Procedure Solutions Management: Video Training Series: Ask An Expert

Ask an Expert – Is Human Factored Writing Applicable In Non-Nuke Industries?

Procedure Solutions Management, LLC - Video Training Series - Ask An Expert - Human Factored Writing Applicable to all Industries?

Procedure Solutions Management, LLC – Video Training Series – Ask An Expert – Is Human Factored Writing Applicable In Non-Nuke Industries?

Ask An Expert – Episode 4 – “How are the Nuclear Standards for Human Factored Writing Applicable to a Variety of Industries?”

PSM’s leadership is known for their work in helping to establish standards for human factored writing throughout the nuclear industry.  Part of this process involved reviewing information from organizations/industries, like NASA and the Airline Industry, that had already successfully implemented similar standardization.   Best practices were gleaned and ultimately, the Nuclear Industry was able to develop and adopt a set of guidelines for its controlled documents that was tailored to meet its needs.  Are the principles, standards, and lessons learned by the nuclear industry applicable to other industries?

In this segment of “Ask An Expert,” Procedure Solutions Management Founder and Chairman of the Board, Stephen McCord, addresses the question:  “How are the Nuclear Standards for Human Factored Writing Applicable to a Variety of Industries?”

 

Procedure Solutions Management has successfully applied the knowledge gained from developing nuclear industry standards to clients in a variety of industries, including: Pharmaceutical, Fossil, Petro-Chemical, and many more.  Furthermore, we believe this information and the lessons learned are applicable wherever you have human beings referencing documents to perform work.  For more information on how we can design a program to meet your company/industry’s needs, visit our services page.  Or, for more information on Technical Writing, subscribe to our blog using the link to the right of this post.

Nuclear Promise – Procedure and Work Instruction’s Perfect Storm – Part 3

What are the real costs associated with maintaining thousands of documents required for the execution of operating and maintaining the plant?

Recap.

In part one, we voiced concerns regarding the nuclear industry’s “Nuclear Promise” and it’s negative impacts on procedures and work instructions.  These concerns were based on my experience working with nuclear sites across the country.  In short, procedures and work instructions that were successfully used many times over a number of years are, in many cases, no longer meeting the needs of the “new” qualified, but less experienced nuclear workforce. The primary findings focused on the areas of insufficient level-of-detail and usability issues (human performance errors).

In part two, we discussed writing staff, which have historically consisted of individuals dedicated to supporting procedure development and work planning.  These individuals are now being impacted by “Delivering the Nuclear Promise” through reorganizations, early retirements, and significant changes in the experience levels of the end user.

As a result of responses to efficiency bulletins associated with “Delivering the Nuclear Promise,” more staff are performing this work as a part-time collateral duty. In many cases, they have had very little or no training in human factored writing, and are unfamiliar with the station’s procedure and/or work package writing quality requirements. Even more frequently, we are finding staff lacking the experience needed to effectively use tools such as MS-Word.

Part 3.

In this final part, we will discuss considerations that should be evaluated in order to strengthen procedures and work instructions as a continued commitment to excellence in safety and reliability. The considerations are focused on the core goals of regaining or remaining competitive while executing this critical business function.

The most frequent response when dealing with the business function responsible for procedures is to reduce or eliminate positions and shift the procedure writing function to the line staff as a new collateral duty. This type of organizational change does see a near term or immediate budget reduction. However, it is particularly problematic because of the additional stress on existing procedures and work instructions caused by the aging workforce and the new staff taking their place This stress causes significant challenges to adequate level-of-detail and usability, or what is typically described as human performance issues.  Thus, the staff working on these critical documents are ill-prepared to support the increased demands created from the newer workforce in addition to their their existing responsibilities to maintain document back logs at or below industry benchmark levels.

So where do we go from here?

To develop a strategy that will realize true cost savings without jeopardizing safety, quality or creating human performance error-likely situations, staff should first understand the real costs associated with maintaining thousands of documents required for the execution of operating and maintaining the plant.

