BushCo Bush Revision DOE Office of River Protection Human Performance

BushCo Bush/001 Revision 0 DOE Office of River Protection Human Performance Assessment and Accident Investigation Report Performed by: BushCo Task Order Agreement BUS001 January 2006 Bush/001 Revision 0 DOE Office of River Protection Human Performance Assessment and Accident Investigation Report January 2006 BushCo DOE Office of River Protection Human Performance Assessment and Accident Investigation Report Bush/001 Revision 0 January 2006 Primary Investigator T. Shane Bush, BushCo Date Contributors Brian Harkins, DOE Facility Representative Jack George, DOE Facility Representative Stephen Walters, Bechtel National Inc. Safety Training Supervisor Gwenna Hill, Bechtel National, Inc. Six Sigma Shayne VanDyke, Bechtel National, Inc. Six Sigma Mike Hassell, CH2M Hill, Tank Farm Project ABSTRACT This document describes a nontraditional, developing human performance approach for accident assessment and investigation used to evaluate recent safety occurrences at the Waste Treatment Plant at the Department of Energy’s Hanford Site. iii EXECUTIVE SUMMARY This report describes a human performance approach for accident assessment and investigation used to evaluate recent safety occurrences at the Waste Treatment Plant at the Department of Energy’s Hanford Site. The results of this nontraditional, developing approach are compared against traditional accident analysis methodology. The comparison was performed to show the capabilities of the approach to incorporate analysis, to greater degrees, of behaviors in the context of the real work environment and therefore be the basis for more targeted, effective decision making and corrective actions. In 2005, the Waste Treatment Plant (WTP) at the DOE Hanford Site in Washington state, experienced an increased number of occurrences, particularly related to electrical incidents. These events concerned both DOE and the WTP contractor. After learning about human performance improvement at the DOE Nuclear Executive Leadership Training and acting upon a request from the local contractor, the DOE Office of River Protection requested a Human Performance Improvement (HPI) Assessment and Investigation of some selected occurrences during 2005-2006. The HPI investigative style is so new to DOE, that no DOE human performance improvement directives, procedures, or even guidance documents are developed to date. This particular report is meant to be a learning tool for DOE and the contractor personnel at the Waste Treatment Plant. It is not meant to replace any other investigative process already in use, but more to enhance existing processes with a new way of thinking. Accordingly, the information found in this report should not be used to draw conclusions. It should be used rather as an indicator about areas where the organization should continue to look for possible improvements. Ten occurrence reports were assessed against human performance investigation principles. These principles were developed as part of a cooperative effort between BushCo and the University of Idaho over the past few years. These principles were founded on the philosophies taught in James Reason’s book Managing the Risks of Organizational Accidents, Sydney Dekker’s book The Field Guide to Human Error Investigation, and the Institute of Nuclear Power Operations “Excellence in Human Performance Fundamentals” course work. Three of the ten occurrence reports were evaluated in detail including interviewing personnel involved in the events. The onsite assessment and investigation took place the week of January 30, 2006, through February 3, 2006. This analysis and investigation resulted in three specific areas with potential human performance weaknesses being identified: 1. 2. 3. Employees are working outside of controls unknowingly Confusion exists about the DOE-contractor relationship The workplace culture is increasing the likelihood of the occurrence of the types of events assessed and described in this report. iv CONTENTS ABSTRACT.................................................................................................................................................iii EXECUTIVE SUMMARY ......................................................................................................................... iv 1. INTRODUCTION.............................................................................................................................. 1 1.1 1.2 1.3 1.4 2. Purpose .................................................................................................................................. 1 Scope ..................................................................................................................................... 1 Background ........................................................................................................................... 1 Methodology ......................................................................................................................... 2 HUMAN PERFORMANCE OVERVIEW ........................................................................................ 3 2.1 2.2 2.3 2.4 2.5 What is Human Performance?............................................................................................... 3 The Human Performance Approach ...................................................................................... 3 Guiding Principles for Excellence in Human Performance................................................... 4 Benefits from Human Performance Implementation............................................................. 4 Human Performance Program Description............................................................................ 6 2.5.1 2.5.2 2.5.3 2.5.4 2.6 Key Human Performance Elements .................................................................... 6 Individual Behaviors ........................................................................................... 6 Leader Behavior .................................................................................................. 6 Organization Processes and Values..................................................................... 7 Human Performance Assessment Process Description ......................................................... 7 2.6.1 Limitations of This Investigation ........................................................................ 8 3. RESULTS........................................................................................................................................... 9 3.1 Concern #1 - Employees Are Working Outside of Established Controls Unknowingly....... 9 3.1.1 3.1.2 3.1.3 3.2 3.3 Excavation of 480-volt Line................................................................................ 9 Cutting of a Propane Line ................................................................................. 10 Installing Weather Boots on Electrical Cords ................................................... 11 Concern #2 – DOE - Contractor Relationship..................................................................... 12 Concern #3 - Work Place Culture ....................................................................................... 12 4. CONCLUSIONS .............................................................................................................................. 13 v 5. 6. RECOMMENDATIONS ................................................................................................................. 13 REFERENCES ................................................................................................................................. 14 Appendix A—List of Occurrence Reports Reviewed................................................................................. 15 Appendix B—Event Reports ...................................................................................................................... 16 Appendix C—Error Precursors................................................................................................................... 23 Appendix D—Human Performance Evaluation Worksheet ....................................................................... 24 Appendix E—Active Error Worksheet ....................................................................................................... 26 Appendix F—Culpability Decision Tree .................................................................................................... 