Let’s Get Focused

Error Reduction Tools Make Us Safer

Like many of us, when I was first introduced to the concept of Human Performance and Error Reduction Tools many years ago, I was somewhat skeptical as to how effective they could be. After all, I work pretty safely, right? I hadn’t suffered an industrial accident or injury in 30 years of working in the nuclear power field. I seldom made mistakes when working, so what was the problem? The problem was I made mistakes – everyone makes mistakes – we are human after all.

Our nuclear industry has embraced the use of Error Reduction Tools (also referred to by some as Human Performance Tools), and with good reason. Nuclear technology is special and unique. We know that errors can have grave consequences. We strive to work error free. We work hard to eliminate hazards. Use of our Error Reduction Tools has been shown to, without question, minimize error rates and improves hazard recognition. From a statistical vantage point, Error Reduction Tool usage has reduced error rates to levels that were never before thought achievable!

A few years back, I attended my first Human Performance training session. The training centered on the use of Error Reduction Tools, and one question posed to each of us by the instructor was to think about things that could go wrong and the consequences. The instructor asked the class “How bad can it get?” And, of course, the pat answer was “yeah, really bad – death and destruction”.

That little question stuck with me. “How bad can it get?” Well, in life sometimes things can get very bad very quickly when things go wrong. It only takes a matter of seconds for things to change forever. An automobile accident, a fall from a ladder, or a component that fails – they all happen in the matter of seconds. Sometimes lives are changed forever.

Let’s Get Focused (continued)

Over the years, those very behaviors we model in the workplace have found their way in to my personal life. Behaviors like a questioning attitude, self-checking or stopping when unsure, these are just some examples. Holding a handrail when taking the stairs used to seem so unnecessary; today it just comes naturally because it is the safe thing to do.

A few years ago I was remodeling a home. One Saturday afternoon I started to cut the tiles for a bathroom floor. Some of the tiles required finishing with a chisel. As I set up to finish those tiles with chisel and hammer, those words echoed; “How bad can it get?” I paused and thought for a moment about what I was preparing to do. I made sure I was wearing the right protective equipment. I checked the work surface to make sure it was clear of debris. Then I was ready to go. When I stuck the chisel, a piece of tile ricocheted off the work table and struck dead center the lenses of my glasses. That very moment became one of clarity for me and the reality of why the use of Error Reduction Tools makes such a difference. That brief pause and thought turned out to be a decision that may have save my eyesight. It sure changed my thinking.

Our Human Performance tools are derived from very basic principles. Most seem fairly simple. Tools such as “STAR” (Stop, Think, Act and Review) or “Procedure Use and Adherence” are basically common sense. The simple act of all workers collectively using and applying these tools is making a difference. If all workers apply these tools in a conscious, thinking way, then all of us will be better at hazard identification and error reduction because will be doing things the same way. And when we do things the same way, it makes it easy to identify those instances when something is forgotten, an unrecognized hazard, or an error that could be prevented. Error Reduction Tools – use them because they make us all safer.

James MooreDirector of OperationsBNI

Diversity Quote

"One must even beware of too much certainty that the answer to life's problems can only be found in one way and that all must agree to search for light in the same way and cannot find it in any other way.”

Eleanor Roosevelt

Lesson #1—Loss of Focus or Attention

An employee was using a bench grinder to polish a piece of metal on the wire wheel. When he turned to talk to another employee, and took his eyes off his work, the piece of metal he was holding became caught between the wheel and the tool rest. His finger was pulled into the wire wheel which instantly shaved off part of his finger.

Discussion: What went wrong? Which example is right, 1 or 2 and Why?

Lesson 3—Horseplay and Unsafe Acts

Employee #1 was using an oxygen-acetylene torch to weld a sign in place. While performing this task, he squirted water from a water extinguisher onto a co-worker who was walking by. In retaliation, the co-worker picked up a bucket full of liquid that he thought was water (but which was actually gasoline) and threw it at Employee #1, who was welding. As a result of this mutual horseplay, Employee #1 suffered third-degree burns over 90 percent of his body.

Humor In Safety

As a gift for his 40th birthday, co-workers give the companies Health and Safety Director an all expense paid fishing trip and vacation.

While on the fishing trip, he is tragically killed and finds himself greeted at the Pearly Gates by a brass band.