The true cost is not identified by looking at the existing head count and associated labor hours responsible for procedure creation and maintenance and then redirecting these labor hours to other work groups. Instead, look at the cost per page for a newly created or revised procedure. In order to determine the true costs the following questions should be evaluated:

  1. How much time does it take per page to create or revise a procedure? (Typically the labor hours range from .5 to.75 pages per hour for new and 1.4 to 1.6 pages per hour to revise.)
  2. When evaluating page counts per hour, current staff should be looked at individually to determine gaps in performance. When gaps are identified, are the tools or familiarity with the tools causing performance gaps identifying the need to look at the quality of the tools and/or training to improve performance and create greater consistency. For example, some plants will use a fillable form when writing procedures, generating a significant amount of manual actions needed to create consistent documents. In contrast, other plants will utilize a macro-enabled MS-Word template that provides automated features to reduce the labor of formatting.
  3. Does the site have a Content and Format Procedure to provide consistent guidance when developing procedures? If yes, does this procedure align with the latest industry standard guidance found in PPA AP-907.005 Writer’s Manual? When consistent guidance is provided for the format and content development of a procedure than less creative input is used that can cause fluctuations in labor hours based on what is thought as best intentions.
  4. When enhancements to procedures or work instructions are requested, is a cost versus benefit performed? Is the actual cost and benefit truly understood or is every change request accepted independent of the cost?
  5. If staff manual actions to create job steps in the text editor areas of Passport, Maximo, SAP etc. has historically been the norm, has any consideration been given to use a macro-enabled “automated” MS- Word template and create the instructions in MS-Word and place as an OLE document in order to minimize the labor expense?
  6. Has the technical review process for procedures or work instructions been evaluated for the cost of performance in addition to compliance with quality requirements and/or gaps to industry standards? Once the cost is understood, are program efficiencies available that can be implemented to lower the cost and improve quality?

These are just a few of the many questions we use to help our customers in making sound business decisions in order to raise the quality of the work performed and a focus on lowering the overall costs. Do you know how much it actually costs to create or revise a procedure or work instruction – per page?

In conclusion, the ultimate goal should be to produce the highest quality product at the lowest reasonable cost. Are you making money or spending it because “this is the way we have always done it?” Are you focused on lowering the costs over the long term or just looking for a quick cost reduction now?


Procedure Solutions Management has the unique ability to help you see what you can’t see for yourself when evaluating measures that can be taken to drastically lower the costs for maintenance and upkeep of procedures and work instructions.

If you like our content, subscribe to our blog using the link to the right of this post. Or, visit our services page for more information on our staffing, training, or consulting services.

Nuclear Promise – Procedure and Work Instruction’s Perfect Storm – Part 2

Delivering the Nuclear Promise.  As the industry changes and old processes are streamlined, the level of detail and elimination of human performance errors in technical documents becomes even more critical.

Part 2 – Nuclear Promise – Procedure and Work Instruction’s Perfect Storm

In Part 1 – Nuclear Promise – Procedure and Work Instruction’s Perfect Storm, I raised a concern based on my observation of challenges with regards to procedure and work instruction quality. These quality challenges include (but are not limited to):  inconsistencies in level of detail resulting from staffing changes associated with the aging workforce and organizational and process changes resulting from executing efficiency bulletins associated with delivering the nuclear promise.

Procedures and Work Instructions are at a critical crossroads today. Impacts occurring from the aging workforce and implementation of efficiency bulletins supporting Delivery of the Nuclear Promise are impacting the availability of experienced/trained resources needed to keep thousands of procedures and work instructions up to date.

Preventing human performance errors in the field requires high quality “consistently developed” procedures and work instructions. For many years and in many cases today, the focus has been on technical adequacy and nuclear safety. As the industry has matured, it was identified that a technical and nuclear safety focus alone was not sufficient in preventing procedure and work instruction user human performance errors. Over time, it was discovered that the usability of a document can be even more of an error-likely situation than a stringent focus on technical adequacy. With support from the Electric Power Research Institute (EPRI), Institute of Nuclear Power Operations (INPO), Nuclear Energy Institute (NEI),and Procedure Professionals Association (PPA) standards have been developed to create a human factored focus in order to eliminate negative trends the industry has experienced.

Through my interactions while traveling (consulting training, advising), I have observed several challenges that are very concerning:

  • The average years of experience of operations and maintenance staff is rapidly lowering.
  • Work instructions and procedures used many times previously are now resulting in stopped work as a result of insufficient detail.
  • Experienced staff that once pushed for instructions written at the “what-to-do” level of detail (in an effort ensure maximum flexibility) are now being replaced at a rapid rate with qualified yet inexperienced staff that demand a greater level of “how-to-do” detail.
  • Even supervisors, although qualified, often do not have the experience to answer in-field questions without referencing documentation that is frequently vague and interpretive.

In addition, requests for new or changes to procedures and work instructions are being sent to smaller numbers of procedure writers and planners and in many cases the upkeep of these documents has been handed back to the line staff and process owners as a collateral duty, second only to their primary job function.