27 Appendix G—Proven Corrective Actions .................................................................................................. 28 FIGURES 1. 2. 3. Conceptual depiction of human performance analysis of the entire work environment. ................... 5 Graphic showing the focus of the human performance approach on the context in which human errors occur: latent organizational weaknesses.................................................................................. 5 Human performance improvement objectives.................................................................................... 6 vi DOE Office of River Protection Human Performance Assessment and Accident Report 1. INTRODUCTION 1.1 Purpose This report describes a human performance approach for accident assessment and investigation used to evaluate recent safety occurrences at the Waste Treatment Plant at the Department of Energy’s (DOE’s) Hanford Site. The results of this nontraditional, developing approach are compared against traditional accident analysis methodology. The comparison was performed to show the capabilities of the approach to incorporate analysis, to greater degrees, of behaviors in the context of the real work environment and therefore be the basis for more targeted, effective decision making and corrective actions. The human performance improvement (HPI) investigative style is so new to DOE, that no DOE HPI directives, procedures, or even guidance documents are developed to date specific to this approach. This particular report is meant to be a learning tool for DOE and the contractor personnel at the Waste Treatment Plant. It is not meant to replace any other investigative process already in use, but more to enhance existing processes with a new way of thinking. Accordingly, the information found in this report should not be used to draw conclusions. It should be used rather as an indicator about areas where the organization (DOE and contractor) should continue to look for possible improvements. 1.2 Scope Through a task order agreement, the DOE Office of River Protection in Richland, Washington, contracted with BushCo of Idaho Falls, Idaho, to complete a human performance assessment and accident investigation of selected occurrence reports of events that occurred at the Waste Treatment Plant during 2005-2006. In addition, BushCo was asked to facilitate a one-day course on “human performance investigation techniques” and to review a completed root cause analysis report that evaluated similar incidents using a traditional approach. This report documents the analysis provided under that task order agreement. 1.3 Background In 2002, the DOE Environment, Safety and Health Office initiated assistance from the Institute of Nuclear Power Operations (INPO) to help introduce its human performance improvement initiative to the DOE complex. To date, numerous DOE and contractor employees have been introduced to HPI concepts and practices. In parallel with the INPO experience, the U.S. Navy and the U.S. Coastguard, the airline industry, the medical industry, and other high-reliability industries have adopted the principles of HPI. As a result of increased interest of DOE contractors in HPI, DOE initiated education opportunities for contractor and federal employees through numerous organizations or events such as Nuclear Executive Leadership Training, National Laboratories Improvement Council, Price-Anderson Amendments Act organizations, Office of Science, and National Nuclear Security Administration. In August of 2003 DOE occurrence guidance document 231.1-2, incorporated HPI principles and techniques. In 2004, the Defense Nuclear Facilities Safety Board Recommendation 2004-1 urged DOE to revitalize the Integrated Safety Management System (ISMS). In response DOE incorporated the attributes of the DOE Human Performance Improvement principles into ISMS documents. 1 In 2005, the Waste Treatment Plant at the DOE Hanford Site in Washington state experienced an increased number of occurrences, particularly related to electrical incidents. These events concerned both DOE and the Waste Treatment Plant (WTP) contractor. After learning about HPI at the DOE Nuclear Executive Leadership Training and acting upon a request from the WTP contractor, DOE Office of River Protection requested a human performance assessment and investigation of some selected occurrences during 2005-2006. Also in 2005, DOE held its first complexwide Human Performance Improvement Workshop in Oak Ridge, Tennessee. Approximately 200 people attended from all across the DOE complex. Presentations were made by DOE, medical and airline organization, the U.S. Navy, universities, commercial nuclear power plants, INPO, Canadian government organizations, the International Society for Performance Improvement (ISPI), and other high-reliability organizations. In early 2006, in response to the increased interest in HPI, DOE Headquarters announced the establishment of a DOE Human Performance Improvement Office under the leadership of the Deputy Assistant Secretary for EH-2. The mission of this new office is to provide HPI support throughout the DOE community. 1.4 Methodology The investigation and analysis were performed primarily by T. Shane Bush of Bushco with onsite support provided by DOE facility representatives Brian Harkins and Jack George; Bechtel National Safety Training Supervisor Stephen Walters; Bechtel National Six Sigma experts Gwenna Hill and Shayne VanDyke; and CHM2 Hill Tank Farm Project employee Mike Hassell. Ten occurrence reports were assessed against human performance investigation principles. These principles were developed as part of a cooperative effort between BushCo and the University of Idaho. These principles were founded on the philosophies taught in James Reason’s book Managing the Risks of Organizational Accidents, Sydney Dekker’s book The Field Guide to Human Error Investigation, and INPO’s “Excellence in Human Performance Fundamentals” course work. Three of the ten occurrence reports were evaluated in detail including interviewing personnel involved in the events. The onsite assessment and investigation took place the week of January 30, 2006, through February 3, 2006. 2 2. HUMAN PERFORMANCE OVERVIEW Human performance improvement (HPI) requires both proactive as well as reactive processes. One of the reactive processes is performing HPI incident and accident assessments and investigations. The HPI approach requires that context is considered when evaluating the actions and behaviors of those involved in incidents and accidents. The traditional approach tends to be non-contextual and has not been able to “Recreate the mindsets” of those involved that is fundamental in the HPI process in determining context. 2.1 What is Human Performance? The Institute of Nuclear Power Operations describes human performance as a series of behaviors executed to accomplish specific task objectives or results. Behaviors are what people do. Results are achieved by behaviors, the mental and physical efforts to perform a task. Although value-added results are important, desired behavior must be the target for improvement. Excellent human performance depends on the alignment of individual and leader behaviors and organizational processes and values. All employees should act to influence both individual and organizational performance to achieve high levels of facility safety and performance. Each employee should exhibit the behaviors that promote the following objectives: • • • • Facilitation of open communication Promotion of teamwork to eliminate error-likely situations and strengthen defenses Searching for and eliminating organizational weaknesses that create conditions for error Reinforcement of desired job-site behaviors. 2.2 The Human Performance Approach The human performance approach teaches that everyone makes mistakes and that people’s error rates are predictable based on the local conditions—or “context”—in which that work is to be carried out. Traditionally, procedures and processes are developed without taking into account human fallibility. A workplace typical assumption is that all workers will be on top of their game all the time (Conklin 2005). In other words, it is assumed that workers will read every sign, understand every procedure step, and follow every rule. Studies by INPO show that people are usually not on top of their game. Divorce, kid troubles, money issues, and human fallibility all contribute to an average error rate of five errors per hour. It has been proved that it is not possible to punish, reward, or intimidate error rates to zero. The key is not only reducing error rates, but in developing strong defenses as depicted in Figure 3. For example, we design and build freeway lanes wider than the average car because we know that people will wander. We also build in defenses like rumble strips, reflectors, yellow lines, and signs to prevent human errors from resulting in accidents and tragic consequences. Work procedures and processes should be no different. People will err. So defenses in procedures and processes are necessary to warn employees when they are moving outside of the work controls, whether consciously or unconsciously. Defenses (rumble strips) in procedures may eroded by last-minute 3 changes in supervision, last-minute changes in job scope, workers who did not attend a pre-job briefing or are new to the job site, and jobs with increased time pressure. 