16th Annual HPRCT Conference
June 21-24 · Sheraton Inner Harbor Hotel
Baltimore, MD
Hosted by Constellation Energy
Optimized Human Error
Evaluation
June 22nd, 2010
Presenter: Terry J. Herrmann, P.E.
Associate, Structural Integrity Associates
[email protected]
2010 HPRCT Presentation – Optimized Human Error Evaluation
Your Presenter
Terry J. Herrmann, P.E.
• BS Mechanical Engineering & MS Engineering Management from Syracuse University
• Over 30 years experience in power generation in the areas of design, construction, testing,
failure / root cause analysis, equipment reliability, and probabilistic risk assessment.
• Developed and implemented programs in root cause analysis, system engineering, and
risk-based applications.
• Recipient of 2002 Kepner-Tregoe® International Rational Process Achievement Award.
• IEEE Subcommittee on Human Factors, Control Facilities and Human Reliability –
Recommended Practice for Investigation of Events at Nuclear Power Plants.
• Contributor to EPRI Report 1016907, Preservation of Failed Parts to Facilitate Failure
Analysis of Nuclear Power Plant Components
2010 HPRCT Presentation – Optimized Human Error Evaluation
Optimized Human Error Evaluation
Participant Input for this Presentation:
• Provide one brief example where you struggled to perform
a human error evaluation.
• Provide one brief example of a success.
• Name one or two key “take-aways” you are most interested
in getting from this presentation.
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Optimized Human Error Evaluation
The objective of performing a Root Cause
Analysis is to optimize the use of the
organizations’ resources (time and cost) in
achieving an effective, long-lasting solution to
identified problems.
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Optimized Human Error Evaluation
Presentation Outline:
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Human Error or Inappropriate Action?
Providing a focused problem statement.
Identifying factors that influenced what happened.
Collecting relevant information.
Selecting effective corrective actions.
Trending effectiveness.
Pitfalls to avoid.
Topics for Discussion.
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Optimized Human Error Evaluation
Human Error or Inappropriate Action?
It all depends on your definition:
- a deviation from accuracy or correctness
- a mistake
- a moral offense
Let’s use the following working definition to describe both:
“A deviation from a desired condition occurred that is
directly related to an action or inaction on the part of an
individual.”
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Optimized Human Error Evaluation
Providing a focused problem statement:
Keep it short (less than 10 words, try for less than 5).
Make the deviation clear.
Avoid making judgments.
Done well, it’s much more cost effective.
Discuss an example provided by someone in the class.
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Optimized Human Error Evaluation
SLIP
ATTENTIONAL FAILURES
Carry out a planned tasks
incorrectly or in the wrong
sequence
LAPSES
MEMORY FAILURES
Missed out a step in a plan
sequence of events
UNINTENDED
ACTIONS
HUMAN
ERRORS
RULED-BASED MISTAKES
MISTAKE
KNOWLEDGE-BASED
Inappropriate response to
an abnormal situation
INTENDED
ACTIONS
VIOLATION
2010 HPRCT Presentation – Optimized Human Error Evaluation
Misapplication of a good
rule or application of a bad rule
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ROUTINE VIOLATIONS
EXCEPTIONAL VIOLATION
ACTS OF SABOTAGE
Optimized Human Error Evaluation
Collecting and Applying Relevant Information:
Determining What Information is Relevant:
• First consider the conditions under which the deviation
occurred (latent weaknesses):
• How clear are performance expectations?
• Pre-job briefs, etc.
• Is needed information accurate and readily available?
• work package, procedures, drawings, displays, etc.
• Level of training/skills for the task.
• Presence of distracters
• job conditions, interruptions, time-critical task, etc.
• What else?
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Optimized Human Error Evaluation
Collecting and Applying Relevant Information:
Determining What Information is Relevant:
• Next consider individual performance factors:
• Fitness for the job.
• fatigue, medical condition, etc.
• Level of commitment to the task.
• Behaviors
• overconfidence, friction between co-workers, etc.
• Past practices performing similar tasks.
• What’s worked before, may not be appropriate for the
current situation.
• What else?
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Optimized Human Error Evaluation
Collecting and Applying Relevant Information:
Determining What Information is Relevant:
• Consider feedback / consequences:
• What impact did the situation have on the individual?
• e.g., injury to self or others, got , etc.
• What was the perceived level of risk to the individual?
• What was the perceived burden to the individual?
• e.g., physical, mental, emotional
• What level of feedback / coaching has the individual
received when performing similar tasks?
• e.g., from supervisor, co-workers, customers, etc.
• What else?
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Optimized Human Error Evaluation
Collecting and Applying Relevant Information:
Determining What Information is Relevant:
• Evaluate barriers to inappropriate actions:
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Optimized Human Error Evaluation
Collecting and Applying Relevant Information:
Collecting Relevant Information:
• Do it soon – before people leave for the day, if possible.
Information that is most likely to change with time
includes.
• Individual’s memory and observer recollections.
• Volatile computer information (e.g., event logs).
• Equipment configuration, prior to troubleshooting,
disassembly and repair.
• Have a plan. It’s best if you develop a standard set of
interview questions and a template report. There is a
significant savings in cost and manpower required to
determine the cause(s) so that appropriate corrective
actions can be taken to prevent similar problems.
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Optimized Human Error Evaluation
Selecting Effective Corrective Actions:
• The corrective actions should be lasting.
• We maximize benefits when we implement the actions
with the least amount of delay.
• We maximize benefits when the corrective actions can
be performed using available resources.
• We maximize benefits when we make use of industry
and plant OE to gain additional insights on the issue.
• We maximize benefits when we use the most costbeneficial approach.
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Optimized Human Error Evaluation
Selecting Effective Corrective Actions:
Types of Actions
Problem
Cause
Effect
Action
Interim action can be either corrective or adaptive
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Optimized Human Error Evaluation
Selecting Effective Corrective Actions:
When developing a plan, it’s important to obtain input
from:
• People who have to provide the resources
• People who have to implement the actions
• People who will be affected by the actions
If these people are not committed to implementing the
plan, the plan is unlikely to be effective.
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Optimized Human Error Evaluation
Trending Corrective Action Effectiveness:
How do we know if we’ve really optimized our human
error evaluations?
• Is the rate of related events decreasing?
• Is the time to perform the evaluation decreasing?
• Have the corrective actions become how we do
business?
• What else might we want to evaluate?
• How can we capture this information most effectively?
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Optimized Human Error Evaluation
Pitfalls to Avoid
(The “law of unintended consequences”.)
• The possibility that something can go wrong is
increased when:
• You don’t have a good handle on what caused the
original problem.
• You take action without considering that the action itself
can create similar or new problems.
Example:
• “Coaching” individuals to follow the procedure instead of
reducing the difficulty of implementing the procedure.
• Discipline was used when an individual committed an
error due to lack of knowledge and misleading directions
from a senior member of the staff.
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Optimized Human Error Evaluation
Topics for Discussion:
• Difficulties in dealing with “soft” issues.
• How many people have pre-defined interview
questions and an evaluation template for
performing evaluations?
• What works well?
• What could be improved?
• Others???
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