(Editor’s Intro) “Our blogs so far have addressed key concepts and theory of high reliability. The question of most senior managers is how to translate the social science research into practice. So we begin a series of guest blogs on exactly that. This first topic is actually split into two blogs; the first, an introduction to the concept, and the second, the application of the concept. This two part series comes to us from Shane Bush of the Idaho National Lab and Brian Harkins of the DOE Office of River Protection. Shane and Brian have been partnering for several years to promote application of high reliability concepts at Hanford. This particular case review was designed to minimize the Δ between work as imagined and work as done by focusing on defenses – or controls as referred to in ISM. Thanks to Shane and Brian for this blog and to the people at Hanford who are working to improve safety and performance by developing high reliability practices!”
Part I: The Concept
T. Shane Bush, CPT
Brian A. Harkins
There is often a difference between how a defense is developed (defense as imagined) and how it is implemented in the field (defense as applied). In the ideal setting those who develop defenses imagine correct field conditions and accurately predict how the user will apply the defense. However, it is often the case that the field conditions are not what were imagined and/or the worker often applies the defense in an unpredictable way. Detecting and reducing the ‘Gap’ between the ‘defense as imagined’ and ‘defense as applied’ can be accomplished by “Evaluating Defenses in Context”.
The ‘Context’ influences the effectiveness of defenses in many ways including:
- Misunderstanding of the conditions that the defense will be used,
- The users misunderstanding of the defense,
- Lack of recognizing a defense,
- Normalization of deviation or system drift, and
- Undetected changes to field conditions.
Thus it is important for organizations to verify the validity of defenses in the ‘Context’ of how they are going to be applied to ensure that the defense will perform as intended. For example if a company requires a worker to maintain three point contact (defense) on a ladder but then doesn’t provide a means of getting his/her tools up to the work place (context), it is predictable that the worker may carry his/her tools up the ladder reducing the probability of maintaining three point contact at all times (Gap). This paper will describe a process that has been used to detect the ‘Context’ in the field. This approach has not only been successfully used as field observation technique but as a tool for ensuring readiness to start and operate a system or process.
It is worth noting that these processes apply to quality the same as they do to safety. If reviewing quality, the defenses that are being “Evaluated in Context” are those defenses that defend against rework or producing an unacceptable product.
Pre-Field Observation Preparation:
Determining and requiring a defense requires a thorough understanding of the defense and its appropriate application. Without this knowledge the wrong defense may be required for a given task that not only doesn’t serve its purpose but may contribute to an unwanted outcome. For example requiring an ‘independent verification’ on a task that requires both workers to be present is a misapplication of the defense. In this case a self check or peer check may be more appropriate. Specific Human Performance defenses have been developed for both “Physical Plant Touchers” and “Paper Plant Touchers”.
Once a defense is determined to be appropriate for a given task, the defense must then be incorporated into the work control process at the right time and in the right way. Thus the first part of the Field Observation process starts with a review of the work control process controlling the task you are to observe. If the work control process is not correct, no amount of field presence will fix it.
As part of a pilot at a major DOE construction site in Washington State, a worksheet was developed using these concepts. The steps were developed as a guide, and while there is plenty of room for improvement, the reader should get a general sense of the concepts. The first file attached is a completed example of the HPI Field Observation Worksheet. The second file attached to this post is a blank form without the sample data entered, so you can try this method at your site or workplace.
(Editor’s Note) “Stay tuned for Part II of Evaluating Defenses in ‘Context’: Applying the Concept. Again we would like to thank Brian and Shane for their contribution to this site, please feel free to leave comments for Brian and Shane in the comment section.”
About the Authors:
Brian Harkins, Director, Verification and Confirmation Division, DOE Office of River Protection. Brian is a former DOE Facility Representative who has a wide-ranging background including RadCon engineering, radioactive waste processing, accident investigation, and safety oversight. During his tenure at DOE he has been involved in piloting Human Performance Improvement (HPI) at DOE sites, performing HPI event investigations, and teaching HPI classes. He has taught HPI to varied audiences from laborers to executives, including a class for Managers at Chernobyl and a class for Managers at European Nuclear Power facilities taught in Germany. Brian has a BS in Mechanical Engineering and 21 years in the nuclear industry.
T. Shane Bush, Idaho National Laboratory Event Investigation SME (Subject Matter Expert) started his career working in commercial nuclear power plants providing Health Physics support. In 1984 Shane started working at the DOE Idaho National Laboratory and has been involved in implementing initiatives such as MORT/AI (Management Oversight & Risk Tree/Accident Investigations) , ISMS (Integrated Safety Management System) and VPP (Voluntary Protection Program), but found his true interest lies in the Human Performance Improvement (HPI) initiative and the study of High Reliability Organization (HRO) attributes. Shane is on a part time professional leave from the INL working with numerous companies in the U.S., Germany, Canada and England. Shane has an MS in Industrial Safety, a BS in Corporate Training, is a Certified Performance Technologist (CPT) and works as an adjunct professor at the University of Idaho facilitating Human Performance courses.