2.3 Guiding Principles for Excellence in Human Performance Within a work culture firmly grounded in human performance principles, the behaviors of people will change and encourage continuous performance improvement. Excellence in human performance is enhanced when people collectively embrace the following underlying principles (INPO 1997) as the basis for human behaviors: • • • • • People are fallible, and even the best make mistakes Error-likely situations are predictable, manageable, and preventable Individual behavior is influenced by organizational processes and values People achieve high levels of performance based largely on the encouragement and reinforcement received from leaders, peers, and subordinates Events can be avoided by an understanding of the reasons mistakes occur and application of the lessons learned from past events. These principles are also taught in the DOE Excellence in Human Performance fundamentals courses. 2.4 Benefits from Human Performance Implementation Changes implemented to enhance safety and production within the commercial nuclear energy industry illustrate the capability of human performance processes and tools to improve safety and production. Commercial nuclear power plants experienced a significant reduction in potential core damage events from 1985 through 1999 (238 annually to fewer than three). Originally, the industry relied on processes and tools to improve performance but had not addressed the human interaction elements of these processes. Industry analysts soon discovered that even when using the best tools, the best procedures, and the best processes, human error will always be the weakest link in performance. Beginning in the early 1990s, human performance processes and tools were implemented in the commercial industry, and contributed to the significant reduction in events. In 2004, this same industry achieved records in production, safety, and efficiency simultaneously by focusing on latent organizational weaknesses as depicted in Figure 2 below. Root causes identified in traditional accident investigations tend to be event specific. For example, if the root cause is determined for why a worker drilled into conduit, corrective actions should prevent drilling into conduit again. Or if the root cause is determined for an electrical incident, the corrective actions should prevent another electrical incident. However, human performance analysts have discovered a lower common denominator than root causes. In keeping with the root cause analogy, human performance looks at the “dirt”: error precursors and latent organizational weaknesses that allowed the “roots” to grow. By eliminating error precursors and latent organizational weaknesses, the “dirt” that allowed the roots to grow is eliminated or greatly decreased. Therefore, the human performance approach addresses organizational performance. Figure 1 illustrates this conceptual view of analysis of human performance. 4 Drill into conduit Fire Hydrant Electrical Panel Back Into Power Pole Root Cause Time Pressure New Technique Changes Root Cause Habit Patterns Root Cause Unclear Goals Root Cause Stress Assumptions Interpretation Error Precursors Simultaneous Hazardous Attitude Workarounds Hidden System Response Complacency Repetitive Actions Organizational Weaknesses Figure 1 (Bush 2003). Conceptual depiction of human performance analysis of the entire work environment. Human Errors Occurrences 70% Latent Organization Weaknesses* 20% Equipment Failures 80% Human Error 30% Individual (Slips and trips) Figure 2. Graphic showing the focus of the human performance approach on the context in which human errors occur: latent organizational weaknesses. 5 Re + M d → ØE [reducing error Individual + AND managing defenses leads to zero events] >>>> Performance Improvement organization & processes Figure 3. Human performance improvement objectives. 2.5 2.5.1 Human Performance Program Description Key Human Performance Elements Excellence in human performance is intended to promote behaviors throughout an organization that support safe and reliable operations of a facility. Progress toward excellent human performance requires a work environment in which individuals and leaders routinely exhibit desired behaviors supported by appropriate organizational processes and values. 2.5.2 Individual Behaviors The collective behaviors of individuals in an organization determine the level of plant safety and performance achieved. Execution of work by individuals is the product of mental processes influenced by diverse factors related to the work environment and the demands of the task, as well as the capabilities of each individual. At high-performing facilities, individuals at any level—whether a corporate officer, manager, supervisor, engineer, technician, or an operator—take responsibility for their behaviors and are committed to improving themselves as well as the task and the work environment. In general, individuals at high-performing facilities exhibit behaviors that promote the following objectives: • • • • 2.5.3 Communication to create a shared understanding Anticipation of error-likely situations Confirmation of, or support for, the integrity of defenses Improvement of personal capabilities. Leader Behavior Leadership is achieved when a set of behaviors is practiced continually to direct and focus individual effort toward accomplishing an organization’s mission. The term “leader” describes any individual who influences the actions of others or of organizational processes. To be effective, leaders must understand the variables influencing both individual and organizational performance. To optimize task execution at the job site, it is important to align organizational processes and values. 6 Leaders integrate appropriate positive outcomes into the work environment to encourage desired behaviors and results. All individuals in a leadership role possess passion for the vision of preventing plant events and the error likely situations that cause them. Consequently, they act to influence both individual and organizational performance to achieve high levels of plant safety and performance. In general, leaders exhibit the behaviors that promote the following objectives: • • • • • 2.5.4 Facilitation of open communication Promotion of teamwork to eliminate error-likely situations and strengthen defenses Searching for and eliminating organizational weaknesses that create conditions for error Reinforcement of desired job-site behaviors Value of the prevention of errors. Organization Processes and Values Organizational processes and values facilitate the many human activities involved in plant design, construction, operation, and maintenance and establish an environment that takes human fallibility into account. The goals, policies, and priorities of an organization directly influence individual and leader behaviors by generating a pattern of shared understandings, processes, and values. Managers are the individuals responsible and accountable for organizational support of worker performance at the job site. However, all individuals within an organization should take it upon themselves to improve organizational processes and promote values of excellence. Through organization and performing as a team, managers can do the following: • • • • Foster a culture that values preventions of events Strengthen the integrity of defenses to prevent or mitigate the consequences of error Preclude, or greatly limit, the development of error-likely situations Create a learning environment that encourages continuous improvement. 