Unlocking the Ways To Get for Millstone

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Transcript Unlocking the Ways To Get for Millstone

Unlocking Ways To Get
“Between the Ears”
Of The Operator
Robert D. Coovert
Exelon Human Performance Manager
The Goal Is
Organizational Impact
“We know that training, CRM for example, does influence
operational behavior…” (Helmreich & Foushee, 1993).
Highly Reliable Organization
(HRO)
 Develops common organization practices
– “Standard operational procedures contribute to reliability if the
outside environment is stable, that is, if the decisions required of
operators fall within a predictable set of contingencies. However, as
seen on a daily basis this is clearly not the case. Operators must deal
with unexpected and unique situations in a very rapid fashion”
 “Anticipates the changing potential for failure, regardless of
past success, because they appreciate that their knowledge is
imperfect and that their environment continues to change”
 Creates safety by anticipating and planning for unexpected
events
Simple Rules for
Changing Behavior
 Training
 Reinforcement
 Accountability
Simple Rules For
How Adults Learn
 Adults learn by doing
• Experiential learning
 Adults learn if it is personally
important to them
KEY LEARNING:
It comes down to Associations
Experiential Learning
 Adults behavior has been shaped by their
experience, if you want to change behavior,
you must provide new "experiences”
 Studies indicate that most adults learn
through "hands on" experiences
Performance Exercises are
Experiential
 Simple exercises designed to provide initial
understanding of a new behavior
– Checking practices
– Communications 1SI8801A
– Verification practices
Performance Exercises
 Focus on observable behaviors
The following Self-Check (STAR) actions are expected to
be observable:
Stop
Point at or touch the equipment.
Read the identification tag.
Compare to the controlling document.
Hesitate for a second or two, followed by:
Manipulate the equipment.
Verify actual system response.
Performance Exercises
Proficiency Exercise
Self Checking
The intent of this proficiency exercise to demonstrate required knowledge and
skill of self checking while performing a task.
A fundamental skill, which cannot be compromised, is component identification.
Distractions, time pressure, multiple tasks, stress, and assuming you’re on the
right train or unit can create an error likely situation. Using STAR correctly can
ensure the correct component is identified. Per HU-AA-101, Self-Check (STAR),
SHALL be used for component identification and equipment manipulation.
The following Self-Check (STAR) actions are expected to be observable:
Stop.
Point at or touch the equipment.
Read the identification tag.
Compare to the controlling document.
Hesitate for a second or two, followed by:
Manipulate the equipment.
Verify actual system response.
Instructions:
1. Use a labeled component consistent with attachment 1, 2, or 3, (EXELONPE-SC-01, EXELON-PE-SC-02, EXELON-PE-SC-03) for this exercise.
2. Call the individual to be evaluated into the area with the component.
3. Using the associated procedure, (EXELON-PE-SC-01, EXELON-PE-SC-02,
EXELON-PE-SC-03), have the individual perform the action.
4. Performing the action should include the following:
 Reading the procedure
 Stop.
 Point at or touch the equipment.
 Read the identification tag.
 Compare to the controlling document.
 Hesitate for a second or two, followed by:
 Manipulate the equipment.
 Verify actual system response.
Simple Examples are
Experiential
Poke Yoke
Markers
How can I convince a
supervisor which jobs are the
best observe?
Vulnerability of
Removal or Installation
 The requirement is to
remove the nuts and
then replace them in
some predetermined
order.
A B C D E F G I
How can I educate a crew on
knowledge based errors?
GEMS
Generic Error Modeling System
30 feet
60 feet
90 feet
How can I educate a crew on
the key to communications?
Communications
 What are your communication standards?
 What communication tools do you use?
– Written
– Verbal
• Three way communications
• OPEN A VALVE
KEY LEARNING:
Create Understanding
Communication Assumptions
 Airforce (P)Problems identified by
pilots and
 (S)Solutions determined by the
maintenance crews
Communication Assumptions
(p) Left tire almost needs replaced
(s) Almost replaced left tire
(p) Test flight OK except autoland very rough
(s) Autoland not installed on this aircraft
Communication Assumptions
(p) Something loose in cockpit
(s) Tightened something in cockpit
(p) Evidence of leak on right main landing gear
(s) Evidence removed
Communication Assumptions
(p) Dead bugs on windshield
(s) Live bugs on order
(p) IFF inoperable
(s) IFF always inoperable in OFF mode
(p) Friction locks cause throttle levers to stick
(s) That’s what they’re there for
Communication Assumptions
(p) Number 3 engine missing
(s) Engine found on right wing after brief search
(p) Aircraft handles funny
(s) Aircraft warned to straighten up, “fly right” and be
serious
How can I educate a crew on
the dangers of overconfidence?
OVERCONFIDENCE
“The danger of overconfidence
is a tendency to become sloppy
and careless. Workers and
supervisors begin to take
chances. Such an attitude is the
perfect medium in which to grow
an accident.”
H. C. Howlett II
What was going through your head prior to, during, and after the accident?
How can I educate engineers
on the potential latent
conditions in the new digital
feed-water control system?
Air Bus A320
“Hazardous and complex
systems are created with
built-in errors waiting to be
triggered.” James Reason
Air Bus A320
Dynamic Learning Activities
(DLA)
 Exercises created with multiple activities
that are designed to teach and reinforce
desired behaviors for an individual
Work Environment Simulators
 Simulators that are created that can support
multiple activities that are designed to teach and
reinforce desired behaviors for an individual or
group of individuals
 Shop setups
 Hogan’s alley / Murphy's alley
 Video
 Control room simulators
 The plant
Shop Talk
Shop Experience
The Good
 It works
 All levels of workers can benefit
 Training / reinforcement
 It’s not the same old thing in the classroom
The Bad
 Return on investment
 Competent instructors
 Management support
 Cost
 Competition for availability
The Ugly
There is no consistent means to evaluate individual and
team performance.
There is an absence of reliable data on events.
Training is lagging behind in organizations / departments
that create latent conditions.
Aspects of increased automation are not being addressed yet
are identified in a number of events.
Lessons Learned from the FAA
There is great variability in the impact of programs and
performance even after training. Incomplete acceptance of
concepts and practices by instructors and evaluators is a
major source.
In the absence of continuing reinforcement, behavior and
attitudes regress almost to pre-training levels.
Human Performance programs between departments and
stations show great variability in execution and impact.
“Training is not likely to leave the
confines of the school house if the
culture is not congruent with what is
being taught.”
Questions