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Procedure Solutions Management: Video Training Series: Ask An Expert
James Bennett

Ask An Expert – What is a Procedure

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Procedure Solutions Management: Video Training Series: Ask An Expert

Procedure Solutions Management, LLC – Video Training Series – Ask An Expert

 

Ask An Expert – Episode 1 – “What is a Procedure?”

What do procedures, work instructions, policies, and guidance documents have in common? Amongst other things, they are all human performance tools designed to help people and companies be more successful in work that is performed by following the direction provided. Most of us would agree that these human performance tools are essential in a variety of industries.  But, what exactly is a procedure? What are the essential elements that can help define and identify them?

In this segment of “Ask An Expert,” our Founder and Chairman of the Board, Stephen McCord, answers the question, “What is a Procedure?”

 

Overall, we hope you find this information useful. Check it out and let us know what you think using the comments section below.

 

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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]
Stephen McCord

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.
Stephen McCord

Can Technically Correct Procedures and Work Instructions Fail?

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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.

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.