2.6 Human Performance Assessment Process Description In human performance assessments or investigations, one of the primary goals is to recreate the mindsets of those involved in the accident or incident scenario. Sydney Dekker, author of The Field Guide to Human Error Investigations, explains that this does not mean getting into the mind of the individuals, but is more related to recreating the environment they found themselves in that may have influenced their decision-making process. In other words, this process of recreating the decision-making environment is an attempt to assess the decisions and behaviors in “context.” Traditional investigation processes, including the DOE occurrence process, tend to be noncontextual in nature. They stress gathering facts at the sacrifice of obtaining a meaningful understanding of how those “facts” (including decisions and behaviors) were influenced. Understanding context is the key to a successful human performance assessment. Traditional investigations would have the investigator read and understand the requirements and become very familiar with the details of the event prior to interviewing the people involved. However, studies performed by BushCo and the University of Idaho shows that this biases the investigator. 7 Knowing what was violated and by whom may influence the questioning technique to prove what is already known rather than finding out what is not known, which is the “context,” or work environment. With this new approach, investigators are encouraged to interview those involved with the incident without knowledge of the details of the event, thus allowing the gathering of information without having been tainted with previous assumptions and information. For example, if investigators know that certain procedure steps were not followed prior to the interview, they will look for evidence to hold up the preconceived notion that this person is probably a “bad apple” who does not follow procedures. Studies have borne out (Dekker 2002, Reason 1997) that most people do not willfully violate procedures. There are reasons that people do what they do. If interviewed correctly, that context can be determined. 2.6.1 Limitations of This Investigation The events assessed for this report occurred during 2005-2006, some as long as 12 months ago. Most of the events had been assessed numerous times before, thus testing the patience of the workers involved. The evidence is very limited at best and missing or unavailable in many cases. Many of the personnel who were involved are no longer available for interviews because of reductions in employment levels at the construction site. Those still available were relying on memory for most facts, which is a significant drawback to an investigation. And perhaps most importantly, the previous occurrence reporting and, in many cases, the previous accident investigation reporting did not gather the information necessary to reconstruct the “context” that, as stated earlier, is so important in this type of an investigation. 8 3. RESULTS As a result of interviews conducted for this assessment, and review of data available from occurrence reports, accident investigation reports, root cause reports, and work control procedures, three areas of concern or weakness related to human performance were identified: 1. 2. 3. Employees are working outside of controls unknowingly Confusion exists about the DOE-contractor relationship The workplace culture is increasing the likelihood of the occurrence of the types of events assessed and described in this report. While the evidence was sufficient to warrant concerns in these areas, it is highly recommended that a more in-depth evaluation be completed before corrective actions are considered. 3.1 Concern 1 - Employees Are Working Outside of Established Controls Unknowingly When reconstructing the context of three different events occurring during 2005 as described below, the analysis team discovered that workers slowly deviated from the work control process to the point where they were working outside of the controls unknowingly. This is especially important because of the difficulty of preventing something you didn’t intend to do in the first place. Training, safety standdowns, or enhancing procedures have been noted as having little effect in these cases and may even contribute to future events inadvertently. Safety stand-downs are often perceived as unnecessary or even condescending to workers. Stand-downs consisting of reviewing well-known procedures and basic safety topics, and generally “cleaning up the shop,” have not been effective at influencing behaviors in situations where the behaviors were not intended. Often, the result of safety stand-downs is that workers are anxious to return to work and exhibit productive behaviors. However, adding training or procedural steps may be counterproductive because these changes quite often introduce more opportunity for error. Interviewees expressed concern that procedure requirements are constantly being changed causing frustration and challenging the workers abilities to keep up on the latest requirements. 3.1.1 Excavation of 480-volt Line The first event was documented in Occurrence Report EM-RP-BNRP-RPPWTP-2005-11 of an energized 480-volt line damaged during excavation work, as summarized below. Prior to excavating, it was decided that the necessary area to be excavated was actually smaller than the excavation permit had identified. The workers re-established controls for a smaller area. This change resulted in a change in the work scope, but since they were reducing the area to be excavated (the “foot print”), it was interpreted as conservatively enhancing safety and, therefore, was not further analyzed at the time. On the morning of this event, the workers assigned to this job had been pulled off of another job, and then redirected back to the first job where the event occurred. At the same time, the regular foreman for these workers was unavailable and a temporary foreman took his place. The worker with primary responsibility for painting the lines admitted that he missed painting the energized line, but explained that the line was outside of the smaller foot print of the planned excavation. He has numerous years of experience and also explained that his regular foreman normally double checks his work before allowing 9 excavation. The temporary foreman was not in the habit of performing this peer check; and normally did not oversee excavation work; therefore the peer check was not performed. The workers involved in this event also expressed some concerns that because they were redirected to this job at the last minute, they perceived some urgency to complete this job in a timely manner. When the smaller excavation area was completed it was determined that they needed to slope the sides of the hole. Which is a normal task associated with this type of work. At about this time, the original track hoe operator was called off to another project. The acting foreman at the time, who was qualified to operate a track hoe, took over operating the track hoe. This change in duties removed him from the oversight role he was fulfilling. Within a few scoops of the bucket, the spotter noticed the 480volt line and stopped the work activity. During the interviews, the workers expressed that when the decision was made to slope the sides of the smaller excavation area they did not recognize they had just expanded the work scope. In conjunction with this, spotters are used to seeing tracer tape or colored Controlled Density Fill (CDF) when the excavation is nearing utility lines. Neither of these defenses were in place on this buried temporary power line. It is the opinion of the investigation team that there is evidence to suggest that the workers slowly drifted into activities that took them outside of the work controls unknowingly. In other words they knew that the original excavation area had been approved for a larger area and thus made a ‘plan continuation error’ thinking they were covered. 