Saint Peter runs over, shakes his hand and says “Congratulations!”

“Congratulations for what?” asks the H&S Director.

“Congratulations for what?” says Saint Peter. “We are celebrating the fact that you lived to be 160 years old.”

“But that’s not true,” says the H&S Director. “I only lived to be forty.”

“That’s impossible,” says Saint Peter, “we added up your time sheets.”

Think they started the day knowing this would happen?

Lesson 4—PPE and Hazard Awareness

Employee #1 was working in a 3 ft deep excavation. He was pulling a water line under the road to replace the existing water line. A coworker was using a back hoe to assist in pulling the pipe through. The motor of the backhoe was running. As the coworker climbed back into the cab, he inadvertently hit the controls for the backhoe bucket. The bucket swung around and struck Employee #1 in the head. Employee #1 suffered a concussion and was hospitalized. The employee was not wearing a hard hat.

Was this event preventable? How and what should have been done differently?

Work should not have to be a death or injury experience. Unfortunately, lack of caution and attention can make it one.

What do you do when you hear someone say "be careful"? Should you listen and participate during Pre-Job Briefings or is it just something else that is slowing down your activities for the day?

Take a minute to really listen to the message whether it is coming from a co-worker or Supervisor leading a PJB. Ask yourself "Why should I be careful?" The answer is, "because accidents happen when you least expect them - and they could happen to me."

Listening Safety

Nearly all sites are filled with various sounds and noises. Each sound we hear is the result of an action of a worker using a tool or a piece of equipment operating. In nearly every case, a tool or piece of equipment will signal its breakdown by a change in the normal operating sound. Everyone on site should condition himself or herself to be able to pick up these advance warning signals even when wearing ear plugs or earmuffs. Your individual safety could easily be dependent on your ability to hear approaching danger.

Things Decreasing Listening Safety • Over concentration on work • Lack of sleep • Improper over eating habits • Use of alcohol or drugs (both legal and illegal) • Poor work place ventilation • Loud radio’s; individual radio with ear plugs

How to Improve Listening Safety Habits• Become acquainted with the proper operational sounds of equipment and tools • Listen closely to instructions. Ask questions if instructions are unclear or confusing • Stay alert

Remember:Although it may be easier to see danger than it is to hear it, your ears are able to perceive warning signals from all around you. Your eyes are only good in the direction you are looking. Fine tune your ears and you can fine tune your exposure to danger and injury.

Perceptions…….

Is there a difference between Perception and Reality?

There could be in some cases, this is the difference from one person to the next. More importantly should there be a difference between perception and reality in our work activities?

Simply put, No. Incorrect perceptions or those which have not been confirmed or validated are uncertainties. When faced with uncertainties it is important for us to seek answers and confirmation of what is going on.

This could be from our daily direction, procedures or processes, or conversations with co-workers. It is not in anyone’s best interest to move on with work activities based on an assumption that we know what is going on or needs to be done. Clear and precise communications is paramount.

If you are communicating—be clear and verify with your audience that the message has been correctly received.

If you are the audience—ask questions and be sure that you understand. Confirm what is in fact Reality.

The more questions you ask and answers you seek, the higher your level of awareness and attention will be driving the potential risks down.

Byron Station “Winter Walking” Safety Alert

IR: 1471295Date: February 5, 2013

Event Summary: On February 5, 2013 at approximately 2400 hours, a Security Officer slipped, fell, and bumped their head while exiting a security vehicle inside the protected area. At the time of the incident the officer was performing patrols and inspections within the Protected Area. Subsequent medical evaluation confirmed that no medical treatment was required (i.e., classified as first aid injury).

Immediate Actions:• The control room was notified• The employee was evaluated by Radiation Protection and then transported to an off-site site medical

facility for further evaluation. • The incident and immediate lessons learned were communicated to all security personnel.

Contributing Factors / Lessons Learned: The ground was not cleared and treated and, therefore, the employee was specifically briefed NOT to enter the area due to the amount of snow and ice that had accumulated. Contrary to SA-AA-2114, Winter Safety, the employee walked on ground that was covered with untreated ice and snow without donning foot traction devices (which were available inside the Security vehicle).

Planned Corrective Actions: Additional investigation and corrective actions will be established in accordance with the Corrective Action Program (CAP).