# Presentation: 693942

## Human Performance Assessment of BNL Arc-Flash Event

- Rob Fisher, President
- Fisher Improvement Technologies, LLC
- 802-233-0760
- Rob@fisherit.com

- www.fisherit.com

## Abstract and Team

- The team was requested to provide an independent assessment of the human performance related issues that may have existed surrounding the arc-flash event at CAD on April 14, 2006. The specific portion of the event being assessed by this team were the injuries received by a BNL employee. A DOE Type-B investigation is in progress to determine the root and contributing causes of the arc-flash.
- The team consisted of:
- Keven Butler, INL Office of Human Performance
- Bill Brown, BNL EENS
- Team Lead – Rob Fisher, President, Fisher Improvement Technologies, LLC
- The team used human performance event analysis tools and comparison to human performance best-practices to identify areas where this event may have had human performance related contributors.
- The team conducted interviews, reviewed documents, consulted with the DOE Type-B team, and reviewed issues with management.

*(Yes that’s how he spells it!)*

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## Human Performance Fundamentals

- Three Tenets:
- The things that cause the small things are the same as the things that cause the big things;
- 85% - 90% of significant events have their roots in something OTHER than just the individual; and
- Errors and Events are different things.
- Once these three tenets are understood – assessment begins at what the individual was doing, thinking and feeling at the time of the event – and why they were doing, thinking and feeling those things.
- Human Performance assessment looks at the individuals, environment, situation, barriers, procedures, processes, rules, organizational impacts and other possible contributing or influencing factors.
- If we believe that people come to work to do a good job every day, then we have to also believe that there were reasons individuals did what they did when they did it.
- Errors should START the investigation process – not END it.

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## Human Performance Assessment Path

- Very quickly, the assessment moved away from the individuals involved, and began identifying potential error-likely situations, error precursors, and latent weaknesses that could have contributed to this or similar events

- switch

- Individual

- Procedures, Processes
- & Rules

***Potential CAD Latent Org. Issues***

***Potential BNL Latent Org. Issues***

- Error Traps &
- Precursors

***Switch failure investigated by ***
***DOE Type-B Team***

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## Definition

- Time Pressure
- Distractive Environment
- High Workload
- First Time Evolution
- First Working Days After Days Off
- One-Half Hour After Wake-up or Meal
- Vague or Incorrect Guidance

- Overconfidence
- Imprecise Communications
- Work Stress
- Fatigue
- Peer Pressure
- Multi-tasking
- Off-normal Conditions

**Error Traps (Precursors)** - An unfavorable condition at the job site or a characteristic of the task or an individual that increases the **probability for error** during a specific action

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## Identified Error Traps

**Identified Error Traps**

- Time Pressure
- Distractive Environment
- High Workload
- First Time Evolution
- First Working Days After Days Off
- One-Half Hour After Wake-up or Meal
- Vague or Incorrect Guidance

- Overconfidence
- Imprecise Communications
- Work Stress
- Fatigue
- Peer Pressure
- Multi-tasking
- Off-normal Conditions

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## Definition

**Error-Likely Situation** - A **task-related predicament** in which there is a greater opportunity for error when performing a specific action or task due to error precursors.  An error-likely situation typically exists when **task-related** factors exceed the capability of the individual (mismatch) at the point of “touching” the physical or paper plant.

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## Identified Error Likely Situations

- Noisy
- Personal protective equipment requirements for the action only

- Job usually done by the CAS technicians however engineer performed the manipulation this time
- Engineer qualified to perform operations on this equipment by title and by virtue of being the Engineer as opposed to being qualified as CAS technicians are

- The Engineer was helping the technicians restore the system
- The Engineer did not recognize when he shifted from troubleshooting to manipulating components that may require personal protective equipment
- Task considered routine for both the technicians and the engineer

- The procedure specifically  described the required actions however personal protective equipment requirements are not in the procedure
- Individuals are responsible for verifying and obtaining the appropriate personal protective equipment with few pointers as to where this information exists

**Individual****Capabilities**

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## Definition

**Latent Organizational Weakness**
- Undetected deficiencies in the management control **processes** (e.g., strategy, policies, work control, training and resource allocation) or **values** (shared beliefs, attitudes, norms and assumptions) creating workplace conditions that can provoke errors (precursors) and degrade the integrity of defenses (flawed defenses).

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## Identified Potential Organizational Weakness

- PPE
- Requirements

- JRA Results

- Procedure

- Procedure
- References

- Work Planning

- Skill-of-the-Worker

***The worker has to “go get” these things to effectively do the job instead of the organization providing them at the worker’s fingertips***
***The organizational weakness is not providing what the worker needs when they need it and relying on the worker’s memory for many of the requirements***

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## Anatomy of an Event

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## Deviation Potential - Simplified

***Difficulty***

***Risk******	******+     Observation***

**Deviation Potential - Simplified**

- Conscious

- Unconscious

- Just don’t comply
- accountability
- personal compliance issue

- Wrong rule
- Misapply rule
- Trying to comply and
- 	taking a shortcut

**Rule Based Errors -**
- 	3 General Categories
- Wrong Rule
- 	*Rule* problem
- Misapplication
- 	*Information* problem
- Don’t comply
- 	*Personal* compliance issue