3.1.2 Cutting of a Propane Line The second event was documented in Occurrence Report EM-RP-BNRP-RPPWTP-2005-0025 and involved cutting a propane line without the appropriate lockout/tagout (LO/TO) in place. As in the first case, this event involved changes in the work scope and reassignment of leadership. There were three utility lines running parallel in the ground that were being rerouted: water, argon, and propane. All three lines were identical in physical features with no markings distinguishing one from another. This will play a large role in the mistakes that were made in conjunction with this event. The regular foreman for the workers involved on this job was scheduled to be gone the week of the event. In addition, one of the workers involved in this event was absent the week prior to the event. Because the foreman was scheduled to be gone, he left some hand written instructions and a schedule for the workers to follow in his absence. It included prefab work and specifically to isolate, LO/TO, and clear all three lines simultaneously by blowing air through them. Temporary leadership on this project changed the work scope a number of times over a period of a few days. On the morning of the event, the workers were in the shop fabricating a new piece of pipe when they received a call stating that everyone was waiting on them at the excavation site and instructed the workers to drop what they were doing and come make the cut on the argon line. During the interviews, the workers expressed some frustration that they had not been notified of the change in plans to make the pipe cut until they received the call stating that everyone was waiting on them. As they prepared to do the cut, there was some discussion on the need for a LO/TO. The workers were confused about whether the LO/TO was complete and even expressed some concern about a missing valve handle on the argon line as being part of the LO/TO process. The workers also expressed concern in the interview process that it was there impression that there was considerable time pressure to complete this job due to the last minute request to cut the argon line. Adding to their confusion, they expressed they had limited knowledge and training in performing a LO/TO. With the foreman and safety professional in attendance they prepped and completed the first cut. Having success with the first cut the workers completed the second cut believing the appropriate controls were in place. Also adding to the confusion was that the piping being cut was underground. The two locations where the cuts were to be made were excavated to allow access to make the cuts. All three 10 utility lines completed a 180-degree underground turn between the two excavated locations where the cuts were to be made. Using a hand-drawn sketch, the workers had to determine which of the three identical pipes the argon line was. Confusing the drawing and making some assumptions during the second cut, they picked the wrong line and proceeded to cut it. After smelling propane, the workers stopped work realizing they cut the wrong line. They then made the appropriate notifications. Once again employees performed work within what they thought was the appropriate controls. There were numerous organization weaknesses that contributed to this event; last minute change in job scope, less than adequate training, non-labeled piping, confusing sketches, change in immediate supervision, etc. 3.1.3 Installing Weather Boots on Electrical Cords The third event was documented in Occurrence Report EM-RP-BNRP-RPPWTP-2005-0026. This incident occurred only days after a sitewide safety stand-down that was intended to stop an adverse trend in these types of hazardous energy incidents. The primary worker involved in this incident was not at work during some of the safety stand-down activities. After comparing the details of this event with the safety stand-down activities, the primary investigator doubts attendance at the safety stand down would have had much of an influence on preventing this event. At the time of this event, a sitewide hold on all work activities requiring hazardous energy control was in place. However, the primary worker did not recognize that this activity was currently prohibited by the restriction on all work involving hazardous energy control. As with the first two incidents, the immediate leadership had been changed and the work scope was modified. On the morning of this event, the working partner to the primary worker was upgraded to temporary foreman. At the beginning of the day, a discussion of the work activity outlined on the STARRT (Safety Task Analysis Risk Reduction Talk) card, authorizing work to commence, was covered. The activities covered on the STARRT card was assured grounding on electrical cords. The primary worker joined his newly assigned partner for the day and started assured grounding activities on the electrical cords. After observing the work of his partner for a period of time, the primary worker voiced in his interview that he wanted to be productive, so he noticed a Mini Load Center (MLC) located nearby that was missing necessary weather protection caps on some of the pig tail leads. The electricians had been directed previously to install missing weather protection caps whenever they were found during their normal work actives. Further, the primary worker knew that the assured grounding activities on the MLC would commence the following week and thus felt that replacing the missing weather cap was getting a jump on work they would be doing next week. The work scope on the STARRT card addressed working on electrical cords that can be deenergized by unplugging them. In this case, the cord (or “pig tail”) that the primary worker was working on was attached to an MLC and could not be unplugged, but instead the worker used the breaker on the MLC to remove the power to the pig tail. While the worker did not recognize it, this choice to work on an MLC, even though it was an accepted practice, changed the job scope from the assured grounding testing on electrical cords as outlined in that mornings STARRT briefing. The primary worker turned the breaker off that he thought powered the pig tail he was working on. He then used a “tic tracer” to confirm the energy was gone. He unknowingly received a faulty reading from the “tic tracer” and proceeded to work on the pig tail assuming it was de-energized. As he worked on the pig tail two of the wires contacted each other and sparked indicating that it was still energized. To put this in context, it is important to understand what led up to the decision to use a tic tracer, which is deemed an inappropriate instrument for performing zero energy checks as addressed in local 11 procedures. The electricians had previously been using an instrument called a Wiggy® for zero-energy verification. “Wiggies” had been removed from service because of some concerns about their reliability. This caused most electricians to switch to the use of a “multi-meter” for zero energy checks. Just prior to this incident, new electrical safety requirements (in accordance with National Fire Protection Association [NFPA] 70E) were being implemented across the construction site. After attending NFPA 70E training, some of the workers interpreted NFPA 70E as requiring a flash hazard analysis prior to using a multi meter in all scenarios. Being conservative, some the workers immediate management restricted the use of multi meters until evaluations were made. This left these particular workers with only a tic tracer to verify that cords were de-energized. Interviews with other electricians working in this particular group revealed that they would have and were performing zero energy checks in the same manner that the primary worker did on the day of the event. There is strong evidence that the primary worker did not understand he was working outside the work controls at the time of this event. His actions were consistent with condoned and accepted practices of his peers. This is a significant concern. If workers are performing work outside of the controls unknowingly, there is no amount of training, safety stand-downs, or procedure changes that would prevent these types of events. You cannot prevent what isn’t intended. The concern with this particular event is not necessarily determining what procedures were violated, near as much as determining where the process failed to inform the workers that they were working outside the controls. 