Managing Maintenance Error Using Human Performance Improvement

1. Managing Maintenance ErrorUsing Human Performance Improvement Department of Energy Human Performance Center

2. Error = Unintended Deviation • The plan is appropriate, but the actions themselves do not go as planned (active). • The actions go as planned, but the plan is inadequate to achieve desired goals(latent). Versus • Violations – actions intentionally deviate from the specified method of working.

3. Why a Human Performance Approach? Human Errors Events 70% due to Organization Weaknesses 80% Human Error 30% Individual Mistakes 20% Equipment Failures

4. Apollo 13 oxygen tank blow out (1970) Three Mile Island loss of coolant (1979) Chicago DC 10 crash at O’Hare (1979) Bhopal India release of methyl isocyanate gas (1984) Piper Alpha oil & gas platform explosion North Sea (1988) Clapham Junction rail collision in England (1988) Phillips 66 chemical explosion in Texas (1989) Embraer 120 in-flight structural break in Texas (1991) Loss of B-757 in Dominican Republic (1996) DC9 oxygen generator fire over Florida (1996) Southwest Air landing accident in Chicago (2005)? Called the worst industrial accident in history Maintenance Error causesMajor Accidents

5. Data from surveys (3 US & 1 Japanese) associated with nuclear power plant events 42-65 % of Human Performance Problems occur in Maintenance

6. Omission Management • Omission errors account for >50% of human factors maintenance problems • Omissions can create common mode failures that affect numerous downstream components • Omissions can lie concealed and interact with local triggering events to cause an accident

7. Types of Omission errors- from aviation maintenance • Fasteners left undone or incomplete 22% • Items left locked or pins not removed 13% • Caps loose or missing 11% • Items left loose or disconnected 10% • Items missing 10% • Tools or spare fasteners not removed 10% • Lack of lubrication 7% • Panels left off 3% • Other 14%

8. Most maintenance errors fall into systematic and recurring patterns Problems are more likely error-inducing situations Limited resources can be targeted to achieve maximum remedial effect The Good News is -Maintenance Error can be managed!

9. Events The Worker Task Factors – the job Local Conditions – at the worksite Organizational Factors – the system as a whole A Systems Approach

10. The Principles ofHuman Performance Humans are fallible Error-likely situations are predictable Individual behavior is influenced by organizational processes and values People achieve high levels of performance by encouragement Events can be avoided

11. What can you do? Instead of trying to change the human condition – change the conditions under which people work Reduce the error-provoking nature of the task, the team, the workplace and the organization Strengthen and improve defenses to limit and contain the bad effects of those errors that will still occur

12. Available tools/equipment Reduce Interruptions and distractions Housekeeping and tool control Manage fatigue –Work schedules Manage boredom - by task assignment Appropriate rules-procedures Reduces action slips Reduces memory lapses that cause omissions Improves task completion Improves attention and memory Reduces complacency & overconfidence Reduces risky decision making Supervision’s role

13. The HPI Vision: Re + Md→ ØE Reducing error + Managing defenses → leads to Zero Events (Occurrences/Accidents)

14. Human Performance Problems in Maintenance The Human Risks Fundamentals of Human Behavior Varieties of Error System Failure & A Model of Organizational Accidents Error Provoking Factors & The Workers’ Toolbox Workplace Tools & Considerations Leader & Organizational Tools Safety Culture Making It Happen – Managing Error Management Managing Maintenance Error Course Topics