PDR HandbookSETTING PEOPLE SAFELY TO WORK

Plan Do Review

Contents04 Introduction

08 PDR at-a-glance

10 Understanding human error

12 What drives human error?

14 Error traps

15 Critical steps

17 Human factors and PDR

18 Human factor tools 18 Questioning attitude 19 Place-keeping 19 Self-checking 20 Peer -checking 20 Independent verification 21 Clear communication

23 Managing and controlling human factors

28 How to hold amazing team talks

30 The PDR form and process

32 Plan 34 Do 36 Review

38 Notes

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Introduction to

Plan Do Review

It provides a clear structure for you to brief your teams in the

field so that you can:

Check their understanding before work starts (Plan)

Make sure work is completed safely during the task (Do)

Capture learning after the task is complete (Review)

At the heart of the PDR process is our how to work safely

philosophy, which is based on three basic principles:

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One team, working together

It doesn’t matter who you work for, we’re all in this together. We can achieve great things if we put our heads together, look out for each other and treat each other with courtesy and respect.

One goal, zero harm Our motto is ‘do it safely or not at all’ and we stand by that. Preventing harm, to people, plant and the environment, comes first, regardless of cost or deadlines. If you think something’s unsafe or doesn’t feel right, stop what you’re doing and ask for advice. Step up and make a difference.

One standard, world class We want to see world-class performance across all our wind farms, so help us improve and never be content with ‘good enough’. There’s always room for improvement. If you think there’s a better way of doing something, let us know.

The PDR ‘Plan, Do, Review’ process helps to ensure that jobs are completed safely and correctly

What this means for you

Firstly, please take the time to read this handbook and

familiarise yourself with the PDR process. This isn’t ‘red

tape’ or another management initiative, it’s a proven way

to make us safer, more efficient and more productive. It’s a

technique used by Nascar and Formula 1 teams, elite sports

teams and world-class businesses. Please get on board.

Secondly, please remember that communication is

what the PDR process relies on. This handbook will

help you structure your briefings, get the most from your

team, and avoid errors that could lead to injuries

or mistakes being made.

As supervisors and experienced engineers, you are vital

to making this work. It may seem obvious, but we couldn’t

do it without you.

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PDR at a glance

Supervisor – office

In advance of the job starting

Pre-planning:

1. LOTO2. Procedures3. Permits4. Risks, hazards and

controls5. Equipment

Plan Do Review

Team – in the field

Immediately beforework starts

Check understanding:

1. Work procedure2. Operating experience3. Critical steps4. Risks, hazards and

controls5. Human factors

Team – in the field

While the job is underway

Monitor & review:

1. Dynamic risks and hazards

2. Deviations / changes to the work plan

3. Human Factor tools to avoid errors

Team – office

Immediately after the job has finished

Build operating experience:

1. What went well & what is repeatable

2. What issues / problems arose

3. What needs to be reported / corrected

Pre-job brief The work Post-job debriefPre-job plan

Understanding human error

Fortunately, most human errors are insignificant in terms of their consequences, but some are more serious, particularly for people who work in high risk environments like us where the stakes are high, e.g:

T Physical injury to people/plant/equipment

T Work at height (falls, drops), manual handling, high voltage, mechanical injury/damage etc

T Environmental breach (emissions, waste, substance mishandling)

T Damage to brand & goodwill (negative publicity)

T Loss of profit / revenue, damage to share price

T Regulatory sanction (fine, enforcement proceedings)

T Criminal prosecution (fines, corporate manslaughter)

Most human error happens at an organization level, although it always seems to be the individual operator who gets the blame for the incident! In reality, their mistake is usually the end of a long chain of organisational failings, from cultural weaknesses (poor leadership, a lack of trust, a blame culture for example) to behavioural or procedural issues that have never been resolved. The root cause of most incidents is seldom the actions of one individual.

Human error can be defined as:

‘an action or inaction that results in an unintended and unexpected outcome’

20%Equipment or Process Failure

80%Human Error

80%Organisational Failing

20%Individual

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Individuals:T Have different attitudes towards risk and risk-taking

T Are not naturally compliant and are hard-wired to take short-cuts

T Become complacent when things become familiar.

T Make mistakes because we don’t predict and manage Human Factors

Organisations:T Respond to risk and incidents with increasingly complex

policies and procedures

T Blame individuals as the cause of accidents rather than their own systemic failings

T Don’t understand, predict or manage situations where human error is more likely

T See safety & quality as ‘compliance’ issues and create a punishment-driven safety culture

T Rarely learn from past experience

What drives human error?

