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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.

Are spending unnecessary labor hours on document formatting?
Stephen McCord

How much does it cost to format a document?

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Today, more than ever, companies are looking for ways to reduce Operating and Maintenance (O&M) costs. Although it is often overlooked, the labor associated with creating and updating documents can be significant and expensive. Equipment modifications, changes in technology, and ever-expanding regulatory requirements are just a few of the driving mechanisms that can require significant changes to documents and drive up costs.  That much is understandable, but, what if I told you that a significant portion of those labor hours are being devoted to formatting.  Thats right, the time spent formatting documents is probably increasing your labor costs.  Let me explain…

As a Supervisor for a commercial Nuclear Power Plant procedure group, I oversaw a group of writers that were all seasoned within their disciplines (operators, maintenance, process experts, etc.) but there were varying levels of MS Word experience among them.  In order to determine how much time writers were spending just to format documents within MS Word (manipulating headers, footers or auto-numbering schemes, adding emphasis, standard blocks of text, or special formatting, etc.) I performed a simple evaluation.

The evaluation method: Each employee recorded the number of hours dedicated just to format the text within their document. Pretty simple, I’m sure you would agree, but the result was surprising…

In short, document formatting is expensive!  The two most significant findings were:

  1. On average, 30 to 50% of the total document development labor hours were dedicated just to formatting. These results ranged due to the varying levels of MS-Word proficiency among the writers and the “as-found” issues within the document that were created over its own life-cycle (previous revisions)
  2. Many content technical errors were attributed to the distraction of formatting.

There are roughly 2,087 hours is a standard labor year.  Formatting doesn’t need to account for half or even 1/3rd or your writer’s time.

In an effort to help companies reduce the labor costs associated with document formatting Procedure Solutions Management will provide a monthly “How-To Format” series through our blog to help reduce the cost and improve the quality of formatting within documents. The focus application will be MS Word (in our experience this is the most common or consistent platform used by many corporations.) The series will address common challenges associated with formatting, i.e. auto-numbering, headers, footers, adding graphs, tables, photos, etc.

Please subscribe and share to learn how you or your team can increase efficiency, improve document quality, and lower your document development costs.

Stephen McCord

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

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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.