1. Human Performance Enhancement System Park Young Ho Dept. of Nuclear & Quantum Engineering Korea Advanced Institute of Science and Technology December 23 2005

2. Contents I. Introduction  Background  Definitions  Goal, Benefits & Premises of HPES  HPES Methodology III. K-HPES IV. Summary

3. Background  The success of human activities depends on numerous factors.  The human performance usually is not the cause of an event but is more often a symptom of underlying causes.  After the accident at Three Mile Island (TMI)Unit2, the need for a systematic approach for finding and correcting the underlying causes of human performance problems was identified  The aviation industry’s widely used and respected Aviation Safety Reporting System (ASRS) was originally selected as a model approach for nuclear industry use.  In 1981, Initial version of the Human Performance Enhancement System is made by Institution of Nuclear Power Operations (INPO).  Participation in the program was officially offered to the industry on a voluntary basis in November 1987, and industry wide training for coordinators and evaluators was conducted in 1988 and 1989.

4. Definitions (1)  Behavior : The actions, Physically or mentally taken by a person to achieve a desired result.  Causal Factor : A condition that shapes the outcome of a situation.  Consequential Event : An event involving inappropriate human performance that results in adverse consequences  Non consequential Event : an event involving inappropriate human performance without adverse consequences  Performance : The result of the actions carried out by an individual to satisfy an objective according to a standard

5. Definitions (2)  Potential Problem : A situation where inappropriate human performance comes close to occurring or could occur under the “right set” of conditions  Root cause : The fundamental cause and associated corrective action that, if corrected, will prevent recurrence of an event or adverse condition  Root cause Analysis : Any method used to identify Root cause of performance problems or adverse trends and Associated corrective action  Voluntary Reporting : Proactive reporting of events and potential problems to management by plant personnel

6. Goal, Benefits & Premises of HPES (1) Goal To improve overall plant operations by improving human reliability through the correction of the conditions that cause human performance problems. Benefits  Provides techniques to identify causal factors and potential contributors to human performance problems.  Augments and supports line management’s function of managing human performance.

7. Goal, Benefits & Premises of HPES (2) Premises  Human performance problems can be reduced and minimized.  An atmosphere that encourage problem identification & resolution and Accountability for correct task performance.  People want to perform well and accept responsibility for their performance.  Accurate identification and correction of causes can prevent repeat events.  The causes of non consequential events are the same as those of consequential events.  Utility sharing of lessons learned promotes better plant and industry wide understanding, identification, and correction of causes of human performance problems.

8. HEPS Methodology HPES Methodology What happened How it happened Why it happened

9. K-HPES (Korean Version-HPES)  In 1993 Korea Electric Power Research Institute (KEPRI) developed K-HPES program based on INPO-HPES.  Like INPO-HPES, K-HPES is also a “plant-level, grass-root effort to identify causal factors and corrective action” for human performance improvement in NPPs.  K-HPES put a special emphasis on the analysis of the operator’s “Cognitive Activities” resulted from his management role, on the premise that operators today may make more errors performing managerial tasks than they do performing control tasks

10. Rasmussen’s human decision –making model Execution Evaluation Interpretation System Identification Task Selection Observation Planning Detection

11. Operator’s model used in K-HPES System State Identification Task Selection DetectionObservationExecution

12. The Key Aspects of K-HPES  Voluntary reporting of events by K-HPES reporters  Anonymity of the reporters  Non-punitive reporting of human errors  Effort to find out root causes of human errors  Effort to generate corrective actions

13. Computer Aiding System for K- HPES Shortcomings of K-HPES  Difficult to consistently perform quality analyses  Takes too much time to conduct analyses  Inefficient of statistical analyses CASHPES Provides various analysis aiding tools with the K- HPES analyzer such as menu-driven analysis guidance and automatic report generation

14. Overall Structure of CASHPES Situation Description Module Event Sequence Composition Cognitive Error Analysis Module Causal Factor Analysis Module E&CF Chart Composition Module Report Composition Module User interface Management Module HPES Analyst Knowledge Base Management Module Databases

15. Overall K-HPES Analysis Procedure Using CASHPES Step1: situation Description Step2: Event Sequence Composition Completed? Step3: Cognitive Error Analysis Step4: Causal Factor Analysis Step5: E&CF Chart Composition Step6: Report Composition Situation Report File Event Sequence File Report File Cognitive Error Classification File Yes No

16. Summary and Further Study summary  In the effort to mitigate human errors in nuclear power plants, a Korean- version Human Performance Enhancement System called K- HPES was developed based on INPO-HPES.  Like INPO-HPES, K-HPES is an effective tool to analyze human errors and ultimately to enhance human performance in nuclear power plant operations.  A computerized aiding system for K-HPES Tentatively named CASHPES analysis with the support of CASHPES. The development of the CASHPES is an effort toward the complement of the K-HPES program. Further Study  Engineering Psychology and Human Performance  Cognitive Reliability and Error Analysis Method

17. Reference 1.Bishop, Joe and Richard LaRhette(1988), “Managing Humana Performance –INPO’s Human Performance Evaluation System,” Proceedings of the 1988 IEEE 4 th Conference on Human Factors and Power Plants, Monterey, California, Junn-5-9,1988 2.KEPCO Research Center (Former KEPRI)(1993), Development of Korean HPES for Nuclear Power Plants (I), KRC-92-J09, Final Project Report.