“ It’ll never happen to me, I’m not that careless”

“ I know what I’m doing, I’ve been doing this job for years”

“ People do it all the time - it’s ok if you don’t get caught”

“ I haven’t got time, I’ve got a job to do...”

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Error traps Critical stepsThere are some situations where human error becomes more likely These can be grouped into four main categories:

Task, Environment, Ability & MindsetRecognising and anticipating these situations makes it easier to avoid human error happening.

It is also important to be aware of critical steps that can be takenA Critical Step is an action that, if performed incorrectly, “will cause irreversible harm to people, the environment, equipment, or that will significantly affect the operation of the plant.”

Critical Steps are, literally, the point of no return.

TaskT Time pressure

T High work load

T Repetitive work

T Unclear instructions

T Complex processes

T Lack of resource

T Critical steps

EnvironmentT Distractions

T Interruptions

T Noise, heat, dust

T Weather

T Difficult access

T Confusing controls

T Poor equipment / tool conditions

T Hazardous work types (e.g. work at height, confined spaces, hot work etc.)

AbilityT Tiredness or illness

T Stress

T Lack of knowledge

T Lack of skill

T Lack of experience

T Physical limitations

T Low ability to communicate

MindsetT Habit patterns

T Assumptions

T Complacency

T Over-confidence

T Unwillingness to challenge

T Willingness to take risks or shortcuts

T Lack of teamwork

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Human factors & PDRHuman factors should be considered as part of the planning team-talk before work starts

T Use the TEAM prompts to think about situations where errors are more likely

T Identify them and discuss what tools you will use to reduce the risk of errors happening

T Human Factors should then be constantly reviewed in the ‘do’ phase during the task. For example, are people showing signs of tiredness? Are there more distractions, etc...

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Human factor toolsQuestioning attitude

Place-keeping

Self-checking (STAR)

Place-keeping is vital to make sure that steps in complex or unfamiliar procedures aren’t missed or repeated.

T Read and understand the entire step

T Mark the step with a circle to indicate that it has been read and understood

T Perform the step as written

T When complete, put a slash through the circle

STOPPause & focus

THINKVisualise the task

Plan for the unexpected

Have a contingency plan

Seek advice if necessary

ACTDo the task: point / touch / verbalise

Follow the procedure

Monitor progress

Stop if it doesn’t feel right

REVIEWDid the job go as expected?

If not, make safe

Make sure your OPEX helps to prevent future errors

Human factor tools

T Approach all tasks with a ‘healthy unease’

T Raise concerns before starting work where possible and make sure they are resolved

T Where a procedure exists, follow it, but if anything is ambiguous or incorrect, stop work, make the job safe, get clarification. Flag it in the task review and get the procedure amended

T Continually review what you’re doing and stop if anything “doesn’t feel right” or you’re unsure

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Peer-checkingThis is a particularly useful tool during complicated procedures and before critical steps (the point of no return).

It involves a second person making sure you are going to do the right thing BEFORE you take any action

T Person A: “I am going to do X, Y & Z in this way”

T Person B checks.

T Person B confirms if that is correct (or not!).

T Person A performs the task with Person B watching and giving live feedback

Independent verification This provides a second check AFTER the action has taken place. Happens in series (not parallel).

Independent Verification is a good technique to run checks before plant has been re-energised or components reassembled.

Clear communicationClear communication is an essential tool to avoid human error in almost every circumstance. It ensures that there are no misunderstandings and that instructions are clear and understood.

When communicating, try to eliminate distractions - get visual face-to-face contact where possible.

When using a radio or phone:

T Confirm name & location of the sender & receiver

T Be clear and concise - use the phonetic alphabet for alphanumeric information

T Check the receiver has understood the message - ask them to repeat it back

T Acknowledge they have understood (e.g: ‘that is correct’)

When communicating numbers:

T Numbers should always be said in single digits

T One hundred and twenty three is relayed as: 1, 2, 3

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T Nine thousand eight hundred and seventy six is relayed as: 9, 8, 7, 6

T 0 = Zero, not ‘nought’ or ‘oh’

T Two thousand and thirteen would be relayed as: 2, 0, 1, 3

T Always repeat back for confirmation!

ALPHA

BRAVO

CHARLIE

DELTA

ECHO

FOXTROT

GOLF

HOTEL

INDIA

JULIET

KILO

LIMA

MIKE

NOVEMBER

OSCAR

PAPA

QUEBEC

ROMEO

SIERRA

TANGO

UNIFORM

VICTOR

WHISKEY

X-RAY

YANKEE

ZULU

Phonetic Alphabet

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Managing and controlling human factors

TIME PRESSURE: acknowledge deadlines, but remind people to work methodically and safely. Don’t cut break time or increase working hours (creating other error traps) Key tools: place-keeping, self-checking

HIGH WORK-LOAD: see above. Try to increase resource/ change shift patterns so people aren’t overworked

REPETITIVE WORK: regular breaks, changes in operative Key tools: place-keeping, self-checking, peer review

Task

Task, Environment, Ability & Mindset

UNCLEAR INSTRUCTIONS: provide clarity and confirm understanding Key tool: questioning attitude

COMPLICATED PROCESSES: discuss in detail during planning team-talk Key tools: clear communication, place-keeping, self-checking, peer review, independent verification

LACK OF RESOURCE: push for more people or time

CRITICAL STEPS: plan ahead and discuss them in detail Key tools: clear communication to make sure exact procedure is understood, self-checking and peer checking, with independent verification if required.

NOISE, HEAT, DUST, WEATHER: use appropriate PPE, plan breaks, use emergency procedures (weather)

DIFFICULT ACCESS: use appropriate access methods, discuss approach during planning team-talk, have a contingency plan in place Key tool: questioning attitude

CONFUSING CONTROLS OR DISPLAYS: Key tools: clear communication, place-keeping, questioning attitude, self-checking, peer-checking, independent verification

POOR CONDITION OF EQUIPMENT OR TOOLS: discuss with EHS team if there are safety implications. Do not start/continue a task if poor condition could cause damage/injury Key tool: questioning attitude

HAZARDOUS WORK TYPES (e.g. working at height, confined spaces, hot work etc): ensure you have completed a full risk assessment and have contingency plans in place. Review LOTO procedure. Ensure team have correct training/skills/knowledge. Put appropriate controls in place to mitigate risks (e.g. PPE, barriers, rescue plans) Key tools: all!

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DISTRACTIONS / INTERRUPTIONS: try to minimise them. Check in with team members Key tool: place-keeping. Stop if safety or quality is compromised

Environment

TIREDNESS OR ILLNESS: check during planning stage. Assess risks and assign tasks accordingly or find alternative resource Key tool: questioning attitude

STRESS: difficult to identify Key tool: questioning attitude

LACK OF KNOWLEDGE, SKILL OR EXPERIENCE: check team credentials in advance. Test knowledge and understanding in planning session. Find alternative resource if necessary Key tools: questioning attitude, self-checking, peer checking or independent verification if no alternative

PHYSICAL LIMITATIONS: check individual’s limitations against task requirements and assign tasks according to physical ability. Find alternative resource if safety / quality at risk Key tool: questioning attitude

LOW ABILITY TO COMMUNICATE: check individual’s understanding in the PDR team talk/huddle. Assign a buddy to check / verify work if needed. Check in regularly for progress Key tools: questioning attitude, peer review, independent verification, communication

MindsetAbilityHABIT PATTERNS: review Operating Experience; ask questions in planning briefing Key tool: questioning attitude

ASSUMPTIONS: ensure planning briefing addresses potential problem areas Key tool: questioning attitude

COMPLACENCY OR OVER-CONFIDENCE: stay alert to potential issues in the team. Use coaching conversations; if there is an ongoing risk to safety or quality, use an alternative resource Key tools: questioning attitude, peer-checking, independent verification

UNWILLINGNESS TO CHALLENGE: see all of above

WILLINGNESS TO TAKE RISKS OR SHORTCUTS: see above

LACK OF TEAMWORK: create a buddy system (also good for peer-checking). Partner less experienced team members with more experienced personnel; engage everyone in planning team talks; eliminate any differences between how you engage & speak to internal employees and contractors Key tools: clear communication, peer-checking, independent verification

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How to hold amazing team talksThe team talk is your primary opportunity to make sure your team understands the task ahead, considers the risks involved and anticipates (and manages) potential human error situationsIt’s your chance (and theirs) to ask questions, clear up any issues, and make sure everyone is on board and ready.

Here are a few tips to make sure you team talks are as effective as they can be.

1. Find somewhere without too many distractions (this may not always be easy!)

2. Speak clearly and slowly and maintain eye contact.

3. Be positive and friendly - people will follow your lead.

4. Encourage discussion.

5. Never assume people know what you’re talking about - check understanding by asking open questions.

6. Use real examples and situations to demonstrate a point.

Authority Gradients Remember not to fall into the ‘authority gradient’ trap. This is one of the biggest causes of human error, and occurs when there is a difference in seniority (e.g. supervisor / junior technician).

