SAFER Dialogue Presentation

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SAFER Dialogue
Brian Harkins
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Principles of Human Performance
1. People are fallible, and even the best make
mistakes. 2. Error-likely situations are
predictable, manageable, and preventable. 3. Indiv
idual behavior is influenced by organizational
processes and values. 4. People achieve high
levels of performance based largely on the
encouragement and reinforcement received from
leaders, peers, and subordinates. 5. Events
can be avoided by understanding the reasons
mistakes occur and applying the lessons learned
from past events.
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PROACTIVE MENTAL FRAMEWORK
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SAFER Dialogue

Summarize Critical Steps
Anticipate Error Traps
Task Preview Before During Pre-job
Pre-job Briefing A Dialogue
Foresee Potential Consequences
Evaluate Defenses
Review Experience
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Summarize Critical Steps

• Not all steps of a procedure are equally
  important.
• Critical steps include
• Actions aimed at changing the state of facility
  structures, systems, or components
• Steps that are irrecoverable or actions that
  cannot be reversed
• Steps where the outcome of an error is
  intolerable for personnel or facility safety.

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Anticipate Error Traps

• Review the job-site conditions using the error
  precursors list.
• Some error precursors are particularly powerful,
  depending on the performance mode of the
  individual performing the action. For instance
• Distractions, simultaneous tasks, and fatigue
  strongly influence skill-based performance
• Mindset and confusing procedures influence
  rule-based performance
• Assumptions, first-time performance of the task,
  lack of knowledge, and inexperience influence
  knowledge-based performance

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Foresee Potential Consequences

• If a mistake does occur at a critical step,
• what is the worst that can happen?
• What is likely to occur?
• Consider the production goals that would not be
  achieved. However, safety and prevention are more
  important than schedule.
• If the potential outcomes of an error are judged
  as too severe, the task should not proceed as
  presently planned.

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Evaluate Defenses

• Review necessary defenses in light of potential
  errors.
• Determine contingencies for potential
  consequences of error.
• Evaluate if additional defenses.
• Evaluate recovery methods should undesirable
  errors or consequences occur.

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Review Experience

• What errors have occurred with this activity in
  the past?
• How have people made mistakes with this task in
  the past?
• Choose operating experience that focuses on the
  critical steps of the task at hand.
• Look at both other similar activities and similar
  critical steps.

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Review of Dive Activities
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Review of Dive Activities

• Observed practice dive
• Attended walk down of KE Basin work area
• Interviewed personnel associated with the
  activity (Divers, Planner, Radcon, NCO, IHS).
• Reviewed work instructions and dive company
  safety manual.
• Reviewed Lessons Learned from INPO, DOE, OSHA,
  and K Basins.
• Reviewed U.S. Navy Dive manual.

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SAFER Dialoguewith Industrial Health Safety

• Summarize Critical Steps
• Performing the dive suit leak test
• Prevention of Diver heat stress
• Back up air supplies
• Un-suiting process
• Emergency use of the SCBA bottle by the diver
• Primary breathing air supply
• Unanalyzed work scope change
• Personnel fall in Basin water.

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SAFER Dialoguewith Industrial Health Safety
Emergency use of the SCBA bottle by the diver

• Anticipate Error Traps (error precursors list)
• Task Demands
• Work Environment
• Unexpected equipment conditions
• Individual Capabilities
• Natural Tendencies/ Human Nature
• Complacency
• Other
• Equipment donned in the wrong order
• Umbilical snagged/ damaged
• Diver not able to reach bottle valve
• Diver not able to get himself to ladder

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SAFER Dialoguewith Industrial Health Safety
Emergency use of the SCBA bottle by the diver

• Foresee Potential Consequences
• Worst Case Death due drowning
• Expected Consequences Work stoppage

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SAFER Dialoguewith Industrial Health Safety
Emergency use of the SCBA bottle by the diver

• Evaluate Defenses

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SAFER Dialoguewith Industrial Health Safety
Emergency use of the SCBA bottle by the diver

• Review Experience
• INPO Report (OE9455) dated 11-30-1998, related
  the experience of a loss of breathing air due to
  breaking off of the air fitting on his dive
  helmet by backing in to an object. Significance
  is that all of the divers air came through that
  one fitting and he experienced a total loss of
  air. The diver was unable to reach the dive
  platform before passing out. He was rescued by a
  second diver working in the water with him but
  was not breathing and his face was pale and blue
  in color when he removed from the water. He was
  revived by dive team personnel. Discussion of
  process and associated problems with rescue,
  treatment, and transport of diver are also worth
  reviewing. Also noted was the divers inability
  to drop his weight belt and surface due issues
  with suit up.

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SAFER Dialoguewith Industrial Health Safety
Emergency use of the SCBA bottle by the diver

• Performance Mode Impacts on critical step
• Knowledge base performance mode
• Strongly influenced by assumptions, first-time
  performance of the task, lack of knowledge, and
  inexperience
• Divers need to practice emergency use of the SCBA
  bottle and exiting pool
• Equipment needs to be donned in the correct
  sequence

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SAFER Dialoguewith Industrial Health Safety
Emergency use of the SCBA bottle by the diver

• Areas for improvement
• To provide more assurance that diver will be able
  to act as expected, Management should consider
  having the divers practice disconnection from
  umbilical hose and return to the surface using
  SCBA bottle.
• Project should add a step to diver dressing check
  list to have the diver check to ensure that he
  can reach the SCBA bottle valve.

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Review Results

• Review identified 28 Areas for Improvement.
• Review identified 24 Lessons Learned that the
  project should review against specific project
  activities.

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Conclusion

• The SAFER Dialogue is a good pre-job or pre-task
  tool
• Its value is
• Craft personnel readily accept and embrace the
  process
• Uses personnel associated with the area (who know
  how things are really done) to do the review
• Good low level review of the current condition of
  barriers
• Helps personnel review their response to events