Issue Date: 12/12/00 - 1 - 71841

NRC INSPECTION MANUALInspection Procedure 71841

HUMAN PERFORMANCE

PROGRAM APPLICABILITY:2515, Appendix B

71841-01 INSPECTION OBJECTIVE

01.01 To assess the adequacy of the licensee’s root causeevaluation and corrective actions with respect to humanperformance.

01.02 To independently assess the extent of condition associatedwith the identified human performance root causes.

71841-02 INSPECTION REQUIREMENTS

This inspection will substantiate that the licensee has adequatelyidentified in their evaluation, the root cause(s)or contributingcauses(s) and taken appropriate corrective actions for each humanperformance related issue.

This inspection will also independently assess extent ofcondition(s) with respect to human performance such that each humanperformance identified problem has been evaluated for potentialimpacts on other plant equipment, programs or processes.

In completing this inspection procedure it is not expected that NRCinspectors perform a full evaluation of each causal factor listedbelow. However, the inspectors should assure themselves that theyhave independently reviewed the underlined topic areas to determinetheir applicability to the human performance issue(s) of concern.The inspector should check each topic area for possibleapplicability and if the area is applicable should then review eachcausal factor within that section of the table. Questions toaddress each causal factor are provided in the specific guidancearea of this procedure.

71841 - 2 - Issue Date: 12/12/00

Topic Areas and Causal Factors:

(See tables starting on page 6 for more detail)

02.01 Human-System Interface

a. Visual Information/display

$ missing$ incorrect$ mistrusted$ visibility less than adequate (LTA)$ content LTA$ organization/format LTA $ too much information$ insufficient information$ identifiers (labels and tagouts, warnings and postings) LTA$ confusing $ accessibility LTA$ navigation LTA (method of movement through displays)$ conflicting$ unstable

b. Control function/control device

$ missing$ accessibility/location for hard-wired controls LTA$ accessibility of soft (software mediated) controls LTA$ movement/motion LTA$ function LTA$ too many concurrent actions$ response/feedback LTA$ identification (labels and tagouts) LTA

c. Alarm/annunciation

$ missing$ too many/not prioritized$ auditory warning LTA$ organization/format LTA$ content LTA$ visibility/conspicuity LTA$ continuously illuminated$ continuously repeated$ disabled$ alarm procedure availability/accessibility LTA$ computer printout and control room log differ$ navigation LTA$ alarm response LTA

02.02 Environment

$ too hot$ too cold$ too humid$ too dark$ too bright$ too noisy$ cramped/inaccessible workplace$ dangerous work place$ distractions prevalent$ high radiation/toxicity$ vibration impedes work

02.03 Communication

$ missing/lack of information$ content LTA

Issue Date: 12/12/00 - 3 - 71841

$ untimely information$ misunderstood/misinterpreted$ inconsistent information$ repeat-back LTA$ verification LTA$ mode/communication devices LTA$ logbook maintenance LTA$ work package LTA$ document management LTA$ standard terminology LTA$ information about system/equipment LTA$ information not sought$ information not used

02.04 Coordination of Work/Supervision

$ supervisory availability LTA$ task description/explanation LTA$ coordination of team activities LTA$ assignments of roles and responsibilities LTA$ task progress monitoring LTA$ chain of command LTA $ oversight LTA$ staff working hours program LTA$ pre-job briefing LTA$ shift turnover LTA$ planning and scheduling work LTA$ resource allocation LTA

02.05 Work Practices

$ formalization of work practices LTA$ self-checking LTA$ independent verification LTA$ walkdowns LTA$ inattention to detail$ lack of questioning attitude$ lack of awareness of equipment status $ lack of awareness of plant condition (situation awareness

LTA)$ lack safe work practices$ improper tools/materials used$ teamwork LTA$ housekeeping LTA$ too many task interruptions$ too many concurrent tasks$ excessive workload $ time pressure to complete tasks$ cognitive overload$ cognitive underload (boredom)

02.06 Procedure use/adherence (for procedure quality use IP 42001or IP 42700)

$ no procedure/unavailable$ procedure/references not used$ procedure prerequisites not met$ procedure steps circumvented$ procedure modification process LTA$ incorrect procedure used$ procedure believed to be incorrect

02.07 Training and qualifications (use IP41500 and NUREG-1220)

02.08 Fitness For Duty

$ substance abuse (chemical and alcohol)$ illness

71841 - 4 - Issue Date: 12/12/00

$ fatigue$ excessive overtime$ working too long without resting/working continuously without

breaks$ too many distractions$ night work$ called into work outside regular schedule

71841-03 INSPECTION GUIDANCE

General Guidance

This inspection procedure is designed to be used to assess theadequacy of the licensee’s evaluation of human performance issues.As such, a reasonable time (generally within 30-60 days) should beallowed for the licensee to complete their evaluation; however, allcorrective actions may not be fully completed upon commencement ofthis procedure.