These individuals, although they are technically qualified in their specific work discipline, often do not have:

  • Adequate computer skills (MS-Word). For example planners experienced in Passport, Maximo or SAP are being requested to write Level One work instructions in MS-Word. In some cases the staff is provided training on a company MS-Word Work Instruction template although the template training was insufficient as it was assumed the planners were proficient in MS-Word and many are not.
  • Adequate training with regards to content an format requirements.  Little or no training has been provided on a stations procedure and work instruction content and format requirements or in many cases no content and format requirements exist.
  • Human performance focus. No training or guidance has been provided that focuses the procedure writers and planners on the elimination of human performance error-likely situations. Too often the staff finds what looks like a well written document and they make it look like that, creating issues where human performance errors are carried forward.

In conclusion, the writing of procedures and work instructions is a critical job, not one intended to be performed as a collateral duty. This is, perhaps, even more pertinent today than it has been in the past.  Eliminating human performance errors requires consistency in document development. When untrained staff is tasked with document development as a collateral duty or a reduced number of existing staff are taxed with more work than they can reasonably perform, document quality will suffer and human performance errors will occur.

As the industry is changing and old “bloated” processes need to be streamlined and the level of detail and elimination of human performance errors in technical documents becomes even more critical, we must recognize the need for consistency in document development. Achieving the level of consistency needed to prevent human performance errors requires the qualification and support of trained dedicated procedure writers and planners.

Join us for an additional discussion of this issue in Part 3 – Nuclear Promise – Procedure and Work Instruction’s Perfect Storm. This final segment will focus on suggestions and creative ideas supported by existing industry guidance on how to eliminate the risk of human performance errors in procedures and work instructions in support of Delivering the Nuclear Promise.


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Nuclear Promise – Procedure and Work Instruction’s Perfect Storm – Part 1

Are you creating a perfect storm for future human error events from the use of the very tools designed to create consistency in the execution of work activities?

 

Delivering the Nuclear Promise

 

Over the last 10 years, generating costs for U.S. reactors has increased roughly 28%.  In response NEI and the nuclear industry developed the Nuclear Promise, which is designed to reduce generating costs by 30% by 2018.  

“Companies that operate America’s nuclear energy facilities have partnered on a multiyear strategy to transform the industry and ensure its viability for consumers as well as its essential role in protecting the environment.

This strategic plan, called Delivering the Nuclear Promise, strengthens the industry’s commitment to excellence in safety and reliability, assures future viability through efficiency improvements, and drives regulatory and market changes so that nuclear energy facilities are fully recognized for their value.” – NEI, Delivering the Nuclear Promise: Advancing Safety, Reliability, and Performance

In redesigning “nuclear power plant processes to improve efficiency and effectiveness to enable a 30 percent reduction in electric generating costs, on average industrywide,” are existing and future procedures and work instructions capable of meeting the needs of the future?

Intro

I have had the rare opportunity to provide Human Factored Procedure and Work Instruction training to 29 plus commercial nuclear generating stations during the last two years. The instruction is focused on providing procedure writers and planners tools designed specifically to eliminate human performance errors and create greater consistency during document development. The instruction is based on two standards. One originally developed by the Nuclear Energy Institute (NEI) and now owned by the Procedure Professionals Association
(PPA) and the other created by the Electric Power Research Institute (EPRI).

  • PPA AP-907-005, Procedure Writer’s Manual, Revision 2 (formerly NEI AP-907-005)
  • Nuclear Maintenance Applications Center: Maintenance Work Package Planning Guidance 3002007020 Final Report, February 2016

The two standards work together to support the elimination of human performance errors that can occur and if left unchecked can lead to industry events as identified by the Institute of Nuclear Power Operations (INPO), World Association of Nuclear Operators (WANO) and the Nuclear Regulatory Commission (NRC).

The problem statement:

As part of the instruction I request each station to provide examples of current documents from each work discipline that will be attending the course. I compare the examples provided to the two industry standards in effort to identify human performance challenges. As a result, I consistently find numerous performance gaps.

