Human performance event free tools

Personnel working at a nuclear facility are responsible for trying to anticipate situations that can lead to interference or faults and to use adequate work methods. The probability for faults or mistakes to happen in various activities can be reduced by using different human performance event free tools. These tools focus on anticipating, preventing and catching active errors before they become events. They help individuals and work teams to maintain control of the work situation [159]. Tools that should be used all the time (called fundamental tools) include [159]:

— Situational awareness;

— Task preview;

— Job site review;

— Questioning attitude;

— Self-checking (also known as STAR: stop, think, act, review), stop when unsure;

— Procedure use and adherence;

— Effective communication;

— Three-way communication;

— Phonetic alphabet.

Conditional or supplementary human performance tools are used depending on the work situation (see Table 24). These can include [159]:

— Pre-job briefing;

— Verification practices, including concurrent verification, independent verification and peer checking;

— Flagging;

— Keeping track in procedures step-by-step (place keeping);

— Shift turnover;

— Post-job review.

Each of these tools is described in detail in Refs [160, 161]. Training and indoctrination in the use of these tools is best practice for all nuclear facility staff, and leadership should encourage and champion their use. Industrial safety training should demonstrate the proper use of these tools in industrial safety. These tools can be applied to minimize industrial safety events and related injuries. Regardless of how conscientious personnel are, they can still make mistakes, sometimes at inopportune times. Errors can be made by omission or commission. Organizations can impact individual behaviour via production levels and pressures, quality management systems applied, workplace human factors and ergonomics, organizational development and learning processes in place, and human performance technology applied, among other things. In nuclear facilities, industrial safety related mistakes can include operating the wrong equipment, working on equipment that is not isolated, wearing the wrong PPE, taking shortcuts within procedures, working outside of procedures, performing unsafe acts and others.

Defences against human error can involve engineered, administrative, cultural and oversight controls.

Ultimately, an individual’s behaviour determines the level of safety and performance achieved. At high performing organizations, individuals on all levels take responsibility for their behaviour and are committed to improving themselves as well as the task and the work environment. Reference [159] covers managing human performance in nuclear facilities, and publications which address the improvement of human performance have been published by

TABLE 24. HUMAN PERFORMANCE EVENT FREE TOOLS AND EXAMPLE APPLICATIONS

Tool Description Industrial safety application examples

Situational awareness tools Situational awareness can be defined as the accuracy of a person’s current knowledge and understanding of actual conditions compared to expected conditions at a given time. It means the individual clearly understands the job requirements, the equipment condition, the work environment (including other workers in the area), and confirms the correct unit and equipment before acting.

Worker explicitly takes time prior to starting a task to look at the surrounding work environment and what hazards are present that could cause injury, as well as the potential for the work to damage equipment or harm personnel in the area. This may necessitate additional controls on the work or changes in work practices.

Task preview Before starting work, individuals conduct a task preview, including reviewing procedures and other related

documents to familiarize themselves with work scope, task sequences and critical steps; a conversation with those who performed the job in the past; and a walkdown of the job site. Critical steps, possible errors, and ‘worst things that can happen’ are identified, and controls evaluated.

Can be part of a pre-job briefing.

Tasks reviewed in detail prior to commencement to ensure the work, its hazards and potential errors and consequences are understood.

Job site review Taking the time necessary to get acquainted with the immediate work area, to develop an accurate

understanding of critical indicators, system/equipment condition, work environment, hazards and team members at a job site.

Inspect work location for new or unanticipated hazardous conditions. A

‘line of fire’ review (see

Section 6.3.2.1(c)) is a good practice at this stage.

Questioning attitude Individuals stop and resolve hazards, warnings, error-likely situations or uncertainties before proceeding with the job. When doubt arises, follow up with the discovery of facts, not assumptions, to reveal more knowledge about the situation and eliminate the doubt.

If unclear with proper protective equipment to be worn obtain advice from an industrial safety professional.

Self-checking (also known as STAR: stop, think, act, review), stop when unsure

Individual focuses attention on appropriate component or activity; thinks about the intended action; understands the expected outcome before acting, and verifies the results after the action.

