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Optimized Human Error Evaluation

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Title: Optimized Human Error Evaluation


1
Optimized Human Error Evaluation
16th Annual HPRCT Conference June 21-24
Sheraton Inner Harbor Hotel Baltimore, MD Hosted
by Constellation Energy
June 22nd, 2010 Presenter Terry J. Herrmann,
P.E. Associate, Structural Integrity
Associates therrmann_at_structint.com
2
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

3
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.

2010 HPRCT Presentation Optimized Human Error
Evaluation
4
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.
2010 HPRCT Presentation Optimized Human Error
Evaluation
4
5
Optimized Human Error Evaluation
Presentation Outline
  • 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.

5
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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
Lets 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.
6
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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, its much more cost
effective.
Discuss an example provided by someone in the
class.
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Optimized Human Error Evaluation
ATTENTIONAL FAILURES Carry out a planned
tasks incorrectly or in the wrong sequence
SLIP
UNINTENDED ACTIONS
MEMORY FAILURES Missed out a step in a
plan sequence of events
LAPSES
HUMAN ERRORS
RULED-BASED MISTAKES Misapplication of a good
rule or application of a bad rule KNOWLEDGE-BASED
Inappropriate response to an abnormal situation
MISTAKE
INTENDED ACTIONS
ROUTINE VIOLATIONS EXCEPTIONAL VIOLATION ACTS OF
SABOTAGE
VIOLATION
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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?

9
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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.
  • Whats 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

12
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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.
  • Individuals memory and observer recollections.
  • Volatile computer information (e.g., event logs).
  • Equipment configuration, prior to
    troubleshooting, disassembly and repair.
  • Have a plan. Its 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
    cost-beneficial approach.

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Optimized Human Error Evaluation
Selecting Effective Corrective Actions
Types of Actions
Problem
Cause
Effect
Adaptive
Corrective (Fix)
Eliminates the cause
Limits the 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, its 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 weve 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 dont 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???

19
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