At least one inspector assigned to this inspection should have hadrecent or refresher training (within 5 years) in a recognized rootcause technique (e.g. HPIP, MORT). In addition, the inspectorshould be familiar with the discipline or system associated withissue.

The tables contained in the Specific Guidance section are providedas guidance to help the inspector fulfill the inspectionrequirements contained in paragraph 02. It is not intended thatthe inspector perform a full evaluation of each causal factor,however to the extent that the human performance issue containsfeatures related to the causal factor that entire section should beconsulted. The intent is that the inspector use the guidancecontained in the tables to verify that the licensee’s evaluationidentified the appropriate deficiencies associated with theperformance issue and that the licensee has initiated a reasonablecorrective action. Should the inspector not be able to make anassessment from the answers to the questions, he/she should consultwith the human factors specialists in headquarters.

Inspectors should be aware that more than one corrective action maybe necessary to correct a particular contributing or root cause.In addition, the inspectors may need to look at several identifiedcontributing or root causes for the human performance issue.Although unlikely, one human performance root cause may cover anentire white, yellow or red input or more likely may be one ofseveral root causes identified within a white, yellow or red input.

Definitions

Root Cause(s) is defined as the basic reason(s) (i.e., hardware,process, human performance), for a problem, which if corrected,will prevent recurrence of that problem.

Contributing Cause(s) is defined as causes that by themselves wouldnot create the problem, but are important enough to be recognizedas needing corrective action. Contributing causes are thoseactions, conditions, or events which directly or indirectlyinfluence the outcome of a situation or problem.

Extent of Condition is defined as the extent to which an identifiedproblem has the potential to impact other plant equipment, programsor processes in the same manner identified in the root causeanalysis.

Human-system Interface (HSI) is defined as the technology throughwhich personnel interact with systems, e.g. alarms, displays,controls, procedures, valve handles, test points.

Issue Date: 12/12/00 - 5 - 71841

Specific Guidance

The information contained in this section provides the inspectorwith specific guidance on how to determine if the licensee’s rootcause evaluation and corrective actions were adequately performedand implemented. The inspector will, using the information providedto him by the licensee (e.g., licensee’s root cause analysis andcorrective action plan/results), selectively apply the guidance inthe attribute table(s) that relates to the problem evaluated by thelicensee to determine whether the licensee’s evaluation andcorrective action processes have adequately considered theattributes contained in the relevant tables. For example, if it isdetermined that a human-system interface deficiency(ies) such asincorrect information being displayed by an instrument wasidentified as a cause by the licensee in its evaluation, theinspector would use the Visual Information table to evaluate thethoroughness of the licensee’s evaluation of this cause. It isintended that the inspector will incorporate an explanation in theinspection report to document the licensee’s responses to items incolumns (1) through (3) for each of the applicable attributes thatthe inspector evaluates.

With respect to "extent of condition", the inspector is expected todetermine if the licensee adequately determined if the identifiedroot cause(s) could have impacted other plant equipment, programsor processes. If the licensee did not adequately investigateextent of condition of the human performance problem then it isexpected that the inspector will independently follow-up. Theinspector should use column 3 as a guide to ask the appropriatequestions to ascertain if other potential areas or conditions alsoneed corrective actions.

Human-System Interface

Visual Information/Display

(1)Causal

Factors:(Root Causeorcontributingcause)

(2)For each of theitems provide theevidence used toidentify the rootcause

(3)For the immediatecondition as wellas for any other

relatedapplicable

conditions hasthe licensee:

(4)References

missing What is the specificmissing information?

provided themissinginformationsatisfactorily?

incorrect What is incorrectabout theinformation?

corrected theinformationsatisfactorily?

NUREG-0700, Rev.1,Paragraph(0700) -1.4

71841 - 6 - Issue Date: 12/12/00

mistrusted Why is theinformationmistrusted?

eliminated thereason formistrustsatisfactorily?

0700 - 1.4

visibilityLTA

(LTA = lessthanadequate)

Why is theinformationdifficult to see? Is it in a poorlocation? Toosmall? Poorcontrast tobackground (color,brightness, glare)?

relocated theinformation?Enlarged thefont? Improvedthe contrastimproved?

0700 -1.1, 1.2,1.3, 1.5

content LTA What specifically isinadequate about theinformation content?

improved thecontentsatisfactorily?

0700 -1.1, 1.4

organization/format LTA

Is theorganization/formatconfusing? Whatspecifically isconfusing?

improved theorganization/format satisfactorilyto eliminate theconfusion?

0700 -1.1, 1.2,1.3

too muchinformation

Is there unneededinformation suchthat the neededinformation isdifficult to find?

removed theunneededinformation orprovided a methodof prioritizingthe neededinformation?

0700 - 1.1

insufficientinformation

Is there not enoughinformation to meetthe need?

added informationto meet the need?

0700 -1.1-10

identifiers(labels andtagouts,warnings andpostings)LTA

Is the equipment notlabeled or labeledpoorly such that itis not easilyidentified? