Category Archives: Cumulative Effects

When do error reduction techniques get in the way of the work? (Cumulative Effects)

Can the slow way be the fastest way? Two of the easiest Cumulative Effects for me to explore are extra Reviews, and the Circle/Slash method of place-keeping. Does it seem backwards to you that we may have created distractions for workers by trying to prevent distractions from causing a worker to make an error? This is not the only negative effect, as more steps and different methods means less time to do the job and more time pressure with a growing industry turnover rate. I want to give some readers a warning here – a little commercial nuclear power jargon is used in this post.

So, how did we end up with Cumulative Effects?

“Cumulative Effects” are not only affecting leadership, but also the last line of defense in the field (the workers). The way I understand the largest contributor to this is the Corrective Action program which typically only reviews effectiveness of Root Causes and maybe some specific Apparent Causes, which leaves a lot of lower level Corrective Actions that may have never been nor are continuing to be effective still within the system.

Stop helping me

You have to wonder if it is just the nuclear industry that has spent so much time, money and resources  adding layers of protection in between barriers that need to be built up with more resilience. Does this happen simply because adding another review step is easy to understand and quick to implement, versus making an existing barrier more robust? Ask yourself if it’s easy, fast, and seems like a S.M.A.R.T. Corrective Action that Management and the Corrective Action Review Board will agree on? This ends up with a lot of excess in the “system” that truly needs to be evaluated for effectiveness. (but where will we find the time and resources to do that?)

[Caution: In this paragraph I am speaking in generalities and these are totally the authors opinions as the note on the far bottom of the web page implies] Extra reviews seem like a fix-all for a struggling organization. As an example, after a while because of mistakes, the tagging/clearance order process gets to be overwhelmed and cumbersome with reviews, and some argue that it’s better that way – I feel like we sometimes miss the happy-medium. Organizations end up in downward spirals sometimes because they have to become aware of their problems, fix them, and prevent future occurrences, all while still getting their scheduled work completed. It is a wonder to be caught up in it and be able to see the welcoming light at the end of the recovery tunnel. Evaluators should involve end-users in discussions about a new way of doing business before making it official. Nothing about good, solid, S.M.A.R.T. Corrective Actions is easy, but adding more reviews seems like we have run out of options, other than “do nothing but raise awareness,” which should be explored sometimes.

Are we being counter-intuitive by adding distractions instead of eliminating them?

An example I’ve heard in the past is that we all have a pool of mental resources, and even thought our pools may be of different sizes (not everyone can be an astronaut, reactor operator, or a surgeon, etc.), we all can run out depending on the given situation. Fortunately, not all of these extra actions distract us from the work we are doing, primarily because skill tasks require less attention based on familiarity. Asking a group of people to change the way they have been doing something successfully, because someone made a mistake, isn’t really getting the stakeholders involved. Everyone performing a risk-important procedure (for those in nuclear a “Reference” or “Continuous” level of use) knows that they should be place-keeping, and ideally, the procedure is set up for the best type of place-keeping. Sometimes signature blocks are best for getting a peer or Quality Assurance check prior to performing a step, and sometimes a simple block being checked is the best form. Place-keeping by Circle/Slash is absolutely the most ideal tool for place-keeping certain tasks – risk-important activities that absolutely must be done in the prescribed method with no possible other way of doing them. Why does Circle/Slash work? See if the following rings a bell – This is the way I always teach it, so please feel free to use this method as a resource:

STOP – Circle the Step 
THINK – Read the Step 
ACT – Perform the Step 
REVIEW – Slash the Step 

This is the bottom line on why it can be so effective: When you use the Circle/Slash technique, you force yourself to Self-Check (STAR) each and every step of the procedure. Quote me on that 🙂

Two lessons on Circle/Slash:

1. Recognizing that some procedures (like AOPs or EOPs) already have place-keeping methods built-in (i.e. signature blocks, check blocks), we have stated in our station’s Procedure Usage Procedure that Circle/Slash will be used as the place-keeping method if no other method exists while performing a Continuous or Reference Use procedure. This frees up certain other methods to be employed if the people that use these procedures disagree with the Circle/Slash method for that particular work.
2. Circle/Slash really takes a little while to get used to, and procedure users should be adept at it prior to performing risk-important tasks, because the tool itself may distract them from actually thinking about what they’re doing. With this in mind how much time is spent practicing the technique prior to do actual field work? If someone thinks that circling and slashing is just about the easiest thing to implement they’ve ever heard of, they have not been in the mind of a nuclear professional who has many other things to be considering as the task is being performed. When used properly, HU Tools should never distract users from their task. If they are distracting the user, then I challenge they should not be used.

Wrap-up

For the record, I see checklists (and quality procedures) as a good thing to help us prevent omission and promote consistency when attempting to multitask when using mental resources. When driving towards the most important part of Human Performance (Situational Awareness), we must always start with recognition.
Recognize that in 2013 we are all super busy and trying to perform at optimum levels as often as possible. I recommend plenty of sleep and deliberately placing your tasks in series whenever possible – I used to have a mantra in I&C: “slow is fast.

Especially for you (a free resource for readers that reached the bottom of the post)

The Human Performance Tools Team will be doing our very best to share more and more resources with you as new posts are generated. Since you’ve read this far in this post we are going to give you an amazing podcast that you may get hooked on. Pat Flynn’s, “Smart Passive Income” has totally got our attention, and this link will take you to a story about two fiancés putting wedding invitations together and which method works better and why… you will be surprised at the results and the theory behind them: Click the picture to take you to the website where you can listen to the podcast and get the pdf transcript! Feel free to tell Pat we sent you! Enjoy.