Copyright © 2007 by the Institute of Nuclear Power Operations, Not for sale nor for commercial use. All other rights reserved.

INPO’s Approach toHuman Performance in the U.S. Commercial Nuclear Industry

Tony MuscharaTony Muschara

Principal Program Manager Principal Program Manager –– HuHuInstitute of Nuclear Power OperationsInstitute of Nuclear Power Operations

2Copyright © 2007 by the Institute of Nuclear Power Operations, Not for sale nor for commercial use. All other rights reserved.

…to promote the highest levels of safety and reliability — to promote excellence — in the operation of nuclear electric generating plants.

INPO’s Mission

3Copyright © 2007 by the Institute of Nuclear Power Operations, Not for sale nor for commercial use. All other rights reserved.

… Nuclear Safety…1. Concentrated Power – reactivity management

λ Reactivity and power level controlsλ Rod control & drive reliabilityλ Instrumentation reliability

2. Decay Heat Load – inventory and coolingλ Reactor cavity and fuel poolλ Secondary plant equipment reliabilityλ Safety system reliability and controlsλ Plant materials integrity and design margins

3. Radioactive Material – barrier integrityλ Containment integrityλ Defect-free fuelλ Primary systems integrity

4Copyright © 2007 by the Institute of Nuclear Power Operations, Not for sale nor for commercial use. All other rights reserved.

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1994199519961997199819992000200120022003200420052006

An event that caused or had the potential to cause:• an appreciable reduction inplant safety or reliability

• excessive radiation exposure or thedischarge of radioactivity off site or

• serious harm to individuals

Significant Events – USA

5Copyright © 2007 by the Institute of Nuclear Power Operations, Not for sale nor for commercial use. All other rights reserved.

Error Rate Reduction

Time

Erro

r Rat

e Before

After

SystemicCauses

RandomCauses

6Copyright © 2007 by the Institute of Nuclear Power Operations, Not for sale nor for commercial use. All other rights reserved.

Hazard – Barrier – Asset

Barrier(s):Less than Adequate

or Missing

Hazard:Human – “touching”

Asset:Object to Protect

eventerror

7Copyright © 2007 by the Institute of Nuclear Power Operations, Not for sale nor for commercial use. All other rights reserved.

What is Managed?λ Assets: people, plant, and property

λ Hazard: human error

λ Exposure: “People touching equipment”

λ Risk: probability and consequences

λ Event: ▼ frequency and ▼ severity

λ Controls:λ error rate (frequency) → reduce active errorsλ defense-in-depth (severity) → reduce latent conditions

8Copyright © 2007 by the Institute of Nuclear Power Operations, Not for sale nor for commercial use. All other rights reserved.

Strategic Approach to Hu

Re + Md → ØERe + Md → ØEReducing Managing Reducing Managing ZZEROEROerror defenses Eventserror defenses Eventsandand leadsleads

toto

IdentifyAnalyzeCorrect

9Copyright © 2007 by the Institute of Nuclear Power Operations, Not for sale nor for commercial use. All other rights reserved.

Anatomy of an Event

Event

Values & Beliefs

LatentOrganizationalWeaknesses

Mission

Goals

Policies

Processes

Programs

FlawedDefenses

InitiatingAction

Values & Beliefs

ErrorPrecursors

10Copyright © 2007 by the Institute of Nuclear Power Operations, Not for sale nor for commercial use. All other rights reserved.

Leadership

Performance Model

1.ORG’L

FACTORS

Source: INPO, Human Performance Reference Manual, 2006.

2.JOB-SITE

CONDITIONS

3.INDIVIDUALBEHAVIOR

4.PLANT

RESULTS

11Copyright © 2007 by the Institute of Nuclear Power Operations, Not for sale nor for commercial use. All other rights reserved.

λ Human unreliability and equipment risk can not be managed the same.

λ Process of assigning controls for human work activities uses a graded approach.

λ Controls are proportionate to the riskor potential consequence.

Risk-based Approach*

* IAEA, Management of Operational Safety in Nuclear Power Plants – a report by theInternational Safety Advisory Group, final draft, 1999.

12Copyright © 2007 by the Institute of Nuclear Power Operations, Not for sale nor for commercial use. All other rights reserved.

Work Execution“touching” the plant

λ Work Preparationλ planning, walkdowns, task assignments

and pre-job briefingsλ Work Performance

λ uneasiness (wariness), situation awareness, Hu tools, teamwork and supervision

λ Work Feedbackλ reporting and observations

Re

13Copyright © 2007 by the Institute of Nuclear Power Operations, Not for sale nor for commercial use. All other rights reserved.

Critical Step

Critical Step – a procedure step, series of steps, or action that if done improperly will cause (immediate) irreversible harm to equipment or people, or significantly impact plant operation

14Copyright © 2007 by the Institute of Nuclear Power Operations, Not for sale nor for commercial use. All other rights reserved.

Defensesλ Engineered Controls

λ equipment reliability, software & hardware configuration, human-machine interface

λ Administrative Controlsλ procedures, training, processes, policies, expectations and

standardsλ Cultural Controls

λ assumptions, values, beliefs, attitudes, work group norms, and leadership

λ Oversight Controlsλ accountability, performance improvement

15Copyright © 2007 by the Institute of Nuclear Power Operations, Not for sale nor for commercial use. All other rights reserved.

Managing Defenses

1. Identify unsafe condition(s)2. Analyze its cause(s) and

extent of condition3. Correct the condition(s)

Md

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Organizational Factors

1. Mission2. Organizational structure3. Clear direction4. Work management5. Administrative controls6. Hazard control

processes7. Training & qualification8. Engineering processes

9. Performance improvement processes

10. Technology11. Human resources12. Conservative decision

making13. Communication14. Managerial/supervisory

practices

17Copyright © 2007 by the Institute of Nuclear Power Operations, Not for sale nor for commercial use. All other rights reserved.

1. Everyone is personally responsible fornuclear safety.

2. Leaders demonstrate commitment to safety.3. Trust permeates the organization.4. Decision-making reflects safety first.5. Nuclear technology is recognized as special

and unique.6. A questioning attitude is cultivated.7. Organizational learning is embraced.8. Nuclear safety undergoes constant examination.

* INPO, Principles for a Strong Nuclear Safety Culture, November 2004.

Safety Culture Principles*

18Copyright © 2007 by the Institute of Nuclear Power Operations, Not for sale nor for commercial use. All other rights reserved.

3

2

1

INPO PerformanceImprovement Model

RESULTSRESULTS

GAPSGAPSACTIONSACTIONS

ImplementingSolutions

ImplementingSolutions

Task Assignment

Action Tracking

Management Oversight/

Reinforcement

Organizational Accountability

Resource Management

Analyzing, Identifying and

Planning Solutions

Analyzing, Identifying and

Planning SolutionsProblem Analysis

Action Planning

Management Review & Approval

Business Planning

Considerations

Performance Monitoring

Performance Monitoring

Trending

Standards

EffectivenessReviews

PerformanceAssessment

Benchmarking

Independent Oversight

Industry OE

Performance Indicators

SelfAssessments

Behavior Observations

Problem Reporting

LEADERSHIP AND

OVERSIGHT

KNOWLEDGEAND SKILLS

CULTURE

Excellence in Performance Improvement

19Copyright © 2007 by the Institute of Nuclear Power Operations, Not for sale nor for commercial use. All other rights reserved.

OR.3 Human Performance

λ Organizational Factors

λ Job-Site Conditions

λ Individual Behaviors

Md

Re

“Station personnel select and apply appropriate error prevention techniques commensurate with the importance of assigned tasks to minimize the frequency and consequences of events.”

* INPO 05-003, Performance Objectives and Criteria, (2005).

20Copyright © 2007 by the Institute of Nuclear Power Operations, Not for sale nor for commercial use. All other rights reserved.

Strategic Approach to Hu

Re + Md → ØERe + Md → ØEReducing Managing Reducing Managing ZZEROEROerror defenses Eventserror defenses Eventsandand leadsleads

toto

IdentifyAnalyzeCorrect