Issue Date: 12/12/00 - 1 - 71841

ˇ ̨ ̋ ̧ ̊ˇ ̇ ̆ ̄ ̋ ̃ ̊ˆˇ ˇ

ˇ ̨ ̋ ̧ ̊ ̇ ̆ ̄ ̃ ̨ˆıÙ ̃ ̇ ̊ÛÚÙ ̊ˆÒðÔÓð

HUMAN PERFORMANCE

PROGRAM APPLICABILITY: 2515, Appendix B

71841-01 INSPECTION OBJECTIVE

01.01 To assess the adequacy of the licensee’s root cause evaluation and corrective actions with

respect to human performance.

01.02 To independently assess the extent of condition associated with the identified human

performance root causes.

71841-02 INSPECTION REQUIREMENTS

This inspection will substantiate that the licensee has adequately identified in their evaluation, the

root cause(s)or contributing causes(s) and taken appropriate corrective actions for each human

performance related issue.

This inspection will also independently assess extent of condition(s) with respect to human

performance such that each human performance identified problem has been evaluated for

potential impacts on other plant equipment, programs or processes.

In completing this inspection procedure it is not expected that NRC inspectors perform a full

evaluation of each causal factor listed below. However, the inspectors should assure themselves

that they have independently reviewed the underlined topic areas to determine their applicability

to the human performance issue(s) of concern. The inspector should check each topic area for

possible applicability and if the area is applicable should then review each causal factor within that

section of the table. Questions to address each causal factor are provided in the specific guidance

area of this procedure.
71841 - 2 - Issue Date: 12/12/00

Topic Areas and Causal Factors:

(See tables starting on page 6 for more detail)

02.01 Human-System Interface

a. Visual Information/display

• missing

• incorrect

• mistrusted

• visibility less than adequate (LTA)

• content LTA

• organization/format LTA

• too much information

• insufficient information

• identifiers (labels and tagouts, warnings and postings) LTA

• confusing

• accessibility LTA

• navigation LTA (method of movement through displays)

• conflicting

• unstable

b. Control function/control device

• missing

• accessibility/location for hard-wired controls LTA

• accessibility of soft (software mediated) controls LTA

• movement/motion LTA

• function LTA

• too many concurrent actions

• response/feedback LTA

• identification (labels and tagouts) LTA

c. Alarm/annunciation

• missing

• too many/not prioritized

• auditory warning LTA

• organization/format LTA

• content LTA

• visibility/conspicuity LTA

• continuously illuminated

• continuously repeated

• disabled

• alarm procedure availability/accessibility LTA

• computer printout and control room log differ

• navigation LTA

• alarm response LTA

02.02 Environment

• too hot

• too cold

• too humid

• too dark

• too bright

• too noisy

• cramped/inaccessible workplace

• dangerous work place

• distractions prevalent

• high radiation/toxicity

• vibration impedes work

02.03 Communication
Issue Date: 12/12/00 - 3 - 71841

• missing/lack of information

• content LTA

• untimely information

• misunderstood/misinterpreted

• inconsistent information

• repeat-back LTA

• verification LTA

• mode/communication devices LTA

• logbook maintenance LTA

• work package LTA

• document management LTA

• standard terminology LTA

• information about system/equipment LTA

• information not sought

• information not used

02.04 Coordination of Work/Supervision

• supervisory availability LTA

• task description/explanation LTA

• coordination of team activities LTA

• assignments of roles and responsibilities LTA

• task progress monitoring LTA

• chain of command LTA

• oversight LTA

• staff working hours program LTA

• pre-job briefing LTA

• shift turnover LTA

• planning and scheduling work LTA

• resource allocation LTA

02.05 Work Practices

• formalization of work practices LTA

• self-checking LTA

• independent verification LTA

• walkdowns LTA

• inattention to detail

• lack of questioning attitude

• lack of awareness of equipment status

• lack of awareness of plant condition (situation awareness LTA)

• lack safe work practices

• improper tools/materials used

• teamwork LTA

• housekeeping LTA

• too many task interruptions

• too many concurrent tasks

• excessive workload

• time pressure to complete tasks

• cognitive overload

• cognitive underload (boredom)

02.06 Procedure use/adherence (for procedure quality use IP 42001 or IP 42700)

• no procedure/unavailable

• procedure/references not used

• procedure prerequisites not met

• procedure steps circumvented

• procedure modification process LTA

• incorrect procedure used

• procedure believed to be incorrect

02.07 Training and qualifications (use IP41500 and NUREG-1220)

02.08 Fitness For Duty
71841 - 4 - Issue Date: 12/12/00

• substance abuse (chemical and alcohol)

• illness

• fatigue

• excessive overtime

• working too long without resting/working continuously without breaks

• too many distractions

• night work

• called into work outside regular schedule

71841-03 INSPECTION GUIDANCE

General Guidance

This inspection procedure is designed to be used to assess the adequacy of the licensee’s

evaluation of human performance issues. As such, a reasonable time (generally within 30-60

days) should be allowed for the licensee to complete their evaluation; however, all corrective

actions may not be fully completed upon commencement of this procedure.

