Human Performance EngineeringA Systems Approach to Operations

Excellence

Concord Associates, Inc.Systems Performance Engineers

9737 Cogdill RoadKnoxville, TN 37932

(865) 675-0930

www.concordassoc.com

The “Socio-Technical” System

Administrative Controls, Procedures, Job Aids

Facilities and Support Organizations

personnel

software

hardware

Human performance engineering matches system demands to human capabilities and limitations and builds the support systems to assure human performance levels are maintained within design requirements.

Selection

Mgmt. Controls Supervision

Procedures Job Aids

Initial Training

Experience & Continuous

TrainingErgonomics

Entry Level

Min Qual.

KnowledgeSkills

AbilitiesAptitudesAttitudes

CognitivePhysiologicalPsychological

Social

Systems Engineering Design

• Life cycle - concept, design, development, operation, decommissioning

• Top down - mission, system, functions, equipment and personnel requirements

• Integrated (iterative) human-system design with testing in all phases

• Front-end loaded• Comprehensive documentation

Assess ExistingSystems

SystemicProblems ?

ProgramRequirements

ContinuousImprovement

Program

HPE DESIGN

Human ErrorConOpsTrainingProceduresHMIMeaures/ Feedback

ProposedNear-Term

Fixes

YES

NO

NO

YESSpecific

Problems ?Evaluation Report MOCProgram

The HPE Process

Human Performance Engineering

HPE

Measurementand

Feedback

HumanError

AssessmentConduct

of Operations

HumanFactors

Engineering PersonnelSubsystems

(Training,Qualification,

Staffing)

Procedures

Human Error Assessment

• Prospective (PHA)– Validity of operator action as a safeguard– Eliminate error-likely situations– Assess likelihood of success/error

• Retrospective (Root Cause)– Human error mechanism

– Contributing factors– Barriers– Impact of enhancements

Human Reliability Analysis Techniques

• OPHRA (Concord)

• Others– THERP (Swain and Guttmann)– SLIM, SLIM-MAUD (BNL, Embrey)– Simulation Model (e.g., SAINT, Siegel, HOS)– OAT (Wreathall), OAET (EG&G)– HEART (Williams)– MAPP (ORNL)– ATHEANA (NRC)

FAILURE

The OPHRA Operations Model

UnitOperator

Correct ActionChosen?

Opportunityto Perform?

FAILURE

Knowledge& Abilities Stress

Access tooperating area

Equipmentoperability

Time to actSystem informationavailable

NO

FEEDBACK

YES

Success

YES

NO

Cue to Action

Conduct of Operations Requirements

Written policies, requirements and guidelines for control of operations activities.

ConOps requirements provide a clear and concise statement of management expectations that establishes a basis for commitment of all employees to operations excellence.

Conops

Well-defined, documented and enforced Conduct of Operations requirements help to control the variability in human performance and keep the system within specified bounds.

Safety Boundary

Optimum

Minimum Performance (Compliance)

Operational Excellence

Design Limit

Typical elements of Conduct of Operations

requirements include:

• Procedure Compliance

• Procedure Writing, V&V

• Communications

• Drills, Monitored Evol.

• Operation Evaluations

• Required Reading

• Safety Observer

• Equip./Piping Labeling

• Control of On-Shift Training

• Shift Turnover• Narrative Logs• Operating Logs• Control Room Activities

• Control of Equipment and System Status

• Timely Instructions to Operators

• Verification• Management of Change

Considerations in implementing enhanced

Conduct of Operations requirements

• Formality and rigor appropriate to risk and importance • Optimize use of existing good stuff - consolidate,

reorganize, increase accessibility and visibility; but don't re-invent

• DO NOT create the impression that you are adding one more "program" - document, clarify, enhance, enforce

• Clearly identify responsibilities and individual accountability• Identify benefits (what's in it for me)• Involve and communicate with all staff levels; get build-in,

not buy-in• Early and continued management support and visibility

Personnel Subsystem Issues Directly Impacting Human Performance

• Personnel selection, entry-level qualifications

• Job design, team, organizational design, staffing levels

• Training, qualification, certification• Fitness for duty, shift work• Career progression

Systems Analysis

ImplementDevelop

Design

Analyze

Evaluate

Performance-Based Training

ISDPROCESS

• Systems approach to training• Training needs driven by job performance

requirements• Training is ONE means to attain desired levels

of performance• Learning objectives based on knowledge,

skills, and abilities required to perform the job acceptably

Performance-Based Training

Performance Based Training (Continued)

• Training media, materials, instruction designed to attain specific learning objectives within constraints

• Testing directly related to learning objectives• Continuous measurement and evaluation of

training effectiveness• Thorough documentation of training decisions• Continuous improvement process

Training and Procedures

There’s more to training and procedures than just training on procedures!!

Procedures are an operating aid for use by qualified,well-trained

operators.

Procedure Classification

Moderate - high frequency

Low complexity

Low consequence

Low - moderate frequency

Moderate complexity

Moderate consequence

Low or very high frequency

Moderate - high complexity

Moderate- high consequence

No Procedure

Reference

In-Hand Use

Human Factors Guidelines

The catalyst tank level must be above 12’. The oil level in ACC034 must also be sufficient. Once that is done, startup gland seal by opening appropriate valves. At the proper time the catalyst feed pump may be started.