The standards specifically target 18 human performance error likely situations. The most frequently identified errors are provided below:

  • Insufficient technical detail
  • Vague interpretive guidance
  • Infield decisions without clear guidance
  • Multiple actions per step
  • Actions or implied actions in Precautions/Limitations, Notes, Cautions, and Warnings
  • Precautions, notes, cautions, and warnings that contain information that do not add value or what EPRI would call “bloat.”
  • Excessive branching and referencing or branching to documents with significant quality issues
  • Inconsistent formatting

As companies respond to “Delivering the Nuclear Promise, Efficiency Bulletins” a perfect storm appears to be forming. As programmatic controls are redeveloped and reorganizations occur the impacts to procedures and work instructions as they relate to level of detail and impacts to human performance are not understood as it relates to changes in the workforce.

Discussion

So why am I writing this blog? First and foremost, the answer is not to generate more work for our small business. This blog is provided to communicate and generate discussion within the community and management teams that are executing “Delivering the Nuclear Promise, Efficiency Bulletins”.

Each commercial nuclear generating station has thousands of procedures and work instructions. The nuclear industry has evolved tremendously since its inception resulting in part from lessons learned from industry events including those such as Three Mile Island, Chernobyl, Fukushima, and quality issues identified through the 10 CFR 50 Appendix B Quality Assurance (corrective action) program controls. As such, procedures and work instructions have evolved.

Procedures are required to go through a very thorough technical and safety review process. Work instructions generally only require an independent technical review. Both procedures and work instructions have especially in recent years come under significant scrutiny for quality challenges as identified by the Institute of Nuclear Power Operations (INPO), World Association of Nuclear Operators (WANO), Nuclear Regulatory Commission (NRC) and as identified by corrective action program controls. The quality challenges surprisingly have not resulted from technical inadequacies but primarily from issues surrounding usability identified as human performance errors. So what has changed?

Less experienced document users and developers!

I am seeing significant inconsistencies as it relates to the level of detail and usability issues (human performance errors). Staff must realize that every step performed by a document user has three primary parts – Who, What and How. The “who” in most cases can be implied, thus the primary focus resides with the writer in determining the “What-to-do and/or How-to-do” for level of detail. Every task an employee performs the “how” must come from somewhere. As the nuclear workforce has matured and the procedures and work instructions have been revised over time the “how’ has been or is being slowly diluted coupled with the addition of other human performance challenges. As the frequency of performance raises staff become more confident and less dependent on step-by-step instructions. But this is changing, and from my observations fairly rapidly. Where the “what-to-do” was acceptable for senior staff the qualified although inexperienced staff require more “how.”

When document guidance is only provided at the “what-to-do” level, the risk of error can be significant as the user can be inadvertently pushed into the “Knowledge Base” performance mode where failure rates can be as significant as 1:2 to 1:10. This is as compared to the “Rule Base” failure rates of 1:100 to 1:1,000 and Skill Based performance mode of 1:1,000 to 1:10,000.

As companies revise current processes and look to potential changes in staff numbers and reorganization in response to “Delivering the Nuclear Promise” we need to be aware that the foundation of human performance “Procedures and Work Instructions” needs to be evaluated consistently and cautiously. Taking credit for existing quality levels for technical adequacy and usability resulting from past success may only lead to a false sense of security and the identification of dormant human performance traps.

Current approved procedures and work instructions used many times successfully are now being found to not meet the needs of the new nuclear workforce. This is at a time when budgets and staff are not available to update these critical human performance tools to the level of attention they routinely demand.

Join us for an additional discussion of this issue in Part 2 – Nuclear Promise – Procedure and Work Instruction’s Perfect Storm.  In Part 2 we will provide industry standard guidance that can be used to identify human performance challenges and tools to support improving the level of detail.


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Procedure Solutions Management: Video Training Series: Ask An Expert

Ask An Expert – What do you mean by, “Human Factored”

Procedure Solutions Management: Video Training Series: Ask An Expert

Procedure Solutions Management – Ask An Expert – What do you mean by, Human Factored?

 

 Ask An Expert – Episode 2 – What do you mean by, “Human Factored”?

Procedures have been around for a long time and there has been a lot of emphasis on making sure that they were “technically correct”.  As things have evolved and the workforce has changed, industries have come to realize that the way in which end users read/follow the procedures is just as important as making sure the content is accurate.  But, what does that really mean and how is it achieved?  Does it matter where a warning is inserted?  How does “Human Factored” affect the end user?

In this segment of “Ask An Expert,” our Founder and Chairman of the Board, Stephen McCord, answers the question, “What do you mean by, Human Factored?”

 

For more information on Technical Writing, subscribe to our blog using the link to the right of this post.  Or, visit our services page for more information on our staffing, training, or consulting services.

Notes, Cautions, Warnings, Precautions, and Limitations – significant human performance failure opportunities?

Notes, Cautions, Warnings, Precautions, Limitations play a significant role in successful procedure and work instruction execution.

When performing a procedure or work instruction, do your workers stop to read the Notes, Cautions, Warnings, Precautions, Limitations? If they are like a majority of users, then the answer is most likely “No!”

In many industries, there is a requirement to perform placekeeping (e.g., circle/slash, check, initial) on this type of information. Yet, even then, the content is often disregarded. Users tend to risk-assess the need to pause and fully appreciate or value the content.

So why the inconsistent performance and how does this performance result in challenges to human performance?

To answer this, let’s first understand the industry standard guidance that describes their use:

  • Notes – Provides supplemental information [at the step level].
  • Cautions – Attract attention to information that is essential to prevent damage to equipment [at the step level].
  • Warnings – Attract attention to information essential to avoid loss of life, personal injury, and health hazards [at the step level].
  • Precautions – Alert the procedure user to those measures that protect equipment, personnel, and the general public from abnormal or emergency situations. Applies generically to the entire document.
  • Limitations – Statements that describe regulatory or administrative limits that the procedure is bound by. Applies generically to the entire document.

So, now that we are all on the same page regarding the usage of these critical human performance tools, let’s look at their content requirements:

  • Written as short and concise statements.
  • Written in a passive voice.
  • Cannot contain an implied instruction or action step.
  • Written such that, if removed from the procedure or work instruction, performance will not be affected.

In addition, for notes, cautions, and warnings the following rules apply:

  • Placed prior to steps to which they apply
  • Must be contained on one page and not expand onto two pages.
  • Must appear on the same page as the impacted step

As you can see, the content requirements are pretty clear. So, why such huge performance inconsistencies?

From the assessments performed by Procedure Solutions Management, LLC (PSM), we have identified the following challenges:

  • No guidance existed. A procedure or work instruction content and format procedure did not exist. As such, no guidance was provided to the technical writers on how to develop a human-factored focused procedure or work instruction; no guidance existed to establish quality standards.
  • Guidance existed but was not enough. Where a content and format procedure did exist, the guidance was not aligned with industry standards.
  • Lacked an understanding of the impact to human performance on the task. Technical writers were either unaware of the procedural content requirements at their site or underappreciated/unaware of the risk to human performance.
  • No formal human factored writing training. Technical writers were either unaware of programmatic requirements or under-appreciated the risk to human performance as they did not understand the “why” behind the requirements.
  • Human performance error likely situations of the Technical Writer. Technical writers were found during the editing process to have their own human performance error likely situations such that actionable or implied actionable content was added without recognizing the error they created.
    • During document authoring it was found that the content of notes, cautions, warnings and precautions and limitations was more consistently developed if this content was added after all action steps were created. Place holders could be added for the location of the information to be added at a later time but no content should be developed until after all action steps are created first. This resulted in the development of higher quality action steps and an almost total elimination of actionable or implied actionable content being added.
  • Blind compliance. Accepting Corrective Action Program requirements that specify specific content to be provided to fix program quality issues that conflicts with human performance requirements and best practices. This was especially problematic when no content and format procedure was present or was present but did not contain the industry guidance for the control of Notes, Cautions, Warning, Precautions and Limitations. As such, corrective action requirements are followed verbatim as nothing was in place programmatically to prevent a corrective action that would fix a quality issue but in of itself also lead to a challenge in human performance.

As a result of these challenges, what is the extent of condition? Here are a few industry examples that were identified to challenge human performance and the safe execution of the task:

Precaution (challenge: Actionable information)

  • Inspect work area for spiders or other creatures/insects & exterminate as required to prevent personal injury.

Warning (challenge: Implied actionable information)

  • Hand protection is mandatory for tasks that possess a risk of laceration or exposure to heat or chemical exposure. The correct gloves should be selected for handling sharp edged or heated materials, or other tasks that expose the hands to safety hazards.

Precaution (challenge: Boiler plate information resulting from a Corrective action)

  • Safety rules, protective equipment, proper tooling, adequate instructions, and training are needed to provide a safe work environment. However, these alone are not enough to prevent accidents. An acute awareness of the surroundings, sound work habits, and commitment to safety will help ensure avoidance of accidents.

In contrast to those above, an example of a well written statement is provided below:

Warning – Electrocution may result from coming in contact with energized bus bar components while performing work in 4Kv Breaker Cabinet 1BKR4312.

In conclusion…

Notes, Cautions, Warnings, Precautions and Limitations play a significant role in successful procedure and work instruction execution. They can save lives and prevent equipment damage but only if written using high quality standards consistently in their format and content.


Interested in learning more about how Procedure Solutions Management can make your Human-Factored writing more successful?  Please contact us for more information.

If you like our content, subscribe to our blog using the link to the right of this post. Or, visit our services page for more information on our staffing, training, or consulting services.

3 Tips For Starting a Procedure Project from Scratch

Having trouble starting your procedure project?

Having trouble starting your procedure project?

Are you starting a new procedure project from scratch and having trouble getting started?

For many people at the onset of an important project (procedure or otherwise), starting is the hardest part.  A large or complicated project can seem overwhelming or intimidating. Some people are slowed by analysis paralysis, focusing on specific details before having a grasp of their overall goals.  Others start without ever thinking anything through and hope things just work out along the way.

Setting up a project for success is actually fairly easy with a little forethought and structure. Below are three tips to help you get a quick and sustainable jump on your new project.

  1. Do your research.

    Review all existing workflow process maps and compliance/business requirements for the procedures and processes you will be writing.  The length or detail of the process maps is fundamental to the development of procedures that will meet or exceed the human factored procedure program requirements.  While evaluating a process map, it is vital to receive 100% alignment from management and the subject matter experts.  Having this alignment will prevent re-work and confusion down the road, as well as setting the correct level of detail.  This research must be complete prior to building the step-by-step instructions. Failure to do this may result in embedding unnecessary human error likely situations as a result of direction changes that can occur during step reorganization.

  2. Establish a plan with clear expectations.

    It’s extremely important to establish a mutually agreed to foundation and framework of the project. This typically includes a charter and project schedule. This will ensure the controls are in place throughout the lifecycle of the project to guarantee a sustainable and successful plan. Start by developing a high-level schedule, or lifecycle, that each workflow process map (or procedure) will follow from beginning through finalization and publication. Consider research, writing, reviewing, incorporation of comments, and approving, as well as metric milestones as needed.

  3. Assemble the right team.

    Involving the right personnel is key to the success of a procedure project.  The team can either be working face-to-face or via web conferencing.  There should be a team lead (Project Manager – in some cases this may also be the procedure writer), procedure writers, reviewers, approvers and dedicated subject matter experts assigned as points of contact. Obtain a listing and contact information of key personnel and subject matter experts and their availability. Include phone numbers, email contacts and notes indicating task/level of involvement. Consider the availability of subject matter experts to address questions timely (in addition to their day to-day work load) as another important factor when assembling the team and creating the project schedule.

For more information on Human-Factored Writing and other Procedure Writing Tips, subscribe to our blog using the link to the right of this post.  Or, visit our services page for more information on our staffing, training, or consulting services.

A critical step as defined by the Institute of Nuclear Power Operations (INPO) is: “A procedure step, series of steps, or action that, if performed improperly will cause irreversible harm to plant equipment or people or will significantly impact plant operation.”[1]

Critical Step – The Great Misconception!

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For any “high risk” industry, the ability to successfully execute tasks in a consistent, high-quality manner is as critically important today as it has ever been. The predictability of the outcome of these tasks is crucial in ensuring the safe and reliable execution of work processes. This is especially true for utilities.  According to a March 2015 Electric Light and Power article, “more than one-half of the current utility workforce will be eligible to retire in the next 6-8 years.” A similar article from Power Engineering puts that number even higher.

The Bottom line is: The aging workforce issue and the resultant hiring of less experienced staff is guaranteed to place higher demands on the creation and/or maintenance (routine updating) of procedures and work instructions.

Which brings us to critical steps…

Many industries have (or are now adopting) rules to identify “critical steps” in procedures and work instructions during the creation or revision of these documents and/or just prior to work execution (e.g. during pre-job briefs).

A critical step, as defined by the Institute of Nuclear Power Operations (INPO), is:

“A procedure step, series of steps, or action that, if performed improperly will cause irreversible harm to plant equipment or people or will significantly impact plant operation.”[1]

If you are in an industry that does not have a “plant,” the significant impact could be simply the direct result of an unfavorable outcome that may include irreversible harm.

Industry guidance also provides the following additional guidance for consideration:

“Critical steps for a procedure or work instruction are identified during the task preview or pre-job briefing.

When preparing to execute a critical step, the performer stops to review the situation to ensure the following:

Current conditions match expected conditions. If job-site or system conditions are different than expected, the performer stops, contacts the supervisor, and resolves the difference prior to proceeding.

The expected results of step performance are understood.

The correct component is verified before the critical step is performed.

The focus is on the task at hand as each action is performed.”[1]

Where is the Misconception?!!  Continue reading…

This industry guidance has been around for a number of years in the commercial nuclear industry and it has been fairly successful.  However, as the workforce changes, a word of caution is needed.

It is important for personnel, and most notably supervisory personnel, to understand that the identification of a critical step using the guidance provided above may only help to identify where the failure is going to occur versus preventing irreversible harm.

Personnel and supervisors must be aware that every action step consists of three main parts: “Who, What, and How.”

I think we would all agree that during critical step identification the “who” is the person designated to perform the step; consequently ownership is clearly identified.

Where the misconception most commonly occurs is ensuring the critical step clearly communicates the correct level of detail to ensure the successful completion of the step; or simply stated: the balance between an instruction step that directs “what-to-do” or “how-to-do.”

At every step, the performer must clearly understand “how” to perform the task. When the step is identified as critical, it must be understood without question. No in-field decisions. No assumptions. So, despite having an understanding of the expected results, it is more imperative that the performer understands “how” the step is to be performed especially if the instruction is written at only the “what-to-do” level for detail.

Conclusion

To conclude, the misconception is this:  despite industry efforts to proactively identify the location of critical steps, it is even more important that the critical step provides the correct level of detail that aligns with the needs of the performer.  Supervisors need to ensure that not only is the expected result clearly understood, but also that the performer clearly understands “how” to perform the task and has the tools to be successful.

Author’s note:  The Institute of Nuclear Power Operations guideline is used as a reference herein.  However, the concept of a critical step is applicable to any high-risk industry.

[1] Institute of Nuclear Power Operations, “Guideline for Excellence in Procedure and Work Instruction Use and Adherence.” Rev. 0, June 2011

Interested in learning more about how Procedure Solutions Management can make your Human-Factored writing more successful?  Please contact us for more information.

For additional details on how to determine the correct level of detail, check out Level of Detail – Not Just the Who, What, How.  If you like our content, subscribe to our blog using the link to the right of this post.

 

Eliminate human error likely situations and improve human performance.

Can Technically Correct Procedures and Work Instructions Fail?

Over the last 58 years, the nuclear industry and its workers have grown and matured together. They have gained vast experience as the performance expectations improved significantly post Three Mile Island (TMI). Procedures and work instructions have evolved from simple “to-do” lists to detailed “step-by-step” instructions with specific usage requirements.

Over the last 58 years, the nuclear industry and its workers have gained vast experience as the performance expectations improved significantly post Three Mile Island (TMI). Procedures and work instructions have evolved from simple “to-do” lists to detailed “step-by-step” instructions with specific usage requirements.

Despite extensive regulatory and performance based focus, the nuclear industry continues to experience procedure and work instruction related events.  Unfortunately, many of these industry events trace back to documents that were evaluated through Quality Assurance Program controlled processes and deemed to be technically correct.

In an effort to improve human performance, industry leaders, such as the Electric Power Research Institute (EPRI), Nuclear Energy Institute (NEI), Institute of Nuclear Power Operations (INPO), and the Procedure Professionals Association (PPA) have responded to this challenge by creating or revising industry standards with a focus on eliminating human error likely situations while maintaining the standard requirements for technical adequecy.  Although these new/revised industry standards are available, nuclear power stations’ programmatic controls typically focus on compliance with Regulatory Guide 1.33, Quality Assurance Program Requirements, and ANSI N18.7-1976/ANS-3.2 Administrative Controls and Quality Assurance for the Operational Phase of Nuclear Power Plants.  While it is true that procedures and work instructions evaluated under these controls may be technically “correct,” it is also true that focusing solely on adherence to these controls leads to missed opportunities in eliminating human error likely situations which leads to human errors and plant events.

At this point, the question routinely asked is…

How after over 30 years of safe operation could we be in a position today where our procedures and work instructions, as identified by the staff, are lacking sufficient detail, are poor in quality, and, in some cases, do not meet industry standards while also containing numerous human performance challenges?”

To answer that, lets consider the following…

Shippingport Atomic Power Station was commissioned in 1958.  Over the last 58 years, the commercial nuclear industry and its workers have grown and matured together. They have gained vast experience as the performance expectations improved significantly post Three Mile Island (TMI). Procedures and work instructions have evolved from simple “to-do” lists to detailed “step-by-step” instructions with specific usage requirements. Today, we must recognize we are at a crossroads.

