# Presentation: 484778

- Human Performance Improvement Implementation and the Benefits to Emergency Response

- Cathie Carter
- May 7, 2008

## Introduction

- What is Human Performance Improvement (HPI)?
- HPI is a valuable tool that helps us focus on the critical steps in reducing or eliminating error likely situations.
- HPI helps us understand the interplay between human behavior and an event, acknowledge that our systems sometimes create opportunities for errors, and realize that to reduce human error we must first understand the context of the situation.
- Hanford adopted the use of HPI to help prevent events and understand why events occur.
- Organizations were challenged to identify how HPI would improve their operations.

## Here’s What We Saw

- Numerous errors during drill conduct:
- Player actions poorly performed, i.e., firefighter bunker gear doffing
***Error Precursor – Unfavorable condition that creates mismatch between a task and the individual***
- Error Precursors:
*Task Demands – Lack of or Unclear Standards; Unclear Goals, Roles or Responsibilities*
*Site training only addresses standard PPE*
*Individual Capabilities - Unfamiliarity with Task, Lack of Proficiency/Inexperience*
*Lack of drill practice on bunker gear removal*

## Here’s What We Saw

- Numerous errors during drill conduct (cont):
- ORR drill problems (radon/drill control)
- Error Precursors:
*Individual Capabilities – Unawareness of critical parameters*
*Drill scope changed at last minute by ORR team*
*Task Demands – Confusing Procedure/Vague Guidance, Time Pressure*
*No standard approach for dealing with radon*
*Inadequate time allowed for pre-drill briefing of new drill scope*
*Work Environment – Recent Shift Change*
*Drill held on a Monday after long weekend*
*Human Nature – Complacency/Overconfidence, Assumptions, Overload Bias*
*Highly experienced controllers/some inexperienced controllers*
*Drill run several times before last-minute changes*
*Controllers assumed comprehensive pre-drill not required*
*Controllers overwhelmed by changes in scope*

**Notes:**
Poor handling of radon issues/several unanticipated actions not adequately controlled.

Drill controllers tried to resolve radon issue without putting drill on administrative hold.  An administrative hold was finally implemented but it took over an hour to resolve the radon issue.  By the time the drill restarted people were out of the drill mode mindset and it was hard for them to jump back into drill play.

Player performance graded satisfactory but inability to adequately control drill wound up as major issue.

## Here’s What We Saw

- Inconsistencies in evaluation of personnel proficiency
- Responders perform some actions well/others not so well
- Acceptable performance for proficiency varies
***Latent Organizational Weakness – Undetected deficiency in organizational process that provokes error***
*Work Practices*
*Existing grading criteria did not provide method for controllers to weigh/measure performance on critical tasks*
*Training*
*Proficiency grading more subjective, based on level of experience of controller*

**Notes:**
Although we have drill templates for consistent drill grading, determination of proficiency is more subjective.

There are lots of actions a responder takes during a drill, but some are more important than others with greater consequence if not performed.

The challenge is trying to figure out how to weight different tasks.  For example, if the event discoverer forgets to call 911 for a fire but performs all other tasks well, are they proficient?

## Here’s What We Saw

- All drill issues submitted into Corrective Action Management process
- Most drills are for training – errors likely as part of learning process
- Pressure for each “issue” to have a corrective action
- Identified corrective actions not always effective
*Work Practices*
*Urge to “create” corrective actions, typically involving training or procedure changes – even for simple errors*

## Here’s What We Did

- HPI orientation provided to all Emergency Preparedness staff
- Advanced HPI training being provided

## Here’s What We Did

- HPI methodology added to drill template to improve drill control and identify error precursors that could negatively impact response
- Administrative hold guidance
- Guidance on handling of radon
- Pre-drill brief modified to include identification of critical steps, areas for potential errors, potential consequences, and barriers to prevent errors

## Here’s What We Did

- Firefighter bunker gear doffing training developed

## Here’s What We Did

- Proficiency criteria developed for each emergency response position
- Critical steps identified
- Emergency responders must successfully complete to be considered proficient

## Here’s What We Did

- Clarified which drill corrective actions are submitted into Corrective Action Management
- Audit team evaluated drills
- Conditions that cannot be immediately corrected
- Groupings of Critical/Simple Errors in a specific area or group (i.e., communications, radiological control errors)
***Condition – something real exists that must be fixed***
***Critical Error – inadequate response that causes failure of drill or critical objective***
***Simple Error – errors that degrade response but do not result in failure***

## Here’s What We Are Doing

- Increasing the use of defense-in-depth to ensure critical tasks are completed and responders are protected
- Standardized response protocol, including prescribed personal protective equipment, being added to facility emergency response procedures based on conservative planning
- Use of double verification for critical tasks being emphasized
***Defense-in-Depth -  a series of barriers which must be violated before harm can occur***

## Conclusion

- Applying HPI principles to elements of the Emergency Management program has improved overall response
- Lower error rate on completion of critical tasks
- Faster response by standardizing response methodology
- More credible corrective actions
- More consistent proficiency evaluations
- Improved, more realistic training for responders
- By recognizing the effect human factors can have on our ability to respond, we are better able to anticipate areas for potential errors and implement steps to minimize the consequences of those errors.