Human Performance Creative Defense Barriers Thinking Tools

Kevin Harris Transmission Test

Human Performance Creative

Defense Barriers &

Thinking Tools

Good Industry Practices

Year is 2005 Where do we start?

•Questioning Attitude•Effective Communication•Task Preview•Job Site Review•Procedure Use•Self-Checking (STAR)•STOP When Unsure•Pre-Job Brief•Place-keeping•Turnover•Independent Verification•Peer Checking•Peer Coaching•Flagging•Post-Job Review

Human Performance Tools

Thinking Tools !

Why? When? How?

Think, Think, Thinking Tools

Where we apply solid habits to place DEFENSE barriers between our human condition to err and the potential for an event !

Why ? When? & How?

Enhanced our Lessons LearnedPost Event

Perform an analysis of each event and often created a Lesson Learned document to share with stakeholders!

Partial Example:Lessons LearnedD165-2007 8/31: Poor work practice of “placing a jumper on a contact”, without isolating thetripping device. Proper work practice would be to isolate the tripping device and then closeexpected path to desired circuit. This could have avoided the inadvertent trip caused by thehuman error. Poor lighting was expressed as a contributing factor. In this instance a light bulbwas burnt out affecting visibility. Poor lighting is a human error trap that needs to be rectifiedprior to beginning work.

D176-2007 9/18: Correct work practice of isolating a tripping device was applied; unfortunately,the incorrect device was identified. Test personnel closed the expected circuit path for testingwhich resulted in an undesired breaker operation. Just prior to these actions the test personnelproperly identified, isolated, and tested successfully several DFR points in the same 115KVpanel. Human error elimination tools that would have applied are; task preview, job site walkdown, questioning attitude, peer check and creating a plan identifying each task. Identifiednomenclature is a Latten Organizational Weakness (LOW) or “land mine” which needs to beaddressed, however, using the tools above may have afforded the test personnel an opportunity toidentify this human error “land mines” prior to taking action. Upon investigation, test personnelfound that there are two relays nomenclatured "86P1/A". For this instance, the intended relaywas the 86P1/A for the 345kV A bus; however test personnel were working on the 86P1/A for the115kV A bus. Test personnel just finished testing the contacts from the 94P and 94B for the 1Xand 2X. The 86P1/A (115kV bus) is mounted in the same panel at the 94P/1X. Looking furtherinto this, there are multiple relays in Plumtree 30G with the same nomenclature. There is nodistinction between any of the 345kV and 115kV A bus and B bus tripping relays on thenomenclature tags on the panels. There are two of all of the following relays: 86P1/A, 86P2/A,94P/A, 86P1B, 86P2/B, 94P/B.

Sharing what went wrong opens the door to also sharing what went well as we learn from each event!

Correct work practice of isolating a tripping device was applied; unfortunately, the incorrect device was identified.

Enhanced our Lessons LearnedPost Event

Perform an analysis of each event and often created a Lesson Learned document to share with stakeholders!

Partial Example:Lessons LearnedD165-2007 8/31: Poor work practice of “placing a jumper on a contact”, without isolating thetripping device. Proper work practice would be to isolate the tripping device and then closeexpected path to desired circuit. This could have avoided the inadvertent trip caused by thehuman error. Poor lighting was expressed as a contributing factor. In this instance a light bulbwas burnt out affecting visibility. Poor lighting is a human error trap that needs to be rectifiedprior to beginning work.

D176-2007 9/18: Correct work practice of isolating a tripping device was applied; unfortunately,the incorrect device was identified. Test personnel closed the expected circuit path for testingwhich resulted in an undesired breaker operation. Just prior to these actions the test personnelproperly identified, isolated, and tested successfully several DFR points in the same 115KVpanel. Human error elimination tools that would have applied are; task preview, job site walkdown, questioning attitude, peer check and creating a plan identifying each task. Identifiednomenclature is a Latten Organizational Weakness (LOW) or “land mine” which needs to beaddressed, however, using the tools above may have afforded the test personnel an opportunity toidentify this human error “land mines” prior to taking action. Upon investigation, test personnelfound that there are two relays nomenclatured "86P1/A". For this instance, the intended relaywas the 86P1/A for the 345kV A bus; however test personnel were working on the 86P1/A for the115kV A bus. Test personnel just finished testing the contacts from the 94P and 94B for the 1Xand 2X. The 86P1/A (115kV bus) is mounted in the same panel at the 94P/1X. Looking furtherinto this, there are multiple relays in Plumtree 30G with the same nomenclature. There is nodistinction between any of the 345kV and 115kV A bus and B bus tripping relays on thenomenclature tags on the panels. There are two of all of the following relays: 86P1/A, 86P2/A,94P/A, 86P1B, 86P2/B, 94P/B.

Human error elimination tools that would have applied are;task preview, job site walk down, questioning attitude, peercheck and creating a plan identifying each task. Identifiednomenclature is a Latent Organizational Weakness (LOW) or“landmine” which needs to be addressed, however, using thetools above may have afforded the test personnel anopportunity to identify this human error “landmine” prior totaking action.

