Brian Harkins U.S. Department of Energy Office of River Protection

1. Human Performance Investigation Brian Harkins U.S. Department of Energy Office of River Protection

2. Point of View Human Performance Improvement (HPI) is a useful tool in event investigations During a recent investigation, use of HPI identified areas of weakness not found using standard event investigation tools

3. Agenda • Why use a Human Performance Approach • How does using HPI in event investigations differ from standard event investigations • HPI Event Investigation Process • Description of the Event • Root Cause Analysis Results • Event Critical Junctures • Conclusion

4. Why use a Human Performance Approach? Human Errors Occurrences 70% Latent Organization Weaknesses* 30% Individual 80% Human Error (Slips, trips, falls) 20% Equipment Failures * Latent Organization Weakness – Hidden deficiencies in management control process or values creating workplace conditions that can provoke an error and/or degrade the integrity of defenses

5. HPI vs. Standard Event Investigation HPI event investigation Review from the perspective of the people involved in the event (context) Evaluate the organization as event unfolds The event is the effect or symptom of deeper trouble in the organization, thus not random Standard event investigation • Review from hindsight point of view – judging each critical step in view of the final outcome • Investigate to find where personnel went wrong • Often look at events as a problem with people, procedures and training

6. HPI Event Investigation The objective when performing an investigation using HPI is to understand why the decisions and actions of the people involved in the event made sense at the time. Once the context is understood then the performance of the organization can be evaluated.

7. HPI Event Investigation Process • Have participants tell the story of the event from their point of view (one-on-one interviews) • Identify (together with the participant) the critical junctures in the sequence of events • Rebuild the world as it looked to participants at each juncture • What did the participant observe? • What knowledge was used to deal with the situation? • What did the participants expect was going to happen? • What options did the participants think they had? • How did other influences effect their decisions?

8. HPI Event Investigation Process (cont.) • Validate critical elements of the participants’ story to distinguish fact from opinion • Reconstruct the sequence of events (this is where event investigation typically starts) • Evaluate the performance of the organization at each critical juncture of the sequence

9. ORP HPI Investigation • ORP decided to conduct an investigation using HPI because of the continual recurrence of events at the WTP construction site. Although we appeared to handle each event adequately, we continued to have similar events. • Contracted with an expert in HPI to: • Review 10 events (occurrence & accident reports) (9 electrical & 1 LO/TO) • Conduct interviews on 3 of the 10 Occurrences (2 electrical & 1 LO/TO)

10. Event Description • Background – Site had just returned to work after a 2 day safety stand down due to LO/TO events and there was a prohibition against working any activities involving hazardous energy. • Electricians (working in pairs) were assigned to conduct assured ground testing on extension cords and a pre-job was held. • In the afternoon, one electrician decided to get a head start on the next week’s work and install a weather protection cap on a mini load center located near where his partner was performing assured ground testing on a cord (Critical Juncture 1)

11. Event Description (cont.) • Electrician used a breaker to de-energize pig tail (Critical Juncture 2), checked for voltage using a tick tracer (Critical Juncture 3), and removed cord end on 240V pig tail • While installing the weather protection cap, the wires touched causing an arch • Electrician reported the event

12. Event Description (cont.) Cord, Cord end, Weather protection cover Mini load center

13. Root Cause Analysis (RCA) Results • Electrician failed to comply with NFPA 70E requirements to perform a zero energy check • Electrician failed to comply with LO/TO requirements “While some problems were identified with work control process and supervision, the common thread was failure by individuals (both supervisors and craft) to effectively implement one or more of the five core functions.” From the Executive Summary of the RCA report

14. RCA compared to HPI Investigation • The RCA found all of the items that the HPI investigation identified as critical junctures but missed their significance because the context used by the RCA team was • in hindsight, and • focused on procedure compliance

15. Critical Juncture 1 - Change in Work Scope • Pre-job for assured grounding on cords • Electricians directed to install weather protection caps whenever they found them missing • Electrician decided to get a head start on the next weeks work while waiting for his partner to finish up a cord • Worker had strong feeling to produce based on years of off-site experience RCA - did not address, but felt the pre-job was inadequate HPI investigation – culture currently existing at the construction site focused on production vs. procedure compliance

16. Critical Juncture 2 – Electrician use of Tic-Tracer • Electricians using tic-tracer because they were not allowed to use multi-meter or Wiggy® – this was validated by interviewing other electricians • Wiggy® was removed across the site due to safety concerns • Supervisor prohibited the electricians from using multi-meters on cords based on his interpretation of newly implemented NFPA 70E requirements RCA – electrician failed to comply with NFPA 70E requirements to perform a zero energy check HPI investigation – working outside of established controls unknowingly

17. Critical Juncture 3 – Electrician use of Breaker • Electrician used a breaker to de-energize pig tail without s LO/TO • Electrician stated that he was doing nothing different than any other electrician, he just selected the wrong breaker • Validated that 8 out of 10 electricians interviewed would have used the breaker without a LO/TO RCA – electrician failed to comply with LO/TO requirements HPI investigation – working outside of established controls unknowingly

18. Conclusion • HPI investigation techniques should be added to our current investigation processes • The value of investigating an event using HPI is in reviewing the context of the event to identify organizational weaknesses not found by other methods • HPI’s broader view identifies areas that impact the organization, not just address areas to prevent the specific event from recurring

19. References • The field guide to Human Error Investigations by Sidney Dekker • Managing Maintenance Error by James Reason and Alan Hobbs