At least one inspector assigned to this inspection should have had recent or refresher training

(within 5 years) in a recognized root cause technique (e.g. HPIP, MORT). In addition, the inspector

should be familiar with the discipline or system associated with issue.

The tables contained in the Specific Guidance section are provided as guidance to help the

inspector fulfill the inspection requirements contained in paragraph 02. It is not intended that the

inspector perform a full evaluation of each causal factor, however to the extent that the human

performance issue contains features related to the causal factor that entire section should be

consulted. The intent is that the inspector use the guidance contained in the tables to verify that

the licensee’s evaluation identified the appropriate deficiencies associated with the performance

issue and that the licensee has initiated a reasonable corrective action. Should the inspector not

be able to make an assessment from the answers to the questions, he/she should consult with the

human factors specialists in headquarters.

Inspectors should be aware that more than one corrective action may be necessary to correct a

particular contributing or root cause. In addition, the inspectors may need to look at several

identified contributing or root causes for the human performance issue. Although unlikely, one

human performance root cause may cover an entire white, yellow or red input or more likely may

be one of several root causes identified within a white, yellow or red input.

Definitions

Root Cause(s) is defined as the basic reason(s) (i.e., hardware, process, human performance), for

a problem, which if corrected, will prevent recurrence of that problem.

Contributing Cause(s) is defined as causes that by themselves would not create the problem, but

are important enough to be recognized as needing corrective action. Contributing causes are

those actions, conditions, or events which directly or indirectly influence the outcome of a situation

or problem.

Extent of Condition is defined as the extent to which an identified problem has the potential to

impact other plant equipment, programs or processes in the same manner identified in the root

cause analysis.

Human-system Interface (HSI) is defined as the technology through which personnel interact with

systems, e.g. alarms, displays, controls, procedures, valve handles, test points.

Specific Guidance

The information contained in this section provides the inspector with specific guidance on how to

determine if the licensee’s root cause evaluation and corrective actions were adequately performed

and implemented. The inspector will, using the information provided to him by the licensee (e.g.,

licensee’s root cause analysis and corrective action plan/results), selectively apply the guidance

in the attribute table(s) that relates to the problem evaluated by the licensee to determine whether

the licensee’s evaluation and corrective action processes have adequately considered the attributes

contained in the relevant tables. For example, if it is determined that a human-system interface
Issue Date: 12/12/00 - 5 - 71841

deficiency(ies) such as incorrect information being displayed by an instrument was identified as a

cause by the licensee in its evaluation, the inspector would use the Visual Information table to

evaluate the thoroughness of the licensee’s evaluation of this cause. It is intended that the

inspector will incorporate an explanation in the inspection report to document the licensee’s

responses to items in columns (1) through (3) for each of the applicable attributes that the inspector

evaluates.

With respect to “extent of condition”, the inspector is expected to determine if the licensee

adequately determined if the identified root cause(s) could have impacted other plant equipment,

programs or processes. If the licensee did not adequately investigate extent of condition of the

human performance problem then it is expected that the inspector will independently follow-up.

The inspector should use column 3 as a guide to ask the appropriate questions to ascertain if other

potential areas or conditions also need corrective actions.

Human-System Interface

Visual Information/Display

(1)

Causal Factors:

(Root Cause or

contributing

cause)

(2)

For each of the items

provide the evidence used

to identify the root cause

(3)

For the immediate

condition as well as for

any other related

applicable conditions

has the licensee:

(4)

References

missing What is the specific missing

information?

provided the missing

information

satisfactorily?

incorrect What is incorrect about the

information?

corrected the information

satisfactorily?

NUREG-0700,

Rev. 1,

Paragraph

(0700) - 1.4

mistrusted Why is the information

mistrusted?

eliminated the reason for

mistrust satisfactorily?