3.2 Concern 2 – DOE - Contractor Relationship DOE has a specific oversight role related to contractor work. This role sometimes is misunderstood or confused, inadvertently resulting in inappropriate worker behaviors. For example, in many of the interviews conducted for this investigation, the workers stated that they believed that if there was another incident or accident that DOE was going to shut the project down. This perception encourages nonreporting. With little to no reporting, limited data will be available to trend, with the result being an inappropriate ratio between close calls, occurrences and incidents. Whether the possibility of being shut down is perceived or real, the resultant behavior is the same. The DOE Occurrence Reporting and Processing Systems (ORPS) as currently used do not capture the appropriate level of context. While the current ORPS guide has incorporated human performance principles to capture context, very few reports addressed this information. Facts related to acts of procedural violations are very important, but understanding what lead up to the act or behavior is even more important in a human performance investigation. During the DOE Human Performance conference in September 2005 in Oak Ridge, Tennessee, a panel of senior executives representing well-known contractors and senior DOE Headquarters staff discussed barriers to having success with Human Performance in the DOE community. The number one barrier discussed was being able to create a “Just” work culture with the current mindsets and processes employed within DOE that are used to determine cause. The contractor community believes that DOE representatives read noncontextual information from occurrence and accident investigation reports and then strongly insinuate consequences for those involved. Often, what looks like a deliberate violation is far from what actually took place when the incidents are put in context. Hence capturing context is critical in our processes knowing that decisions are being made and opinions are being formed by people in influential positions. 3.3 Concern 3 - Work Place Culture While the previous concerns in this report are part of the workplace culture, specific cultural issues were identified during interviews that warrant separate discussion. 12 During the interview process and while reconstructing the “context” of these events, it became apparent that most of the workers interviewed had spent the bulk of their careers in the private sector. Work in the private sector tends to reward at risk behaviors. Typically, the private sector leans so heavily toward production, that private-sector electricians are not only allowed, but encouraged to complete jobs quicker and faster, even if they have to take short cuts. In the interview process, these workers said if they were to request the same level of protection and rigor on a private sector job as in the DOE environment, they would be asked to leave the job. This work history common to several workers has resulted in some very ingrained behaviors—or “strong rules” in human performance lexicon. Despite being aware of this issue, some managers have tried to compensate or correct these ingrained behaviors with procedures and training. There is evidence in this report that these measures have not been very effective. Changing ingrained behaviors is very difficult to do. Behaviors are what define your culture. It is a well documented fact that changing a culture is a long term resource intensive proposition. The interviews revealed that most of the workers have been in a “product oriented” environment (private sector) for most of their careers. DOE requires us to work in a “process oriented” environment which is contrary to where they have been. There is plenty of evidence to warrant an in depth evaluation of this issue. 4. Conclusions As a result of interviews conducted for this assessment, and review of data available from occurrence reports, accident investigation reports, root cause reports, and work control procedures, three areas of concern or weakness related to human performance were identified: 4. 5. 6. Employees are working outside of controls unknowingly Confusion exists about the DOE-contractor relationship The workplace culture is increasing the likelihood of the occurrence of the types of events assessed and described in this report. 5. Recommendations While the evidence was sufficient to warrant the concerns noted in section 4, because of the limitations put on this investigation it is highly recommended that a more in-depth evaluation be completed before corrective actions are considered. At the time of this report, DOE headquarters is in the process of developing a team of HPI experts and developing guidance documents related to all aspects of HPI. In the meantime, DOE Office of River Protection and local contractors should consider developing in house expertise in human performance principles and processes if it is decided that the HPI philosophy is going to be incorporated into current processes. Self study, DOE human performance fundamentals workshops, and benchmarking are strongly suggested. In addition, appendix B to this report has captured the initiating actions, flawed defenses, and error precursors for some randomly selected WTP events. This information can be used to help determine trends and common organization weaknesses. Appendixes C-F are common human performance tools used to gather and analyze the data typical captured in appendix B. Finally, appendix G is a list of proven corrective actions broken down by error mode (captured in appendix B) and as defined in the DOE ORPS Guide 231.1-2. 13 6. References Dekker, Sidney, 2002, The Field Guide to Human Error Investigations, Ashgate Publishing, Hampshire, England. National Academy for Nuclear Training, 2002, Human Performance Fundamentals Course Reference, Revision 6, Institute for Nuclear Power Operations. Reason, James, 1997, Managing the Risks of Organizational Accidents, Ashgate Publishing Limited, Hants, England. 14 Appendix A List of Occurrence Reports Reviewed 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Occurrence Report EM-RP-BNRP-RPPWTP-2005-0006 Occurrence Report EM-RP-BNRP-RPPWTP-2005-0011 Occurrence Report EM-RP-BNRP-RPPWTP-2005-0014 Occurrence Report EM-RP-BNRP-RPPWTP-2005-0015 Occurrence Report EM-RP-BNRP-RPPWTP-2005-0016 Occurrence Report EM-RP-BNRP-RPPWTP-2005-0024 Occurrence Report EM-RP-BNRP-RPPWTP-2005-0025 Occurrence Report EM-RP-BNRP-RPPWTP-2005-0026 Occurrence Report EM-RP-BNRP-RPPWTP-2005-0029 Occurrence Report EM-RP-BNRP-RPPWTP-2005-0030 15 Appendix B Event Reports Event: 05-028 - 480V Cable Damaged During Excavation Work Initiating action: Excavation of Soil with 480 V cable buried - backhoe bucket cut cable Flawed Defenses: Excavation Permit -Conflict in interpretation of requirements. Specifically, requirement to pothole the 480 V cable and to keep all “located” items clearly marked (located items are BOTH surveyed and potholed). Permit also states All LIVE electrical lines within the limits of excavation will be potholed within 5 feet. Field interpretation was that the cable was believed to be outside the 5 foot area, which allowed for not potholing, contrary to permit requirements and briefing expectations. Excavation procedure states that “Laborers and/or other craft who will be directly involved in the excavation should use paint to mark the location of underground commodities and interferences a listed on the permit prior to the pre-excavation meeting.” Procedure direction is not a “requirement” but rather is a guidance (should verse shall) Error Precursors/Error Drivers: 1F - Interpretation requirements: Field interpretation was that the cable was believed to be outside the 5 foot area, which allowed for not potholing, contrary to permit requirements and briefing expectations. Accident Report 1F - Interpretation requirements: Approval granted to machine excavate within 2 feet of utilities - specifically for the DIW line only. No discussion for the 480 V line (relevance is unclear - either they knew that they were within 5 feet or not - if they knew, then rational for not potholing is not valid If they did not know, then the allowance to go within 2 feet is not relevant. Accident Report 1H - Lack of or unclear standards Issue is where does the 5’ boundary start? Is it in the excavation area that includes the slope area or not. The original map had been for a larger footprint that would have included the slope area and area surrounding it. The field decision was to only pothole the area within 5 feet of the excavation area without the slope included. Verbal discussions with ORP FacRep. 16 2B - Changes/Departure from routine Pre-excavation briefing was conducted with Laborers, Operating Engineers, Teamsters, Under Ground Services Coordinator (FE), and Supervision (Superintendent, Forman, and General Foremen). Pre-excavation briefing identified the requirement to pothole the 480volt temporary power cable and to keep all located items clearly marked - This activity was not performed as briefed. Accident Report Reference: Bechtel Accident Investigation Report 24590-WTP-BAI-SA-05-028 Occurrence Report EM-RP--BNRP-RPPWTP-2005-0011 24590-WTP-GPP-CON-3202 Rev.4 Conflicting information: Occurrence report talks about painting - accident report discusses “survey and potholes - the two do not agree in principle on the control mechanisms. Procedure states “should use paint”. Also, much more information regarding pressure of schedules, operators leaving and foreman doing the work, decisions to change scope, etc. that is not captured in the reports. 