Before

Human Factors Guidelines

1.1 VERIFY Catalyst Makeup Tank level is greater than 12 feet.

NOTE: The dip stick has four marks, each indicating 1/4 level.

1.2 IF oil level in sump is below 3/4,

THEN FILL sump with ACC034 oil.

CAUTION

Vessel over pressurization or depressurization may occur if the following steps are not performed properly.

1.3 VERIFY CFP-001, Catalyst Feed Pump Suction Valve is OPEN.

1.4 LINE UP gland seal as follow:

1.4.1 OPEN GS-750, Catalyst Feed Pump Gland Seal Supply.

1.4.2 OPEN GS-751, Catalyst Feed Pump Gland Seal Return.

1.5 START CFP-001, Catalyst Feed Pump.

After

System

Functions

Tasks/Jobs

Personnel

Interface

Issues in Human-System Design

mission success, system performance requirements,

user needs/satisfaction

requirements analysis, allocation to human, hardware,

software, facilities

task requirements, conditions, demands on humans - time, accuracy,

precision, perception, vigilance

capabilities/limitations - knowledge, skills, abilities, attitudes; physiological,

psychological, cognitive, social

facilities, workspace, controls, displays, habitability, accessibility,

protective equipment

7/29/98 Concord Associates, Inc. 40Integration of Human Factors into the Systems Engineering Process

Incidents,Oper. Data

Audits, Reg.Reviews

EmployeeFeedback

Lessons Learned(Mods /Futu re Designs)

Conti nuousPerformanceImprovement- HF E Design- Procedures- Training- M gt . Systs- Human Resources

Integrated AcceptanceTesting

Conceptual Design,Requirements Definition

PreliminaryDesign

Detailed DesignProcurement &Construction

TurnoverOperations &Maintenance

HumanInterfaceOperat ionalTest ing

ProceduresWalkdowns

IntegratedSoftwareTest ing

Facilit iesAcceptanceTest ing

PersonnelQuali ficationsTest ing

Detail ed Task,Workload, andTi meline Analysis

Detailed DesignHum an-MachineInterfaces

Detailed DesignProcedures & Doc. Design

Detailed DesignSof tware/DataSystems

Detailed DesignFacilit ies

Detailed DesignPersonnelSubsystem

Training Prog.Des. Complete

HFEDetailedDesignT &E

InitiateTrainingProgram

HFE Preliminary DesignHFE Conceptual Design

Process Safety Analysis

Requirem entsSynthesis

Prelimi naryPhase T &E

TradeoffStudies

DesignConcepts

PersonnelSubsystemRequirem ents

Facility/Environ.Requirem ents

Sof tware/DataInterfaceRequirem ents

Procedures & Documentat ionRequirem ents

Equip InterfaceRequirements/Concepts

T&E P lan

Conceptual/ Inherent Safety AnalysisSi ting/Emergency Response PlanningQRA (when warranted)

Preliminary PHA Fi nal PHA 5-yr Updates (Reevaluation)MOC Updates

Analyze sim ilarsystem experience

Top-Level Requirem ents

Funct ion anal ysis/ allocat ion

Task and operational sequence anal ysis

Prepare HF E methods & data

Preli minary staff inganal ysis, roles, maintenance concepts

T&E Requirem entsDefinit ion

Human Reliabili ty Analysis

HFE Detailed Design Operational HFEProgram

F eedba ck

Concord Associ ates, Inc. 9/96

Operational Performance Feedback

LessonsLearned

Operational Experience

Sources

Analysis

• Audits• Self Assessments• Perf. Measures• Incident Reports• Near-Miss Reports• Industry Events• Govt. Reports• ER Drills• Training• Evaluations• Self-Reports• PHA Findings

• Root Cause• Performance Trends• Reliability Analysis• Human Error Analysis• Equipment Failure

Analysis• Training Needs• Systems Analysis

Information Management System System Users

Effective measures will:

• Discriminate degrees of success/failure as precisely as necessary

• Monitor performance on a continuous basis• Help move from audits to performance

management (reactive to proactive)• Clarify the relationships among performance

variables (indicators); i.e., support a "systems view"

Multiple Levels and Measurement Issues

Goals ManagementDesign

Organization Goals

Organization Design

Organization Management

Process Goals

Process Design

Process Management

Job/Individual Goals

Job/Individual Design

Job/Individual Management

Authority Referenced Measures

Involve all stakeholders to identify measure needs, objectives, constraints

Select authority, and extract rating strategies

Synthesize a measure that can be used by everyone to evaluate performance and get the same ratings as the authority.

Implementation Strategy

• Establish Human Factors Requirements– Complete life cycle– Human-centered design and operations

– Part of integrated performance management - safety, quality, environment, productivity

• Build in acceptance (involvement at all levels)

• Staged incremental implementation - policy, education, demonstration, implementation

Order of Implementation

• Human Factors Requirements (apply to new designs and PHAs immediately)

• ConOps

• Procedures (overlaps ConOps procedure use)

• Training

• Feedback, Lessons Learned, Measures

• Human Factors Design Improvements (existing facilities)

HPE - Pathway to Operations Excellence

The Valley of Compliance

The Peaks of Excellence