0700 - 1.4

visibility LTA

(LTA = less than

adequate)

Why is the information difficult

to see? Is it in a poor

location? Too small? Poor

contrast to background (color,

brightness, glare)?

relocated the

information? Enlarged

the font? Improved the

contrast improved?

0700 - 1.1, 1.2,

1.3, 1.5

content LTA What specifically is

inadequate about the

information content?

improved the content

satisfactorily?

0700 - 1.1, 1.4

organization/

format LTA

Is the organization/format

confusing? What specifically

is confusing?

improved the

organization/format

satisfactorily to eliminate

the confusion?

0700 - 1.1, 1.2,

1.3

too much

information

Is there unneeded information

such that the needed

information is difficult to find?

removed the unneeded

information or provided a

method of prioritizing the

needed information?

0700 - 1.1
71841 - 6 - Issue Date: 12/12/00

insufficient

information

Is there not enough

information to meet the need?

added information to

meet the need?

0700 - 1.1-10

identifiers (labels

and tagouts,

warnings and

postings) LTA

Is the equipment not labeled

or labeled poorly such that it is

not easily identified? Are the

identifiers missing, inaccurate,

confusing or difficult to detect?

Do tagouts obscure other

information?

labeled or improved the

information labeling

satisfactorily? Provided

evidence that warnings

and postings are

inadequate? Improved

the identifier program to

eliminate problems?

0700 - 1.1, 1.2,

1.3

confusing Is the information as

presented confusing? What is

the source of the confusion?

taken steps to eliminate

the confusion?

0700 - 1.1, 1.2,

1.3

accessibility LTA Why is the information difficult

to access?

improved the

accessibility of the

information?

0700 - 1.1, 2.5

navigation LTA

(method of

moving through

displays)

Is it difficult or cumbersome

accessing the desired

display?

taken steps to improve

display access?

0700 - 2.

conflicting Are there conflicts between

multiple sources of the same

information?

corrected the source of

the information conflict?

0700 - 1.4

unstable Is there a mismatch between

the parameter being

measured and the displayed

information for that

parameter?

identified the source of

the mis match

(e.g.,display, signal,

sensor)? Corrected the

source of the information

mismatch?

0700 - 1.4

Control Function/Control Device

(1)

Causal Factors:

(Root Cause or

contributing

cause)

(2)

For each of the items

provide the evidence used

to identify the root cause

(3)

For the immediate

condition as well as

for any other related

applicable conditions

has the licensee:

(4)

References

missing What specific control

function is missing?

provided the necessary

control function where

needed?

accessibility/

location for hardwired controls

LTA

Is the control too high? Too

low? Too far from

associated displays? Is it

blocked/covered by other

equipment?

moved the control to a

satisfactory location or

removed impeding

equipment?

0700 - 3.1, 3.3,

3.4

accessibility of

soft controls LTA

Is the control accessible?

Why is the control

inaccessible?

improved the

accessibility of the

control?

0700 - 2.1, 3.1,

3.2, 3.4
Issue Date: 12/12/00 - 7 - 71841

movement/

motion LTA

Is the direction of motion

correct/intuitive? Is it difficult

to operate (tension too great,

range of movement too

great, too small?). Is the

control size/shape

uncomfortable?

corrected the control

movement/motion/feel?

0700 - 3.1, 3.2,

3.3

function LTA Is the function of the control

appropriate? Does it do

what is required of the

task/action?

corrected the control to

provide the required

function?

0700 - 2.1, 2.2,

2.3, 2.5, 2.6,

2.7

too many

concurrent

actions

Does the operator have to

perform too many control

actions concurrently or within

too short of a time period?

corrected the

concurrent action

problem satisfactorily?

0700 - 2.1

response/

feedback LTA

Is the response/feedback

satisfactory? Can the

operator understand what

the control action has

accomplished? Is

response/feedback timely?

provided a satisfactory

and timely

response/feedback?

0700 - 2.4, 3.4

identification

(labels and

tagouts) LTA

Is the control function not

labeled or labeled poorly

such that it is not easily

identified?

labeled or improved the

control function labeling

satisfactorily?

0700 - 2.1, 3.1,

3.2, 3.3, 3.4

Alarm/annunciation

(1)

Causal Factors:

(Root Cause or

contributing

cause)

(2)

For each of the items

provide the evidence used

to identify the root cause

(3)

For the immediate

condition as well as

for any other related

applicable conditions

has the licensee:

(4)

References
71841 - 8 - Issue Date: 12/12/00

missing What specific alarm is

missing? What function

needs to be alarmed that

currently is not?

provided the needed

alarm satisfactorily?

0700 - 4.2

too many/not

prioritized

Do too many alarms activate

simultaneously such that the

operator does not know how

to respond? Are the alarms

not prioritized?

reduced the number of

alarms such that the

operator can respond

properly? Has the

licensee implemented

an effective alarm

prioritization system?

0700 - 4.2, 4.3,

4.4, 4.5

auditory warning

LTA

Auditory warning too loud?

Too soft? Wrong pitch? Not

sufficiently discriminable

from other alarms or

background?

corrected the auditory

deficiencies?

0700 - 4.5.6.3

organization/

format LTA

Are the alarms located and

grouped in a way that makes

it difficult to quickly locate

alarms that are related to

each other and to the

systems that trigger them?

corrected deficiencies

in location and

organization of alarms?

0700 - 4.1, 4.5

content LTA Is the information presented

by the alarm insufficient to

quickly and clearly

understand the condition

which it is intended to

convey?

corrected the alarm

presentation to convey

the intended

information?

0700 - 4.1, 4.2,

4.5

visibility/

conspicuity LTA

Why is the alarm difficult to

see or discern? Is it in a

poor location? Is it obscured

by other equipment? Is it too

small? Does it visually

standout from its

background? Is the

information presented on the

alarm difficult to read do to

size, color, contrast, font,

number of characters, etc.?

relocated or redesigned

the alarm or removed

obscuring equipment?

0700 - 4.5,

4.10

continuously

illuminated

Is an alarm condition

continuously illuminated, if

the continuous illumination is

not necessary for operator

information or action?

corrected all

inappropriately

illuminated alarms?

0700 - 4.2

continuously

repeated

Does an alarm

inappropriately continue to

activate even after it has

been acknowledged?

corrected alarms that

inappropriately repeat

after acknowledgment?

0700 - 4.2

disabled Has an alarm been

inappropriately been

disabled? Has the licensee

determined why?

corrected this problem?

alarm procedure

availability/

accessibility LTA

Are the alarm procedures

readily available and

accessible?

adequately improved

procedure availability

and/or accessibility?

0700 - 4.5, 4.9
Issue Date: 12/12/00 - 9 - 71841

computer

printout and

control room log

differ

Are the alarm list and control

room log consistent?

determined the source

of the difference and

resolved the problem?

navigation LTA Are computer-based alarms

accessible without excessive

need to search thru

numerous computer

screens?

adequately improved

the navigation for alarm

systems?

0700 - 4.6.1

alarm response

LTA

What was inadequate about

the alarm response controls,

methodology or procedure?

adequately improved

the response?

0700 - 4.5.3,

4.6, 4.9

Environment

(1)

Causal Factors:

(Root Cause or

contributing

cause)

(2)

For each of the items provide

the evidence used to identify

the root cause

(3)

For the immediate

condition as well as

for any other related

applicable conditions

has the licensee:

(4)

References

too hot What is the evidence that the

working environment was too

hot for sustained safe task

performance? What is the

evidence that support tools and

equipment (coolers), protective

gear (Cold Suit), or appropriate

work practices and procedures

(exposure limits) were

unavailable or not used.

taken steps to reduce

the temperature?

0700 - 7.3.1,

7.3.2, 8.5.1

NUREG/CR5680, Para.

(5680) - 4.2,

4.3, 4.5

too cold What is the evidence that the

working environment was too

cold for sustained safe task

performance? What is the

evidence that support tools and

equipment (heaters), protective

gear (insulated clothing), or

appropriate work practices and

procedures (exposure limits)

were unavailable or not used.

taken steps to increase

the temperature?

0700 - 7.3.1,

7.3.2, 8.5.1

5680 - 5.2, 5.3,

5.5

too humid What is the evidence that the

working environment was too

humid for sustained safe task

performance? What is the

evidence that support tools and

equipment (fan), or appropriate

work practices and procedures

(exposure limits) were

unavailable or not used.

taken steps to reduce

the humidity?

0700 - 7.3.1,

7.3.2, 8.5.1

5680 - 4.2, 4.3,

4.5
71841 - 10 - Issue Date: 12/12/00

too dark What is the evidence that the

working environment was too

dark for safe task performance?

What is the evidence that

support tools and equipment

(temporary lighting) or

appropriate work practices and

procedures were unavailable or

not used.

taken steps to improve

the lighting?

0700 - 7.3.3,

7.3.4, 8.5.3

5680 - 6.2, 6.3,

6.5

too bright What is the evidence that

lighting in the working

environment impeded safe task

performance or personnel

safety? What is the evidence

that brightness, aim, location,

glare or beam angle adversely

effected visual performance?

taken step to reduce

the brightness, glare,

etc.?

0700 - 7.3.3,

7.3.4, 8.5.3

5680 - 6.2, 6.3,

6.5

too noisy What is the evidence that the

working environment was too

noisy for sustained safe task

performance or masks

necessary auditory signals and

communications? What is the

evidence that protective gear

(hearing protectors) or

appropriate work practices and

procedures (exposure limits)

were unavailable or not used?

taken steps to reduce

the noise?

0700 - 7.3.5,

8.5.2

5680 - 3.2, 3.3,

3.5

cramped/

inaccessible

workplace

What is the evidence that

cramped/inaccessible

workplaces detracts from

sustained safe task

performance? What is the

evidence that support

equipment (creeper, ladder),

training, labels, or appropriate

work practices and procedures

were unavailable or not used?

taken steps to enlarge

the working area

and/or improve

access?

0700 - 7.4, 8.2,

8.5.2

dangerous work

place

What is the evidence that the

work environment contributes to

slips, falls or other physical

injuries? What is the evidence

that poor housekeeping

contributed to the situation?

What is the evidence that

warnings and cautions are not

present?

taken steps to correct

the dangerous working

conditions?

distractions

prevalent

What is the evidence that

distractions impede safe task

performance? What are the

distractions?

taken steps to

eliminate the

distractions?
Issue Date: 12/12/00 - 11 - 71841

high radiation/

toxicity

What is the evidence that

excessive radiation or toxicity in

the working environment

adversely effected sustained

safe task performance or

personnel safety? What is the

evidence that support

equipment (alarming

dosimeter), protective gear (rad

protection suit), or appropriate

work practices and procedures

(exposure limits) were

unavailable or not used.

taken steps to correct

the situation?

vibration impedes

work

What is the evidence that there

was excessive vibration in the

working environment which

impeded sustained safe task

performance? What is the

evidence that equipment was

insufficiently balanced, damped

or isolated, protective gear, or

appropriate work practices and

procedures (exposure limits)

were unavailable or not used.

taken steps to reduce

the vibrations?

5680 - 2.2, 2.3,

2.5
71841 - 12 - Issue Date: 12/12/00

Communication

The factors below apply to (1) both written and/or verbal communications, (2) both intra- and interdepartmental communications and (3) all situations e.g. control room, work stations, pre-job

briefings, shift turnover, etc.

(1)

Causal Factors:

(Root Cause or

contributing

cause)

(2)

For each of the items

provide the evidence used

to identify the root cause

(3)

For the immediate

condition as well as

for any other related

applicable conditions

has the licensee

taken steps to ensure

that:

(4)

References

missing/lack of

information

Did the sender send and the

receiver receive the

necessary information?

the necessary

information is sent and

received?

NUREG-1545,

Para. (1545) -

2.3, 2.4, 2.5,

2.6

content LTA Was the information correct?

Was the message appropriate

for the work environment, the

job at hand, and the receivers

level of knowledge? Was the

terminology familiar to the

receiver?

the proper, accurate

and concise

information is

provided?

1545 - 2.3.1,

2.4.1, 2.5, 2.6

untimely

information

Was the message sent at the

correct time to be useful?

information is

transmitted in a timely

manner?

1545 - 2.4.1

misunderstood/

misinterpreted

Did the receiver interpret the

message consistent with the

sender’s meaning?

message content is

clear and

understandable?

inconsistent

information

Was the information

consistent with other

information about performing

the task?

transmitted messages

contain consistent

information?

repeat-back LTA Did the receiver confirm

receipt and understanding of

information by repeating what

was heard in appropriate

situations.

the proper repeat-back

procedure is

understood and

implemented?

1545 - 2.4.1

verification LTA Did the sender ensure that

the information was received

and understood? Did the

receiver confirm the correct

interpretation of the

message?

message verification

procedures are in

place and properly

implemented?

1545 - 2.4.1

mode/

communication

devices LTA

Was the message produced

so that it was easy to hear or

read?

all communication

devices are available

and in proper working

order?

0700 - 6.1, 6.2,

6.3

1545 - 2.4.1

logbook

maintenance

LTA

Are entries accurate and

timely? Do they reflect plant

activities and status?

logbooks are properly

maintained according

to plant procedure?
Issue Date: 12/12/00 - 13 - 71841

work package

LTA

Is the information complete?

Is it accurate?

work packages are

properly filled out, and

contain complete and

accurate information?

document

management

LTA

Were there omissions and/or

technical inaccuracies in

developing and managing

technical documentation

resulting in communication

errors?

the document

management system is

effective and is

implemented properly?

standard

terminology LTA

Was standard terminology

used?

standard terminology

is in place and is used

in all appropriate

communications?

information

about system/

equipment LTA

Were deficiencies or status

changes reported/recorded?

system/equipment

status is properly

understood, reported

and recorded?

information not

sought

Did the receiver seek out the

information needed to perform

the job?

necessary information

is requested as

appropriate?

information not

used

Did the receiver use the

necessary information?

necessary information

is used when

received?

Coordination of Work/Supervision

(1)

Causal Factors:

(Root Cause or

contributing

cause)

(2)

For each of the items

provide the evidence used

to identify the root cause

(3)

For the immediate

condition as well as for

any other related

applicable conditions

has the licensee taken

steps to ensure that:

(4)

References

supervisory

availability LTA

Were supervisors available to

the workers as necessary?

the proper supervisors

are available when

required?

NUREG/CR5455, Vol. 2,

Sec. (HPIP) -

16

task description/

explanation LTA

Did the supervisors ensure

that the workers understood

the assigned tasks? Did the

supervisors coordinate

between departments as

necessary?

workers fully understand

what they are to do and

how to accomplish it?

coordination of

team activities

LTA

what was the evidence that

there was insufficient

coordination of team activities

team coordination is

understood and being

implemented?

HPIP - 16

assignments of

roles and

responsibilities

LTA

Did the supervisors match

tasks to the appropriate

personnel?

assignments are

appropriate to the skills

and availability of

personnel?

HPIP - 16
71841 - 14 - Issue Date: 12/12/00

task progress

monitoring LTA

Were the work activities

tracked?

work activities and

progress are

appropriately monitored?

chain of

command LTA

Were reporting responsibilities

clear?

reporting responsibilities

are clear and are being

implemented properly?

oversight LTA Did the supervisor provide

appropriate oversight of all

work activities within their

organizational unit?

oversight is being

appropriately

implemented?

HPIP - 16

staff working

hours program

LTA

Was circadian cycle

considered during scheduling

work? Was overtime

considered during work

scheduling? **** See fitness

for duty for additional

questions.

the Commission’s policy

statement was taken into

consideration in the

overtime planning and

implementation?

Generic Letter

82-12,

Commission

Policy

Statement

10 CFR 26.20

pre-job briefing

LTA

Did the supervisor ensure

adequacy of pre-job

briefings? Was a pre-job

briefing held if necessary?

pre-job briefings contain

complete and accurate

information, including all

necessary cautions and

warnings, and are

conducted properly?

HPIP - 16

shift turnover

LTA

Did the supervisor ensure

adequacy of shift turnover?

shift turnover process

has been improved to

provide complete and

accurate status

information?

planning and

scheduling work

LTA

Was work planned adequately

e.g. site visits, job walkthru,

special requirements and

constraints identified? Were

personnel workload and

workflow well managed? Was

work prioritized? Were

possible conflicts identified?

the work planning and

scheduling process has

been improved to

mitigate the problems

identified?

HPIP - 16

resource

allocation LTA

Were sufficient workers

assigned, appropriate

materials available and

sufficient time allocated for the

job?

sufficient resources

have been made

available to accomplish

the planned activities?

Work Practices

(1)

Causal Factors:

(Root Cause or

contributing

cause)

(2)

For each of the items

provide the evidence used

to identify the root cause

(3)

For the immediate

condition as well as for

any other related

applicable conditions

has the licensee:

(4)

References

formalization of

work practices

LTA

Are work practices

formalized? How were work

practices formalized?

developed a formal work

practice?
Issue Date: 12/12/00 - 15 - 71841

self-checking

LTA

Was there evidence of selfchecking? Was there

adequate self-checking?

emphasized self

checking in training?

independent

verification LTA

Was there evidence of

independent verification?

Was there adequate

independent verification?

supplied adequate

staffing for independent

verification?

walkdowns LTA Did a walkdown occur during

turnover? Was the walkdown

conducted adequately?

improved the walkdown

process?