17 Event: Power Lines Cut During Door Repair by Carpenters Initiating action: Cutting the door frame with the Circular Saw. Flawed Defenses: Supervisory verbal direction to verify conduit removed before cutting as the control set. Error Precursors/Error Drivers: 1A – Time Pressure (in a hurry) Potential high winds for the day would shut down the job, as such; there was an urgency to proceed with the job with deliberate speed. Critique report. 2C – Confusing displays/controls Carpenter accepted the visual indication of the L&T on the panel board as being acceptable to work without verification of actual isolation. The L&T was hung earlier to address the light, but was not part of the isolation attempt for moving the conduit. Accident investigation and critique. 3D – Imprecise communication habits The carpenter had been directed by his supervisor to not saw until the electricians were done moving the conduit. The carpenter did not verify with the electricians that they were done prior to starting the cut. Accident report, fact sheets, critique. 3G – “can do” attitude for safety-critical task Personal belief in prevailing importance of accomplishing the task (production) without consciously considering associated hazards – specifically, contrary to verifying with electricians prior to cutting, the carpenter started cutting. 4C – Assumptions Suppositions made without verification of facts – the Carpenters assumed the L&T also included the conduit 4F – Inaccurate risk perception Personal appraisal of hazards and uncertainity based on either incomplete information or assumptions – willingness to commence cutting without verifying with the electricians that the conduit had been moved. Reference: Bechtel Accident Investigation Report {No Number Provided} Occurrence Report EM-RP--BNRP-RPPWTP-2005-0006 18 Event: 05-039 - GFCI Short During Energy Checks Initiating action: Removal of GFCI outlet to perform safety check causes short circuit Flawed Defenses: Distribution Panel breaker schedule did not reflect as built condition. The Distributing panel DID NOT contain a breaker schedule - additionally, the markings on the breakers themselves did not reflect the actual configuration. Breaker #6 was labeled GFCI, however, another breaker, #26, also supplied power to GFCIs. Supplier provided facility with a trailer that had latent errors - specifically the vendors distribution panels did not contain breaker schedules as required. Error Precursors/Error Drivers: 1H - Lack of or unclear standards The breaker panel was associated with a temporary trailer and the procedures for configuration control did not contain any specific guidance for ensuring updating of breaker schedules. Occurrence Report - Contributing Cause 2. 2E - Hidden system responses Due to the failed GFCI, the ability to easily perform zero energy checks without partial disassembly was impeded. As such, the outlet cover had to be removed and partial disassembly was chosen to gain access to terminals. 2F - Unexpected equipment conditions The panel did not identify the circuit that the GFCI was on as having any load, let alone the GFCI. There was a breaker that did have a label for GFCI. 2F - Unexpected equipment conditions The wiring inside the outlet box was such that the wire was between the screw and the casing creating a rub/contact point that eventually led to a short circuit during assembly. When combined with the breaker not being properly labeled, the lack of a breaker schedule, and the failed GFCI, backing out the screw resulted in a short circuit. 2G - Lack of alternative indication I am not sure this one is appropriate - the alternative indication was necessary due to the failed equipment, and it was known to be necessary by the electricians. The short occurred when they were attempting to gain alternative verification that the system was de-energized. Reference: Bechtel Accident Investigation Report 24590-WTP-BAI-SA-05-039 Occurrence Report EM-RP--BNRP-RPPWTP-2005-0016 19 Event: Propane Line cut Initiating action: Cutting the propane line instead of the Argon line. Flawed Defenses: Lock and Tag implementation Work Control – Application of Construction practices to performance of work on operating systems (defined for this purpose is a system that has hazardous energy that requires controls prior to performing work – unlike a partially built system that has not been placed in service where an accidental cut would have re-work impact, but likely not a safety impact) Error Precursors/Error Drivers: 1F – Interpretation requirements There were three lines to choose from to support the cutting operation, only one of which was the right one to cut – the workers had to interpret in the field, using a drawing and only having limited visual of the system, which one was right without any opportunity to have an independent verification. 1H – Lack of or unclear standard Worker L&T and/or organizational L&T not verified installed prior to performing work. Had no impact/consequence on the event (i.e., if L&T had been installed, the event still would have happened). However, if the workers had verified adequacy, opportunity to positively identify the lines could have resulted in knowledge that would have prevented the event. Accident investigation page 1. 2B – Changes/Departure from routine Unfamiliar task – moving from one site to another gave an opportunity for a special orientation error. Fitter cut what he thought was the right pipe. Accident report 2B – Changes/Departure from routine Departure from planned activity – originally planned to have all lines purged and tagged out and then cut – which removes impact of cutting the wrong pipe. Decision to sequence the work activity introduced a risk for cutting the wrong piping with consequence that was not recognized. Accident report 2B – Changes/Departure from routine Departure from planned activity – original foreman changed out because he was sick. 3B – Lack of knowledge Unawareness of factual information necessary for successful completion of task. The three lines looked same with no markings to differentiate – as such field interpretation to 20 perform task was required. The Journeyman was considered the expert by the Apprentice and cut the line that he was told to cut. Accident Report 4C – Assumptions Pipefitter cut the pipe without verification or validating that it was the right pipe. 4D – Complacency Underestimating the difficulty or complexity of the task – this is a corollary to the recognition that a consequence could be encountered for cutting the pipe. Reference: Bechtel Accident Investigation Report {No Number Provided} Occurrence Report EM-RP--BNRP-RPPWTP-2005-0006 21 Event: “T” Post Electrical Shock Initiating action: There are three distinct “initiating actions” associated with this event: • The worker completing the electrical path between the “T” post ground • Unknown individual that installed the “T” post • Unknown worker(s) that installed the power cable Flawed Defenses: Worker touching “T” post – none Worker installing “T” post – the standard practice that “T” posts can be installed up to a depth of 18” without excavation controls is not effective within 3 feet (or so) of the penetration (due to bend radius) Workers Installing Power Line – While work package validated that the cable was buried to a depth of 24”, the radius around the post Error Precursors/Error Drivers: 2F – Unexpected equipment conditions (Installation of “T” post) Encountering the cable at 14” of depth was not expected – while it was close to the cable entrance into the ground, there was no clear understanding or controls to prevent installation within a certain distance. 4D – Complacency/Overconfidence (Conjecture on part of team – associated with Installation of Cable) While the cable was verified to eventually reach 24”, it did not achieve this depth for an extended length – well outside expected bend radius. Installation team was complacent in reaching the required depth in the minimum reach. 