Post on 27-Mar-2015
transcript
Dr. Bill Corcoran
June 22, 2010
16th Annual HPRCT ConferenceJune 21-25 · Baltimore Inner Harbor Hosted by Constellation Energy
President, Nuclear Safety Review Concepts Corporation, Windsor, CT 860-285-8779
Human Quality(Lines of Inquiry When Human(s) Don’t Perform Satisfactorily in Service and/or Aren’t Suitable for Their Intended Purpose)
© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
PECONUCLEARA Unit of PECO Energy
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44
Needed to Probe Human Quality (HuQ)
Some knowledge of Human Behavioral Technology (HBT)
Some knowledge of Business Issue Investigation (aka RCA)
Empathy, compassion, curiosity, skepticism Perspective: A good investigation makes
the despicable explicable.
5© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
Human Quality (HuQ)
What’s the Problem about HuQ? What is HuQ? Looking at the Problem as a Quality
Problem Lines of Inquiry Conclusions
6© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
What’s the Problem about HuQ?
All reported consequential events resulted from Inactions of humans Behaviors of humans and/or Conditions affected by humans
Established by humans Desired by humans Tolerated by humans and/or Undetected by humans
7© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
What is HuQ? I
A Quality Item Is demonstrated to meet its qualitative and
quantitative (Q/Q) acceptance criteria Will perform satisfactorily in service
Function-what it’s supposed to do Situation-conditions under which it is supposed to do it Time-when it’s supposed to do it and for the time it’s supposed to do it
Is suitable for its intended purposes
8© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
What is HuQ? II
Is it the same for humans? What are the Q/Q acceptance criteria? What is satisfactory performance in service? What are the intended purposes?
9© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
Looking at the Problem as a Quality Problem
The Item Its source Its history How it was treated How it was used The environment that it was used in Accountability for quality
10© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
Lines of Inquiry (LOIs) I
Facts HuQ is never a direct cause HuQ is never the root cause HuQ is never a root cause
LOIs What is the nature, the magnitude, the location, and the
timing (NMLT) of the HuQ Issue? What are the factors that resulted in the NMLT of the
HuQ Issue?
11© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
Lines of Inquiry (LOIs) II
What are the factors that resulted in the NMLT of those factors?
For each factor Creation Non-discovery Failure to effectively address
12© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
Lines of Inquiry (LOIs) III
For each factor Missed opportunities Barrier inadequacies Earlier, better, cheaper, safer, more risk-
informed, more safety culture indicative, more compliant ways of identifying and/or addressing the HuQ Issue and/or its factors before the event
13© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
Lines of Inquiry IV
For each HuQ Issue Significance
Significance of HuQ Issue Significance of each factor
Extent Extent of HuQ Issue Extent of each factor Factors resulting in the extent
14© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
Conclusions
HuQ issues are like other Q issues Perform satisfactorily in service Suitable for intended purposes Meet Q/Q acceptance criteria
HuQ issues have logical Lines of Inquiry
15© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
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Questions?
© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu