ADVANCE \y115**NRC INSPECTION****MANUAL**

ADVANCE \y122

ADVANCE \y149Inspection Procedure 71841

HUMAN PERFORMANCE

PROGRAM APPLICABILITY:2515, Appendix B

71841-01INSPECTION OBJECTIVE

01.01To assess the adequacy of the licensee(s root cause evaluation and corrective actions with respect to human performance.

01.02To independently assess the extent of condition associated with the identified human performance root causes.

71841-02INSPECTION 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.

Topic Areas and Causal Factors:

(See tables starting on page 6 for more detail)

02.01Human-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

02.02Environment

· 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

02.03Communication

· 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

02.04Coordination 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

02.05Work 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)

02.06Procedure 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

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

02.08Fitness For Duty

· 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

71841-03INSPECTION 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 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**

Control Function/Control Device

Alarm/annunciation

Environment

Communication

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

Coordination of Work/Supervision

Work Practices

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

TRAINING AND QUALIFICATIONS (USE IP41500 AND NUREG-1220)

FITNESS FOR DUTY:

71841-04RESOURCE 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 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.

71841-05REFERENCES

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

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

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