- Physical

- Mental

- Peer

- Supervisor

- Corporate

- Personal

- Difficult tasks
- Unnecessary tasks
- Unreasonable tasks
- Easy to shortcut
- Contact with
- 	other organization
- Has to stop and do
- 	something else

- Taught once -
-     must remember now
- Stated earlier -
-     must remember now

- Injury
- Personal financial
- 	loss if caught
- Equipment damage

- Corporate financial
- 	loss if caught
- Equipment damage
- Root Cause & Corrective actions

- Verbal reminders
- Non-punitive
- No supervisory
- 	involvement

- (or underling)
- Non-punitive
- No management
- 	involvement

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## Identified Deviation Potential

***Deviation Potential = ***

***Difficulty***

***Risk******	******+     Observation***

**Identified Deviation Potential**

- Conscious
- Violation

- Unconscious
- Deviation

- Just don’t comply
- accountability
- personal compliance issue

- Use tribal knowledge
- Use Wrong rule or Misapply rule
- Trying to comply and taking a shortcut
- Slip or Lapse

- Physical

- Mental

- Peer

- Supervisor

- Corporate

- Personal

- PPE Requirement location
- Unnecessary for most of task

- Told a year earlier
- Task originally was not to manipulate switch

- Low perception of risk for task

- Peers working side-by-side
- Did not know he was manipulating switch

- No supervisor present
- nor required

****

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## Changing Circumstances & Perceived Boundaries

- Task Elements
- As Planned

- Task Elements
- As Perceived
- By Worker

- True Task
- Elements

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## Start of Task

- As Perceived
- By Worker

**Start of Task**

- Task Elements
- As Planned

- Task
- Elements Match
- Perception

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## Something Changes

- Individual
- Task
- Perception

- True
- Task
- Elements

- Individual finds themselves outside of the Plan, Process, Procedure, or anticipated situation without recognizing it.

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## Team Observations

- The team observations fall into several general categories:
- “Just-in-time” PPE requirements
- Too many external references left to the workers to decipher
- Fuzzy lines of demarcation as to roles and responsibilities regarding work among multiple groups
- Workers knowing a rule cannot be followed, but management doesn’t know this
- Unclear lines between troubleshooting and work

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## Team Observations

- The individual injured was hurt because of the switch failure and resultant arc-flash, NOT because of a human error.
- The only human error identified was the failure of the Engineer to be wearing the prescribed PPE at the time of switch operation, and this error had little or no impact on his injuries.
- There were no visual ‘triggers’ for the individual to follow to remind him during this routine task that he may need to stop and put on PPE.
- Had this individual not operated the switch, and someone in the prescribed PPE operated the switch, they would have been injured in similar or possibly worse ways.
- The other individuals in the room could not have reasonably prevented the error from occurring because:
- There were no PPE requirements for the task, and none in the procedure.
- The first time in several hours that PPE would be required is at the instant the switch was operated.
- The switch was operated while the other personnel were engaged in a different task and did not know switch manipulation was occurring.

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## Team Observations

- The BNL SLAC Arc-Flash event lessons learned implementation does not accurately describe:
- Standing / operation location – based on the damage to the switch box, an individual standing the way the lessons learned training described may have been injured far worse than the injured individual.
- For many of the higher rated switches, the individual cannot physically stand as recommended and still effectively operate the breaker.
- People who routinely perform this task have known this for over a year – very few management personnel the team talked to knew this.
- Work on energized internal circuitry is not routine, and the majority of slides were devoted to this situation.
- Two of the recommendations from the SLAC training could not or routinely would not be done by the field personnel – it is not a great leap to see how the third element could be missed.
- The proposed labels to be placed on switches to describe dangers and PPE requirements after flash calculations have been performed do not match NFPA70E PPE categories or current BNL PPE requirement descriptions.
- Application of the Arc-Flash calculations and use of NFPA70E does not appear to be consistent.

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## Team Observations

- There was little recognition of the shift between performing troubleshooting and performing ‘work’ (placing a system in service, operating a system, etc.).
- Troubleshooting does not appear to be well documented
- Engineering performed operations vice remaining in an oversight or troubleshooting role
- Operations were performed using hand signals in a noisy area as the primary communication method – this is apparently done routinely.
- Understanding of the level to which PPE protects people is not consistently understood across the facility.
- PPE is described as the elements to be worn or used, as opposed to how things are worn or used.

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## Team Observations

- BNL Engineers are not required to have or wear PPE when responding to the field, but expected to put on the right gear at the instant it is needed.
- Technicians were provided PPE but Engineers were only provided PPE upon their request.
- Managers, supervisors and workers have not effectively internalized human performance fundamentals and the capability of recognizing the impact of individuals, processes, organizations and the environment on field performance.

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## Things for BNL to Consider

- Consolidating requirements as close to the worker as possible – don’t make people go get them, or expect them to know them off the top of their head
- Recognizing the differences between research, troubleshooting, and ‘work’ and how to manage these differences safely
- Recognizing the differences between control of systems by Engineers and operation / removal / restoration of systems by technicians and how to manage these differences safely
- Consistently apply PPE rules by area or location versus by action or activity
- Providing appropriate PPE at the locations needed
- Educating personnel on recognition of error traps, error likely situations and latent organizational weaknesses and the impact they have on performance
- Improving individual’s capability to recognize when a task begins to deviate from the expected path – and the actions needed at that time
- Placing more emphasis on preparation to implement BNL lessons learned from significant events prior to rolling out the implementation strategy

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