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?


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.

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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?


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.


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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