Prevention Tools
Techniques and behaviors that are designed to reduce the likelihood of error by the individual or group.
What are Human Performance Tools?
Errors resulting in undetected organizational-related or equipment flaws that lie dormant until challenged.
What is a Latent Error?
• People are fallible, and even the best make mistakes.
• Error-likely situations are predictable, manageable, and preventable.
• Individual behavior is influenced by organizational processes and values.
• People achieve high levels of performance based largely on the encouragement and reinforcement received from leaders, peers, and subordinates.
• An understanding of the reasons mistakes occur, and application of the lessons learned from past events, can avoid future events.
What are Human Performance Principles?
A systematic process for identifying the major contributing factors of problems or events and an approach for responding to them.
What is Root Cause Analysis?
Alpha, Bravo, Charlie, Delta, etc.
What is Phonetic Alphabet?
Understanding the procedure purpose, scope, and intent and following its direction
What is Procedure Use and Adherence?
The number of Forced outages in a period with duration <= 4 hours and MW curtailment >= 100 MW or 25% of Rated Power.
What is a nuisance error?
Observable (action) and non-observable (thought) activity by an individual; “what people do.”
What are behaviors?
Unfavorable prior conditions that reduce the opportunity for successful behavior and performance of task.
What are Error Precursors?
Used in conversations, whether face-to-face or using radios/telephones when directing an action or communicating critical information associated with a work activity.
What is Three-Part Communication?
Physically marking steps in a procedure, work instruction or other document controlling an activity, to prevent the omission or duplication of the steps; to maintain an accounting of steps in progress, steps completed, steps not applicable, and steps not yet performed.
What is Placekeeping?
Errors that change equipment, system, or plant state triggering immediate undesired consequences.
What is an Active Error?
A procedure step, series of steps, or action that, if performed improperly, will cause irreversible harm to plant equipment or people or significantly impact plant operation.
What is a critical step?
The preferred type of root cause analysis used to evaluate an event where human error is suspected.
What is Problem Identification Correction (PIC) analysis?
Used whenever the responsibility for continuing or completing a task or job function is being transferred from one individual or team to another.
What is Turnover meeting?
A collaborative technique that involves asking others to validate the intended behavior and then observe/check the behavior of the worker performing a critical step or series of steps to verify correct performance. This technique takes advantage of a fresh set of eyes not trapped by the performer’s mindset.
What is Peer Checking?
An error in planning or judgment. Knowledge based performance is based on the individual's knowledge of how the system works and of its current state, and on decisions made in light of this knowledge. Knowledge based mistakes may arise because knowledge is inaccurate or incomplete.
What are Knowledge Based Errors?
Time pressure; peer pressure; distractive environment; multi-taking; high workload; overconfidence; fatigues are examples of what?
What are Error Precursors?
This should be used during decisions regarding activities that could result in significant consequences; decisions regarding infrequently performed activities; inconsistencies are noted during work activities-unexpected conditions, incorrect or confusing information, unexpected equipment performance or work practices.
What is Questioning Attitude?
Used following major evolutions and critical activities to capture information that will enhance future performances and identify opportunities to strengthen defenses against error and events.
What is Post-Job Critique?
This is conducted before the start of all field, shop work, or equipment isolations and tagging activities (except for daily or more frequent activities).
What is Pre-job Brief?
Any occurrence that could have resulted in undesirable consequences but did not; ranging from minor breaches in defenses to incidents in which all the available safeguards were defeated, but no actual losses were sustained.
What is a "near miss"?
An undesirable change in state of structures, systems, or components or human/organizational conditions (health, behavior, controls, and so forth) triggered by human error that exceed established significance criteria and have consequence.
What is an event
These help prevent unwanted actions (trips, slips, etc.)
What are barriers?
Used when work is being performed by cross-functional teams or individuals from multiple departments.
What is Job Site Huddle?