Prior to operating isolation devices, the individual confirms the correct device and what is expected upon operating the applicable device (e.g. pump flow stops, indicating lights change state, etc.).

Procedure use and adherence Procedure adherence means understanding a procedure’s intent and purpose, and following its direction. The user performs all actions as written in the sequence specified by the document. However, if it cannot be used safely and correctly as written, then the activity is stopped, and the procedure is revised before continuing.

Work procedure may specify required PPE, and when PPE is not available then the work is stopped until the desired PPE is available or alternate acceptable PPE is incorporated into the written procedure.

Effective communication Effective communication is an important defence in the prevention of errors and events. Oral communication possesses a greater risk of misunderstanding compared to written forms of communication. Misunderstandings are most likely to occur when individuals have different understandings, or mental models, of the current work situation or use terms that are potentially confusing.

Therefore, confirmation of verbal exchanges of operational information between individuals must occur to promote understanding and reliability of the communication.

TABLE 24. HUMAN PERFORMANCE EVENT FREE TOOLS AND EXAMPLE APPLICATIONS (cont.)

Tool Description Industrial safety application examples

Three-way communication Three-way or the ‘repeat back’ method is used to communicate changes to physical facility equipment during work activities via face to face, telephone, or radio and requires three verbal exchanges between a sender and a receiver to promote a reliable transfer of information and understanding. The person originating the communication is the sender and is responsible for verifying that the receiver understands the message as intended. The receiver makes sure he or she understands what the sender is saying.

Used when transferring instructions to another person verbally, for example:

Sender: “Please close valve 3-3312–Valve 22.”

Receiver: “I understand that you want me to close valve 3-3312–Valve 22.”

Sender: “That is correct.”

Phonetic alphabet Several letters can sound alike when spoken and can be confused in stressful or noisy situations, for example, ‘D’

and ‘B’. The phonetic alphabet specifies a common word for each letter of the alphabet. For example, 2UL-18L and 2UL-18F would be stated “two uniform Lima dash eighteen Lima” and “two uniform Lima dash eighteen Foxtrot”.

When operating isolating devices or specifying information in a nuclear facility over phone, radio or face to face.

Sender: “Please open circuit breaker 2-53300–circuit breaker 22 Charlie.”

Receiver: “I understand that you want me to open circuit breaker 2-53300–

circuit breaker 22 Charlie.”

Sender: “That is correct.”

Pre-job briefing Meeting of individual performers and supervisors conducted before performing a job to discuss the tasks, critical steps, hazards and related safety precautions. This meeting helps individuals to better understand the task(s) to be accomplished, applicable operating experience, blackout conditions and associated hazards. Sometimes called a ‘tailgate’ or ‘tailboard’ meeting in construction environments.

Typically held at the start of a shift or a new work assignment (e.g. travel to a new site). Advanced techniques have the workers brief themselves on the work and hazards with supervisors taking more of an oversight role.

Verification practices, including concurrent verification, independent verification and peer checking

Refers broadly to four tools: peer checking (PC);

concurrent verification (CV); independent verification (IV); and peer review (PR). These tools involve a second (or more) person to confirm actions and results achieved by a performer. While PC focuses on preventing a mistake by the performer, IV and CV focus more on confirming correct configuration or status of equipment or documents.

PR is a defence to detect errors and defects before completion of documents by reading and checking the quality of another’s work product (design, calculation, procedure, work package, etc.).

Second individual verifies the sequence and correctness of isolations proposed for work protection.

Flagging If a component is physically near other similar looking components and is handled multiple times, flagging helps the user consistently touch the correct component. An individual distinctly marks the correct component with a flagging device that helps the performer visually return to the correct component during the activity or after a distraction or interruption. Individuals can also use flagging to identify similar components that are not to be touched or manipulated.

Physically marking work sites and equipment being worked on by ropes, tape or other means.

the IAEA, INPO, the International Society for Performance Improvement, the United States Department of Energy and WANO.