1 Human Performance Tools System Operator Conference September and September 25-27, 2012 Memphis, TN Sam Austin Manager, System Operator Training Tennessee Valley Authority

2012 System Operator Conference 2 Learning Objectives At the conclusion of this training session, you should be able to: Name the 5 basic principles of human performance. List the barriers that prevent human performance errors and discuss how these barriers can break down to cause events. Discuss the underlying basis for the 5 human performance tools presented today, and when to use these tools. Apply the 5 human performance tools to your daily job Identify the fundamental aim of human performance tools

2012 System Operator Conference 3 Outline of Topics 5 basic principles of human performance Breakdown of barriers that prevent human error 5 human performance tools Applying and using human performance tools Aim of using human performance tools

2012 System Operator Conference 4 Five Basic Principles of Human Performance People make mistakes Error-likely situations are predictable and preventable Organizational values influence individual behavior High levels of performance are achieved based largely on encouragement from peers Events can be avoided by understanding root causes and lessons learned

2012 System Operator Conference 5 Is it a Question of Competence or Fallibility? Pride – an excessively high opinion of ones’ ability. Pride tends to blind us to the value others can provide. Pride hinders teamwork. People think their competence is being questioned when they are corrected about not adhering to expectations.

2012 System Operator Conference 6 The issue is human fallibility, NOT a human being’s competence. Because of the limitations of human nature, error- prevention methods should be used to control error. Is it a Question of Competence or Fallibility?

2012 System Operator Conference 7 Barriers That Prevent Human Error Events Individual Barriers (Proper use of Human Performance Tools) Programmatic Barriers Organizational Barriers Management Barriers Initiating Action Poorly written procedures, failed or non-existent barriers, ineffective management Weak skills, failed or non- existent barriers Significant Event Break-down of barriers lead to error events

2012 System Operator Conference 8 NERC Industry Advisory November 08, 2011: Reducing Human Performance Errors by the Use of Configuration Control Practices

2012 System Operator Conference 9 NERC Industry Advisory By developing and implementing proper configuration control, entities can reduce exposure to the inherent risk of human performance errors that occur during the maintenance and testing of protection systems.

2012 System Operator Conference 10 NERC Industry Advisory Some of the suggested tools to use: Maintenance Alteration Log – “procedure use” Peer Review/Peer Check Self Check Place Keeping

2012 System Operator Conference 11 Error Prevention Methods/Human Performance Tools STOP when unsure PEER-CHECKING: Have peers check your work PROCEDURE USE & ADHERENCE: Use and adhere to all procedures PLACE KEEPING: Keep your place! SELF-CHECKING: Check yourself and each step of your work

2012 System Operator Conference 12 Stop When Unsure When confronted with a situation that creates a question, a person is in uncharted (unfamiliar) territory—a knowledge-based performance situation Whenever a question is encountered and what to do about it is uncertain, stop and get help. Given the chances for error are particularly high in a knowledge-based situation, the best course of action, when unsure, is to take a time-out and get another person’s ‘mind’ focused on the problem.

2012 System Operator Conference 13 Stop When Unsure When that “gut feeling” is telling you that something is not right, stop. Get help from those who possess the expertise, not necessarily from those of higher rank. Don’t be embarrassed, stop and get help!

2012 System Operator Conference 14 Stop When Unsure When to use the tool When…… You get unexpected results You are in unfamiliar situations You have uncertainty whether or not you are in compliance with expectations, procedures, or regulations

2012 System Operator Conference 15 Peer Checking Peer checking is an error-prevention technique: a verbal agreement between two individuals prior to a specific action and/or task one will observe or check the behavior of the other to prevent an error by the performer. One person acts as the performer, and the second person, an experienced peer familiar with the activity, acts as the checker.

2012 System Operator Conference 16 Peer Checking Peer-checking is merely two persons (performer and checker): self-checking in parallel agreeing together that the action is the correct action to be performed and…… on the correct component! Peer checking augments self-checking, but does not replace it. This technique takes advantage of a fresh set of eyes not trapped by the performer’s task focused mind-set. The checker may “see” hazards or potential consequences the performer does not see.

2012 System Operator Conference 17 Peer Checking When to use the tool When…… You are in an error-likely situation with critical steps There is a history of error or unfavorable operating experience with a particular action Mis-identification, mis-operation, or improper installation or assembly can have undesirable impact on people’s safety or plant equipment The checking is requested by a peer

2012 System Operator Conference 18 Procedure Use & Adherence Procedures help users to perform activities correctly, safely, consistently, and in accordance with design requirements. Procedures direct people’s actions in a proper sequence and minimize reliance on one’s memory and the choices made in the field. Procedures incorporate the policies, operating experience, effective work practices and management decisions about how a task is to be performed.

2012 System Operator Conference 19 Procedure Use & Adherence When to use the tool When….. Your activities involve manipulation, monitoring, or analysis of equipment or physical work in the field.

2012 System Operator Conference 20 Place Keeping Place keeping is used to mark the steps in a procedure or work document that have been completed or that are not applicable, so that steps are not accidentally omitted or repeated. Methods include circle/slash, check box, or sign – offs.

2012 System Operator Conference 21 Place Keeping When to use the tool When….. Using a procedure or work document to perform critical activities. You are suspending performance of a procedure. Keep your place to identify the last step completed.

2012 System Operator Conference 22 Self Checking – “STAR” Stop – Think – Act – Review Self-checking helps prevent errors when: “touching” plant equipment to change its status or… even when revising a document important for plant safety and reliability. Self-checking is particularly effective during skill-based tasks that could be performed without much conscious thought. This technique helps boosts attention at important points in an activity before an important action is performed. If attention is not focused, error is likely!

2012 System Operator Conference 23 Self Checking When to use the tool When….. Critical steps must be identified Equipment must be manipulated You experience a time pressure, or “hurried” feeling The task is interrupted – self check when resuming steps CHECK AGAIN!

2012 System Operator Conference 24 Human Performance Tools in Use Play Video

2012 System Operator Conference 25 Fundamental Aim of Using Human Performance Tools Help the individual maintain “positive control” of a work situation and to prevent errors that cause harm. Positive control means that “what is intended to happen” is what happens and that is all that happens. Despite rigorous use of these error-prevention tools, people will still make errors. But, rigorous application of these basic tools may eliminate “events”. This is accomplished by placing barriers between you and the manipulation of equipment, that if operated improperly, triggers an “event”. Good use of tools prevent breakdown of the barriers that will prevent error events!

2012 System Operator Conference 26 Summary The main points of this training session are: Humans are fallible and we all make mistakes. Human performance tools, such as self- and-peer checking, adherence to procedure, etc, help the system operator maintain positive control of a work situation. Incorporating human performance tools in the application of your job will help minimize mistakes and NOT trigger events.

2012 System Operator Conference 27 Questions?