4F – Inaccurate risk perception (Conjecture on part of team – associated with Installation of Cable) While the cable was verified to eventually reach 24”, it did not achieve this depth for an extended length – This could reflect a lack of risk perception on the part of the installation crew for getting the cable to the requisite depth as soon as practical. Reference: Bechtel Accident Investigation Report 24590-WTP-BAI-SA-05-050 Occurrence Report EM-RP--BNRP-RPPWTP-2005-0024 22 1 2 3 4 0.5 1.5 2.5 3.5 4.5 0 Appendix C Error Precursors PRECURSORS 23 PRECURSORS La 2C ck U ha or ne xp ng Un ec es cle te /D ar C pt S om d E r t pl qu In Ro ds ac ip t ut en me erp in cy nt r R e /O C q ve on rts rc id T on tio R i me fid ns ep e In et Pre nce na et s iv s Si cu m ra A e A ure ul te s ta s ct n R um ion C D eou isk pt s on is f u tra s M Per ions si n ct u ce H g D ion ltipl ptio id n d is s/I e La en pla nte Tas ck Sy ys ru ks or ste or ptio Im al m Co ns pr te ec rn Re ntro is La ativ spo ls e C ck e ns om o In e m f K dic s un no at ic w ion C atio led an n ge -D Ha H o A bits ab tt i t it u Pa de t te rn s Appendix D Human Performance Evaluation Worksheet HUMAN PERFORMANCE EVALUATION WORKSHEET A. Tracking Number:___________________ B. Description of Error (either latent or active): Error Number _____ of _____ User-numbered with #1 being the most significant (use a separate form for each error evaluated) C. Error Mode: 1. ❏ Rule-Based 3. ❏ Knowledge-Based 2. ❏ Skill-Based Error D. Error Drivers – List “Driver Codes” from Attachment 2. Provide brief explanation of why they apply. ❏ N/A, No applicable drivers Appropriate for Use in this task 1. ❏ 2. ❏ 3. ❏ 4. ❏ 5. ❏ 6. ❏ 7. ❏ 8. ❏ 9. ❏ 10. ❏ 11. ❏ 12. ❏ Check if Used 1. ❏ 2. ❏ 3. ❏ 4. ❏ 5. ❏ 6. ❏ 7. ❏ 8. ❏ 9. ❏ 10. ❏ 11. ❏ 12. ❏ Check if used but ineffective 1. ❏ 2. ❏ 3. ❏ 4. ❏ 5. ❏ 6. ❏ 7. ❏ 8. ❏ 9. ❏ 10. ❏ 11. ❏ 12. ❏ Check if Represents a failed defense 1. ❏ 2. ❏ 3. ❏ 4. ❏ 5. ❏ 6. ❏ 7. ❏ 8. ❏ 9. ❏ 10. ❏ 11. ❏ 12. ❏ E. Human Performance Tools for Individuals and Teams ❏ N/A for this error 1) Self Checking 2) Peer Checking 3) Independent Verification 4) Knowledge/Training 5) Procedure Use 6) Questioning Attitude 7) Place-Keeping 8) Effective Communication 9) Job Briefing/Reverse Briefing 10) Management/Supv. Involvement and Coaching 11) Turnovers 12) Other: Briefly explain why the checked items represent failed defenses: F. Management Control Systems/Failed Defenses, Organization Weaknesses (refer to Attachment 4): ❏ N/A for this error 1. ❏ Training 2. ❏ Procedures/Programs 3. ❏ Policies/Expectations/Standards 4. ❏ Corrective Action Program 5. ❏ Observation/Coaching 6. ❏ Goals and Priorities 7. ❏ Task Structure 8. ❏ Organization, Roles, and Responsibilities 9. ❏ Values and Norms 10. ❏ Planning and Scheduling 11. ❏ Decision Making 12. ❏ Engineering Analysis 13. ❏ Other: Briefly explain why the items checked represent failed defenses: 24 Human Performance Evaluation Worksheet Instructions Section A Enter Tracking Number and Error number (a self-assigned sequential number). Assign Error Numbers based on the significance the error played in causing the event with number 1 being the most significant. Error Description -Describe the error or behavior. Error Mode -Use Attachment 6 to help determine whether each error was a knowledge-, rule-, or skill-based error. Briefly state why the selection was made (e.g., this is a rulebased error because the technician failed to follow the procedure as written). Error Drivers (check only those that played a significant role in the error). Refer to Attachments 2 and 3. List those significant precursors/ drivers that apply and provide a brief factual explanation of why they apply, for example, imprecise communication habits -The technician did not repeat back the ordered action and the controller did not stop the technician to require an accurate repeat back before allowing the activity to proceed. Section B Section C Section D Section E Human Performance Tools for Individuals and Teams List those individual or team human performance tools that represent failed defenses against successful completion of the task. Provide a brief factual explanation of why these are considered failed defenses. Enter "N/A" if the error was not induced by poor individual or team performance. Section F Management Control Systems, Failed Defenses, Organizational Weaknesses List those "systems" that represent failed defenses against successful completion of the task. Provide a brief factual explanation of why these are considered failed defenses. Enter "N/A" if the error was not induced by poor management control system. 25 Appendix E Active Error Worksheet Description of Active Error Preparation 1 2 3 4 5 6 7 8 Was an effective pre-job brief? Were personnel directly involved in the active error present for the brief? Were the critical steps identified along with an error reduction tools to ensure proper performance during the brief? Was a TWIN analysis performed and were actions identified to reduce human performance errors? Were potential errors identified by SAFE analysis and actions taken where appropriate? Have personnel directly involved in the active error performed this task before? Was the impact of the activity fully understood prior to performance (e.g., proper mindset, assumptions verified)? Was fatigue a contributor to the active error (e.g., end of shift, end of 4 day rotation, extended hours)? ❏ Yes ❏ Yes ❏ Yes ❏ Yes ❏ Yes ❏ Yes ❏ Yes ❏ Yes ❏ No ❏ No ❏ No ❏ No ❏ No ❏ No ❏ No ❏ No Execution 1 2 3 4 5 6 7 Were proper communication techniques used? Were the field conditions and work environment conducive to proper performance of the activity (e.g., lighting, labeling, accessibility)? Was procedure use and adherence followed? Were the proper error reduction tools effectively applied to the activity? Did the activity being performed contain the appropriate barriers to ensure proper task performance (e.g., notes, cautions,)? Was supervision present during the activity? Were the appropriate actions taken when unexpected conditions arose? ❏ Yes ❏ Yes ❏ Yes ❏ Yes ❏ Yes ❏ Yes ❏ Yes ❏ No ❏ No ❏ No ❏ No ❏ No ❏ No ❏ No Post-Execution 1 2 3 4 Did the active error go unnoticed until it revealed itself? Were opportunities present for the individuals directly involved to detect the active error? Were opportunities present for the supervision to detect the active error (e.g., documentation review)? Was a post-job critique held? ❏ Yes ❏ Yes ❏ Yes ❏ Yes ❏ No ❏ No ❏ No ❏ No 26 Appendix F Culpability Decision Tree Was the behavior intended? (a) Yes No No Medical Restrictions? (d) No Did employee knowingly violate - No requirement? (h) Yes Pass substitution -Yestest ? (l) No History unsafe acts? (p) Yes No Yes Were the consequences intended? (b) Were they communicated and clearly understood? (e) Were requirements available, workable intelligible & correct? (i) Deficiencies in training & selection or inexperience? No (m) Yes Corrective training or counseling indicated (q) Yes No Yes Yes No Possible negligent error (n) Blameless error (r) Intentional, sabotage, (c) System induced violation (f) Possible intentional violation (g) Possible intentional Violation (j) System induced violation (k) System induced error (o) 27 Appendix G Proven Corrective Actions Methods to correct Rule-Based Errors include: (continued) • • • • • Training on fundamentals, including improving knowledge of procedure bases. Practice on transition between procedures. Validation and Verification training Clarification of vague rules, such as explaining "how to" do a required action or explaining the desired outcome (criteria) to determine whether success was achieved. Promoting practice of verbalizing intentions Methods to correct Knowledge-Based Errors include: • • • • • • • • • Improved problem solving skills/Root Cause Analysis Familiarization with the Work Process Knowledge oriented training Assign role of "Devil's Advocate" during key decision making meetings. Improved communication Work specialization Avoid overconfidence Consultation and networking Assessing all options Methods to correct Organizational and Process Failures include: • • • • • • • • • • Simplify overly complex Work Processes Repair inadequate interfaces between organizations and between processes Perform continuous or periodic Monitoring of organizational and process performance Improve personnel skills and knowledge Implement simple and effective accountability systems Assure organizations and personnel are compatible with the work assigned Implement simple and effective work prioritization systems Implement processes to attend effectively to emerging issues Assign adequate resources to lateral integration between organizations Implement rigorous self-improvement programs 28 Proven Corrective Actions The chart below depicts the type of human performance tools likely to improve performance in the areas covered. 29