“Landmine” = Same nomenclature for 345kV Bus and 115kVBus Relays!

Proactive Approach Leads to New Defense Barriers

• Thinking Tools Roll Out to NU Internal stakeholders.

• Conducted by Field Supervisors

• Listen to the people who do the work

• Work together on solutions

• Foster a work environment to allow for a healthy creative questioning attitude

The people who do the work are the ones who have the answers!

Fast, Simple & Easy

Human Performance Defense Barrier Tools

Proactive Approach Leads to Simple Defense Barriers

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Fast, Simple & Easy

Proactive Approach = Scenario Training

• Thinking Tools Training Scenarios.

• Kick off Thinking Tools awareness!

• Hands on Situational Scenarios to apply new knowledge with a Peer Coach present.

Peer Coaching Means We Care!

Weekly Topic: Turnover – communication is the key

Human Performance: Turnover - Error Elimination Tool

Effective communication is key to the successful turnover of a task. During turnover, be sure to transfer the knowledge you learned while the task was in your hands to the next person or team. It's all about putting yourself "in their shoes."

Highlight HU Tools:– When?– Where?– How?

Proactive Approach = Communicate

Event Pyramid

Minor Error

Close Call

Substantial

Error

Events

Error-likely situations are predictable,manageable, and preventable!

Think of Error-Likely situations as unintentional "Landmines" in our workenvironment we sometimes work around or “step on” during discovery.

Our Goal is the Proactive Recognition / Elimination of “Landmines.”

LANDMINES = Latent Organizational Weakness’ or LOWs

Proactive Approach Go After The LOWs

Go After the Landmines (LOWs)

See Something ? Say Something!

Communicate Thinking Tool Use

Infused in Process or Procedure

84 – 94 percent of all human error can be directly attributed toprocess programmatic, or organizational issues.

Human Performance tools such as Three Way Communication is employed to identify equipment to be operated and readiness to do so. Human Performance tools such as Pre job Brief, Self Checking, Peer Review, Flagging and STAR are also regularly employed.

Thinking Tools Employed

Peer Verified magnet ~ Flagging

“As Built Print of Record”

“Trust but Verify”

Procedure Use:• Review Maintenance Manual• Review Department Administrative Guide• Review relay test plan• Review “As Built Prints of Record”

Self Check: STAR = Stop Think Act Review

People come to work wanting to do a good job.

Peer Check


Tape fence around relays under test ~ Flagging

“As Built Print of Record”

“Trust but Verify”

Procedure Use:• Review Maintenance Manual• Review Department Administrative Guide• Review relay test plan• Review “As Built Prints of Record”

Self Check: STAR = Stop Think Act Review



Each Switching evolution starts with:

• Job Site Walk Down

• Task Review

• Flagging

• Independent Review

• Pre Job Brief

Employed throughout:

• Positive Questioning Attitude

• Effective Communication

• Three Way while switching

• STOP when unsure!!

Self Check: STARStop Think Act Review

Flagging

Thinking Tools EmployedProcedure Use:

• Highlight steps during walkdown.

• Receive switching verbal commands from operator and repeat back.

• Number and write time each step completed during execution.

• Check off each switching step as they are read back to operator.

• Operator confirms or not.

Placekeeping

StartFinish

Self Check: STARStop Think Act Review



Self Check = STARStop Think Act Review


Insulating Boots to keep the conductive crimp from contact with a source of energy while poised or waiting to be landed!

Relay Removed for Repair

As a Block

Influencing Behavior through Coaching

Front Line Supervisors have the greatest impact on how work actually gets done within an

organization!

Coaching to Influence Behavior

IMPACT: A tool to guide and document. Document to measure how we are doing. IMPACTS’ value is in guiding personnel providing and receiving real time positive feedback.

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Kevin E. HarrisKevin has 25 years of service with Northeast Utilities in the field of Test and Commissioning of Generation, Substation and Switchyard facilities. Currently, Kevin serves as a Field Supervisor for Northeast Utilities Transmission Construction, Test and Maintenance Team. He started his career with Northeast Utilities Nuclear Production Test Group. After 11 years as a Nuclear Electrical Test Specialist, he continued his career as a Senior Test Analyst for Northeast Utilities unregulated Test Group, Northeast Generation Services. In this capacity, he maintained or commissioned electrical distribution and generation apparatus to include protection and control relays for nuclear generators, merchant generators, hydro generators, pharmaceutical, Industrial and commercial customers. In 2004, Kevin joined the Northeast Utilities Transmission Group with an opportunity to participate in the startup of the newly formed Transmission Test Department. During 2007, he participated in an opportunity to explore human error reduction with several consultants. Kevin has since co-championed a successful human error reduction effort within the Northeast Utilities Transmission Group. In 2012, Kevin presented on Electric Utility Industry Practices with Human Performance Tools at the first annual NERC conference on Human Performance in Atlanta, GA. He followed the NERC presentation opportunity with a presentation on a supervisors perspective at the first PPI Human Performance Conference in Galveston, TX.

[email protected] Cell 860 597 0824 , Office 860 652 6840

Human Performance Creative Defense Barriers Thinking Tools

Documents