T Junior team members may be unwilling to challenge and raise issues with more senior people.

T Team leaders and supervisors may be unwilling to listen to or trust less senior people.

The team talk is the most important part of the

‘setting to work’ process!

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REVIEW [with the team once the job is complete]

1. What lessons/solutions can be taken forward? Whatwent well and what could make the job more efficient?

near misses, defects, equipment issues)?

2. What issues or problems arose?

3. What needs to be reported & corrected (e.g. injuries,

DO [at the work site while work is underway]

1. Monitor and control Dynamic Risks & Hazards

3. Use Human Factor Tools to reduce risk of human errors

using procedures, questioning attitude, communication)(self-checking, peer-checking, independent verification,

2. Pause to discuss and check the team’sunderstanding of any deviations

PLAN [huddle at the work site before work begins]

Team members:

1. Outline the Work Procedure – what, who, how

2. Review Operating Experience – past learning

3. Identify Critical Steps – plus special measures

4. Identify Risks, Hazards & Controls

5. Use the Human Factor TEAM prompts to discussthe risk of human errors and ways to prevent them

Date

Site name

Emergency #

WTG #

Radio channel

Hub entry

Extended LOTO

WTG Config

Lock Out, Tag Out ( LOTO )

Work Procedures

signaturePre-job verification

Work scope summary

Supporting documentation

Person in charge / job lead

TASK INFORMATION

The ‘Plan-Do-Review’ (PDR) process ensures that jobs are completed safely and correctly once pre-job planning has been completed. It gives a clear structure to brief your team in the field, checking their understanding before work

starts (PLAN), making sure work is completed safely during the task (DO) and capturing learning after the task is complete (REVIEW) to share experience and improve. Supervisors / job leads should use this form as a guide and submit it to the Project Lead once the job has been completed.

THE PDR PROCESS

GETTING YOUR TEAM TOGETHER: THE HUDDLEFind somewhere without too many distractions / speak clearly and slowly, make sure everyone can hear you / be positive, friendly and enthusiastic – people will follow your lead / never assume people know what you’re talking about – check understanding by asking open questions / use real examples and situations to demonstrate a point.

The job is not complete until the review has been held The aim is to gather direct feedback after the job in terms of what issues arose and went well, what could be improved when the job is performed in the future, and what needs to be reported up for corrective action. The output will ensure corrective action is taken, and also form part of the Operating Experience for the next PDR

1. What lessons / solutions can be taken forward? What went well and could make the job more efficient?

2. What issues / problems arose? Were there injuries? Were errors made? What caused them? What should bedone differently in the future to prevent errors and injuries or improve the job?

3. What needs to be reported and corrected (e.g. injuries, near misses, defects, equipment issues)?

1. What lessons / solutions can be taken forward? What went well and could make the job more efficient?

2. What issues / problems arose? Were there injuries? Were errors made? What caused them? What should be done differently in the future to prevent errors and injuries or improve the job?

3. What needs to be reported and corrected (e.g. injuries, near misses, defects, equipment issues)?

RE

VIE

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This part of the process ensures that safety and quality standards are maintained while the task is underway. It’s all about staying alert to changing circumstances

Your pre-job ‘desktop’ planning should be complete. Before work starts, hold your team huddle at the work site to check that everybody understands the plan

1. Monitor & control Dynamic Risks & Hazards. What’s changing? (e.g. weather, new people involved, wildlife)

2. Pause if there are deviations to the work scope or work procedure. To make sure everyone understandswhat’s changed: pause, gather your team, discuss the deviations, check people’s understanding and continue

3. Use Human Factor Tools to reduce the risk of human error: Self-checking (STOP, THINK, ACT, REVIEW)Pause, visualise and plan, verbalise and do the task, review what you’ve done / Peer review (before criticalsteps) Ask a colleague to verify that what you are about to do is correct / Independent verification (aftertask done) Ask a colleague to verify what you have just done is correct / Using procedures Check they’re up to date; use place-keeping; stop if unsure, suggest changes if needed / Questioning attitude Don’t make assumptions; raise concerns before starting; review and stop if unsure / Communication Make sure radios work; communicate clearly; use phonetic alphabet; verify understanding

1. Outline the Work Procedure – what you’re doing (step by step); who does what; how different parts of the jobneed to be done

2. Review Operating Experience – use learning from previous jobs. Have any of the team done this job before?Do you have previous PDRs / lessons learned to review?