HPIP - 16

inattention to

detail

What evidence does the

licensee have that the root

cause was inattention to

detail? Why was inattention to

detail selected as the root

cause?

fixed the problem to

prevent recurrence?

lack of

questioning

attitude

What evidence was there of a

questioning attitude? Was

there evidence of a general

lack of questioning attitude?

put into effect programs

that are likely to improve

questioning attitude

among staff?

addressed any generic

findings?

Lack of

awareness of

equipment status

What evidence was there of a

lack of awareness of

equipment status?

taken the appropriate

steps to assure that staff

is aware of equipment

status?

Lack of

awareness of

plant condition

(situation

awareness LTA)

What evidence was there of a

lack of awareness of the plant

condition?

address any generic

findings?

lack safe work

practices

What is the evidence that

supports that staff is not using

safe work practices? Does

the evidence support the

finding?

address the finding with

an appropriate corrective

action? Does the

corrective action address

any generic findings?

improper tools/

materials used

Why was improper equipment

used? Availability? Did the

work control system indicate

the appropriate tools needed?

addressed this issue?

teamwork LTA What is the evidence of lack

of proper teamwork?

taken steps to improve

teamwork ? Are these

steps adequate?

HPIP - 16

housekeeping

LTA

What is the evidence of poor

housekeeping?

taken steps to improve

housekeeping? Are

these steps adequate?

too many task

interruptions

What is the evidence that task

interruptions had an impact on

job performance?

taken steps to eliminate

or reduce the

interruptions?
71841 - 16 - Issue Date: 12/12/00

too many

concurrent tasks

What is the evidence that

working too many concurrent

tasks was responsible for/or

contributed to human

performance error? Did the

licensee complete a check of

work request records as soon

as possible after the event?

Did the licensee interview

personnel involved with the

event concerning their

perception of their workload

as soon as possible after the

event?

redistributed work

responsibilities?

excessive

workload

What is the evidence that

excessive workload was

responsible for/or contributed

to human performance error?

Did the licensee complete a

check of work request records

as soon as possible after the

event? Did the licensee

interview personnel involved

with the event concerning their

workload as soon as possible

after the event?

taken action to reduce

excessive workload?

time pressure to

complete tasks

What is the evidence that

working under excessive time

pressure to complete tasks

was responsible for/or

contributed to human

performance error? Did the

licensee interview personnel

involved with the event

concerning their perception of

time pressure to complete

tasks as soon as possible

after the event?

reduced the effects of

time pressures?

cognitive

overload

What is the evidence that task

complexity was responsible

for/or contributed to human

performance error? Did the

licensee interview personnel

involved with the event

concerning their perception of

the complexity of the tasks

they were performing as being

a contributor to the event?

taken steps to relieve the

cognitive overload?

cognitive

underload

(boredom)

What is the evidence that

boredom was responsible

for/or contributed to human

performance error? Did the

licensee interview personnel

involved with the event

concerning their perception of

the complexity of the tasks

they were performing as being

a contributor to the event?

taken steps to relieve

bordom?
Issue Date: 12/12/00 - 17 - 71841

Procedure use/adherence (for procedure quality use IP42001 or IP42700)

(1)

Causal Factors:

(Root Cause or

contributing

cause)

(2)

For each of the items

provide the evidence

used to identify the root

cause

(3)

For the immediate

condition as well as for

any other related

applicable conditions has

the licensee taken steps

to:

(4)

References

no procedure/

unavailable

Why did the procedure not

exist or was unavailable?

ensure a procedure was

made available?

procedure/

references not

used

What is the evidence that

a procedure/reference

was not used?

ensure that

procedures/references will

be used in the future?

SECY-90-337

procedure

prerequisites not

met

Why were prerequisites

not met?

ensure all procedure

prerequisites will be met in

the future?

SECY-90-337

procedure steps

circumvented

Why were procedure

steps circumvented?

ensure that steps will not

be circumvented in the

future?

SECY-90-337

procedure

modification

process LTA

What is the evidence that

the procedure modification

process is LTA? What is

wrong with the process?

correct the deficiency? SECY-90-337

incorrect

procedure used

What is the evidence that

an incorrect procedure

was used? Why was an

incorrect procedure used?

ensure that incorrect

procedures will not be used

in the future?

procedure

believed to be

incorrect

What is the evidence to

believe that the procedure

was incorrect? Was it

incorrect?

restore confidence in the

correctness of procedures?
71841 - 18 - Issue Date: 12/12/00

TRAINING AND QUALIFICATIONS (USE IP41500 AND NUREG-1220)

FITNESS FOR DUTY:

(1)

Causal Factors:

(Root Cause or

contributing

cause)

(2)

For each of the items

provide the evidence used

to identify the root cause

(3)

For the immediate

condition as well as

for any other related

applicable conditions

has the licensee:

(4)

References

substance

abuse

(chemical and

alcohol)

What is the evidence that

substance abuse was

responsible for/or contributed

to human performance error?

