncovered by any other monitoring method. Note how closely the RS0 data correlate to the actual occurrence.
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WALKING-WORKING SURFACES INCIDENT R4 sum 6 Connections were being made to a large holding tank, requiring welding, cutting, and other operations to be performed on, in, and around it for an extended period.
The tank was cylindrical and positioned horizontally.
A design engineer walking on the curved tank surface slipped and fell.
This resulted in a lost-time back injury.
RSO Results Listed below are two specific RSO responses pertaining to working on tank surfaces.
These should have been used by the designers of the holding tank, since the responses were reported for another facility well before construction of the holding tank was started.
1.
"There is no platform around the boiler tank surface to work on.
There is nothing to stand on when using a wrench to change valves.
One slip of the wrench and down you will come to the floor."
2.
"To me it is unsafe to be working off of a 12' ladder and m the round part of the boiler tank top.
It is not safe to. ark there without a platform."
Listed below are specific problems mentioned in an RS0 study conducted at the building of the holding tank, during the tank's fabrication but before the incident:
1.
" Ladders are grossly unsafe as used around the tank.
Rope, step-l ladders, and steel ladders are slippery."
l 2.
"No staging - nothing to walk on while on tank top.
Lucky no one j
has slipped off of tank!"
3.
"The area is not suitable for a portable ladder, and the operator must lean over a sizable area of free space in a most precarious position to operate the valves. No catwalks near valves."
4.
"There is a safety hazard from climbing on or over piping some of which is 10-20 feet above the ground with no walkways."
5.
"There isn't room for temporary ladders and there are no permanent ladders.
It would be easy to break your neck."
CASK
- TRANSFER INCIDENT
-m v
R5 sums In performing a transfer of radioactive material from a water tank to a storage canal, a large transfer cask was used.
The material was drawn only part way into the cask, and a shielding door at the bottom of the cask was only partially closed.
The material then protruded from the cask bottom, suspended by a cable which passed through a pulley mounted on the cask upper superstructure.
The crane operator began to raise the cask from the tank, realized that the l
sample was not completely inside the cask, and attempted to perform a horizontal traverse to the storage canal. The cask superstructure struck an overhead obstruction, causing the material to drop (on its supporting cable) to the building floor. The building was evacuated. A recovery plan was developed and the material was later transported to the storage canal without further incident.
RS_0 Results Listed below are specific problems associated with this event (which are also relevant problems reported by RSO prior to the event):
-s si w'
l.
Casks were improperly loaded (wrong cask, wrong sample, or " sample pulled too far") (reported 8 times).
2.
A Health Physics radiation survey instrument was inoperative (reported 5 times).
3.
Constant Air Monitors, Remote Area Monitors, and Personnel Friskers were ineffective as indicators of the highest radiation situacions (reported 5 times).
4.
Cask doors were mismanipulated (procedural inadequacy or procedural deviation) (reported 5 times).
5.
There were too many people around the tank area (reported 5 times).
6.
The Health Physics monitoring was insufficient to evaluate the job hazards (reported 3 times).
7.
Personnel failed to react to Health Physics direction (reported 3 times).
E.
Radiation was streaming between a cask and a shielding block (reported 2 times).
G
- A shielded container for radioactive material, which essentially prevents escape of radiation during transport of the material.
f 9
9.
There was insufficient Health Physics awareness of job conditions or Operations-Maintenance awareness of sources and fields (reported 2 times).
10.
Crane operator-rigger inattention resulted in radiation exposure of personnel (reported 2 times).
- 11. Rigger identification is difficult when other personnel are standing around the job area (reported once).
12.
A Maintenance Foreman stood around without any effort to guide or assist the crew (reported once).
- 13. The Operations Assistant Shif t Supervisor felt that no action could be taken in item 12, above, unless the " situation became dangerous" (reported once).
- 14. There were ambiguities in craft responsibilities (reported once).
- 15. An individual " reading along" with a procedure failed to track the work of a craftsman who was working without referring to the proce-dure (case cited omitted step) (reported once).
- 16. A Health Physics radiation survey instru.nent pegged at full scale due to the improper choice of instrument (reported once).
- 17. There was a failure to back out of a detected high radiation situation (reported once).
18.
Crane motion was initiated with a sample in wrong position (reported once).
- 19. A stuck sample was freed by raising the cask and realigning (reported once).
- 20. An exact duplicate of the cited incident occurred, up to the point at which the crane operator successfully reinserted the material i
into the tank rather than attempting to transfer it to the storage canal (reported once).
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bG REFERENCES (1)
" MORT - The Management Oversight and Risk Tree", by W. G. Johnson, U.S.A.E.C., SAN 821-2, February 12, 1973 (2)
Personal Comunications, Alan D. Swain, Ph.D., January 1976 (3)
"The Human Element in Systems Safety:
A Guide for Modern Man gament",
by Alan D. Swain, Ph.D., Industrial & Comercial Techniques Ltd.,
April 1974 (4)
RS0 Studies, Aerojet Nuclear Company, RS0-ll, RS0-16, RS0-18 O
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Other SSDC Publications n This Series SSDC-1 Occupancy-Use Readiness Manual SSDC-2 Human Factors in Design S50C-3 A Contractor Guide to Advance Preparation for Accident Investigation SSDC-4 M)RT User's Manual
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