3. Identify Critical Steps. What parts of the task might require special precautions (e.g. an Icing ApproachChecklist, Catastrophic Turbine Failure Checklist)? What additional safety checks / human factor tools may beneeded to prevent errors/incidents before and during Critical Steps?

4. Identify Risks, Hazards & Controls. These might include the weather, wildlife, hot work, work at height,manual handling, lifting, live plant, confined spaces, slips/trips, moving plant etc. There may be others. Identifyand put controls in place (e.g. PPE, barriers, specialist equipment, LOTO, signage etc)

5. Identify & discuss Human Factors using TEAM prompts to understand what makes errors more likely andwhat you can do to prevent them:

TASK / e.g. time pressure, high work load, repetitive work, unclear instructions, lack of resources, critical steps

ENVIRONMENT / e.g. distractions, noise/heat/dust/weather, difficult access, poor equipment, hazardous work types

ABILITY / e.g. tiredness, illness, stress, lack of knowledge, skill or experience, physical limitations, low communication ability

MINDSET / habit patterns, assumptions, complacency, over-confidence, unwilling to challenge, risk-taker, poor teamwork

DO

PL

AN

JOB LEAD / SUPERVISOR’S GUIDE

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Critical StepsT These are the parts of a task that, if performed incorrectly, “will

cause irreversible harm to people, the environment, equipment, or that will significantly affect the operation of the plant.”

T Identify critical steps in your pre-job brief.

T Put additional checks and controls in place to make sure they are performed safely and correctly.

Risks and HazardsT Risks and hazards should have been identified as part of the

‘desktop’ pre-planning phase and controls put in place before work starts (e.g. LOTO, barriers etc).

T This is your opportunity to discuss the key risks, hazards and controls to make sure team members are aware of them in the field.

T Perform a final risk assessment with the team before work starts to identify any new risks/hazards on site.

Human FactorsT This is the time to consider Human Factors using the TEAM

model (Task Environment, Ability, Mindset).

T You may need to explain some of the Human Factor tools to team members (e.g. place-keeping technique, clear communication).

Work ProcedureT Ensure that everyone knows what needs to be done, any

specific techniques/procedures that need to be followed, and who does what.

T Speak clearly and slowly.

T Check understanding with open questions.

Operating ExperienceT Ensure that everyone knows what needs to be done, Operating

Experience is your accumulated knowledge and experience of the task. Ideally, each team should have an OPEX coordinator to collate and share OPEX. In the pre-job brief, you can discuss:

F Personal on-the-job experience F Previous errors, incidents and near misses F Training, pre-job briefs and post-job debriefs F Toolbox talks, team talks, learning briefs F Risk assessments, method statements & procedures

T Discuss experience from past jobs.

T Bring previous PDR reviews if you have them.

T Be specific.

T Ask team members for their experiences.

T Identify positive things you want to do again, and things you need to avoid doing.

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Plan

Using Human Factor ToolsT Check that Human Factor tools are being used per the plan.

T Stay alert to new causes of Human Error - e.g. changes in the task demands (changing deadlines, fewer people available), changes to the work environment (distractions, light, noise, other teams) and individual ability (fatigue).

Maintaining Safety & QualityT Monitor and control dynamic risks and hazards.

T Manage changes to the work scope / procedure.

T Continue to use Human Factor tools to reduce human error.

Dynamic Risks & HazardsT Make sure you and your team are alert to dynamic risks

and hazards as work is underway (e.g. changing weather, distractions, lighting etc)

T If it is something everybody needs to be aware of, stop, contact each team member individually or gather the team together to discuss.

T Put controls in place as appropriate.

Changes to the PlanT If your work scope or work procedure needs to change, pause,

gather your team together and explain the changes.

T Make sure everybody is aware of the changes and understands what practical impact this has.

Do

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Review - Continuously ImprovingT The task is not complete until the review has been done!

T Can be done individually (if a lone-working task), or as a team (all should be present where possible).

T A key learning opportunity for everyone involved in the task – encourage questions and discussion.

T Important to capture the output, which will contribute to overall OPEX and go into planning the next job.

Post-Job ReviewT What went well?

F What could be repeated in the future?

F What would make the job more efficient / safer / better?

T What issues arose?

F What errors or mistakes happened?

F Were there any injuries or near misses?

F Did any unforeseen risks or hazards occur?

F Was there a lack of resources / equipment?

F What could be done in the future to avoid these issues?

T What needs to be reported or corrected?

T Make sure you report any injuries or near misses to help the EHS team learn and improve safety.

T Communicate any defects or equipment issues that need to be fixed.

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Review

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Notes

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© General Electric Company 2020 v1.1 PDR