Did the licensee complete

for-cause testing as soon as

possible in accordance with

10 CFR 26.24 (3) in cases of

suspected substance abuse?

assured that substance

abuse would not be

tolerated at the plant?

correctly and fully

implemented all

elements of their FFD

program and

procedures including

training and FFD

testing.

10 CFR 26.20,

26.24

illness What is the evidence that

Illness/injury was responsible

for/or contributed to human

performance error? Did the

licensee complete a medical

records check of personnel

directly involved as soon as

possible after the event?

adequately

implemented its

behavior observation

program and assured

that sick employees

would not be assigned

to safety significant

jobs?

10 CFR 26.20

fatigue What is the evidence that

fatigue was responsible

for/or contributed to human

performance error?

adequately

implemented its

behavior observation

program and assured

that fatigued individuals

are removed from duty?

10 CFR 26.20

Generic Letter

82-12

excessive

overtime

What is the evidence that

excessive overtime was

responsible for/or contributed

to human performance error?

Did the licensee complete a

check of the shift logs and

timekeeping records as soon

as possible after the event?

taken action to reduce

excessive overtime?

10 CFR 26.20

Generic Letter

82-12
Issue Date: 12/12/00 - 19 - 71841

working too long

without resting/

working

continuously

without breaks

What is the evidence that

personnel working excessive

time without rest breaks was

responsible for/or contributed

to human performance error?

Did the licensee complete a

check of the shift logs and

timekeeping records as soon

as possible after the event?

Did the licensee interview

personnel involved with the

event concerning their work

periods as soon as possible

after the event?

assured that fatigue

would not result from

working too long?

10 CFR 26.20

too many

distractions

What is the evidence that

being distracted was

responsible for/or contributed

to human performance error?

Did the licensee interview

personnel involved with the

event concerning their

perception of distractions as

being a contributor to the

event?

reduced distractions

from critical work

situations?

night work What is the evidence that

working under nighttime work

conditions was responsible

for/or contributed to human

performance error? Did the

licensee complete a check of

the shift logs and

timekeeping records as soon

as possible after the event?

Did the licensee interview

personnel involved with the

event concerning their work

periods as soon as possible

after the event?

reduced the effects of

night work?

called into work

outside regular

schedule

What is the evidence that

working irregular hours/hours

outside regularly scheduled

hours was responsible for/or

contributed to human

performance error? Did the

licensee complete a check of

the shift logs and

timekeeping records as soon

as possible after the event?

Did the licensee interview

personnel involved with the

event concerning their work

periods as soon as possible

after the event?

reduced the effects of

unscheduled work

hours?

adequately and

correctly implement its

FFD procedures for

call-ins?

71841-04 RESOURCE ESTIMATE

It is estimated that this procedure will take between 8 and 40 staff-hours to complete for each

human performance issue. The inspector or inspectors assigned should be familiar with the

discipline associated with the subject of the licensee’s evaluation and should have had training in

one of the appropriate root cause analysis methods. The resource determination should be at the
71841 - 20 - Issue Date: 12/12/00

discretion of regional management depending on the number of topic areas that have been

identified as related to the human performance issue. For planning purposes, a resource estimate

near the lower end of the scale should be used for licensees with corrective actions programs that

have been determined to be thorough during the annual inspection for the identification and

resolution of problems. For licensees with corrective action programs that have been previously

determined to be ineffective, a resource estimate near the higher end of the scale should be used.

71841-05 REFERENCES

10 CFR Part 26, Fitness for Duty Programs

SECY-90-337, Procedural Adherence Requirements

Generic Letter No. 82-12, Nuclear Power Plant Staff Working Hours

NUREG-0700, Rev. 1, Vol. 1 - Human-System Interface Design Review Guideline

NUREG-1220, Rev. 1, Training Review Criteria and Procedures

NUREG-1545, Evaluation Criteria for Communication-Related Corrective Action Plans

NUREG/CR-5680, The Impact of Environmental Conditions on Human Performance

NUREG/CR-5455, Vol. 2, Development of the NRC’s Human Performance Investigation Process

(HPIP), Investigator’s Manual

END