As these highly experienced nuclear workers retire, they are replaced by workers from other industries or workers just entering the workforce. These workers have not grown with the industry as it has developed, nor been privy to the the same experiences and growing pains. Thus, the modern nuclear worker requires a different type of tool that is not only focused on its technical adequacy, but is also developed to specifically address potential human error likely situations that the original workforce learned as the industry has evolved.

The original nuclear workers did not grow-up with computers as their primary tool to support their success as compared to the modern nuclear workforce today. As such, how the modern nuclear worker receives and comprehends information is not the same as what was envisioned with the release of Regulatory Guide 1.33 and ANSI N18.7-1976. Therefore, today the emphasis on human factoring during the development of procedures is essential versus a focus on ensuring only technical adequacy.

Today’s workers have grown up receiving, assimilating, and comprehending information differently. For example, a study conducted by the American Press Institute in 2015 revealed that Facebook was the number one news source for millennials on thirteen of twenty-four topics that were surveyed and number two on seven others.   According to the same study, when these individuals want to delve deeply into a subject, the majority don’t turn to newspapers, radio, or television.  Instead 57% go straight to a search engine. Social interactions are evolving as well thanks to the introduction of SMS, Twitter, Instagram, Snap-chat, etc. where all of this communication is performed in short bursts of information. Basically, these workers expect to communicate and receive information in this manner. When handed a 100 page technical document where it is common to find multiple thoughts per step and vague interpretive guidance, the gap from their norm introduces a significant human error likely situation.

Conclusion

Technically Correct Procedures and Work Instructions can still fail, especially when you take into account the aging workforce, the experience levels of those entering the workforce, and changes in technology and information consumption.  In order to prepare procedures and work instructions for the new nuclear workforce, a new paradigm is needed with the following considerations:

  • The nuclear industry must recognize that the quality assurance standards content as it relates to procedures and work instructions has not been revised since the mid 1970’s with regards to procedures and work instructions. The requirements do not support the modern nuclear work force as it is evolving today. Quality assurance standards should be evaluated with a specific focus on human performance versus a technical only approach.
  • The industry standards created by EPRI, INPO, NEI, and the PPA are essential tools that should be considered for placing a greater emphasis on the human factors associated with technical writing versus a focus on technical writing alone.
  • Nuclear Power Reactor Operators must recognize that the tools designed to improve human performance require a trained “human factored” technical writing staff that is available to continually create or revise procedures to the newer industry standards.

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LEVEL OF DETAIL – Not just the Who, What, and How!

Think about the direction here. Is it providing the "what-to-do," of the "How-to-do," or neither?

Level of Detail.  Think about the direction here. Is it providing the right amount of “what-to-do” or “How-to-do?”  Is it falling short on both?

When writing a document (procedures or instructions) that is intended to provide direction, how do you know when you have the right amount of detail? Too much detail can cause the person doing the task, the performer, to focus more on what is written than the work actually being performed. On the opposite side, if insufficient detail is provided (“what-to-do”), the performer must obtain the “how” from somewhere, such as:

  • Engineering documents
  • Past experience
  • Peer
  • Prints or drawings
  • Procedures
  • Subject matter expert
  • Supervisor
  • Training
  • Vendor Manuals
  • Etc.

In all cases a balanced approach is critical for successful task execution or the human performance risk can negate the benefits of what the document was intended to accomplish.

As a writer it is critical to remember that for each and every step the performer has to obtain the “how” from somewhere. To create the balance between a step’s “What-to-do” and the “How-to-do” take into account the following considerations collectively for each and every step:

  1. At a minimum the task performer should be considered qualified although inexperienced and will have minimal or no direct supervisory input.
  2. Based on the simplicity of the task, the task performer is qualified and is capable of performing the task consistently error free independent of the human performance risk and does not need to rely on written instructions to be successful.
  3. As task complexity increases, the level of detail should rise, especially when a large number of actions are involved.
  4. As task frequency increases, the level of detail may lower. Although consideration should be given to the impact of complacency.
  5. Level of detail varies directly with the degree of standardization required. Increasing the level of detail provides more standardization and more consistent results.
  6. The level of detail should be increased as the risk of personal injury, equipment damage, and potential regulatory challenges rises.

For more information on Level of Detail and other Procedure Writing Tips, continue reading our blog.  Or visit our training page for more information on our PPA Certification Course PLUS.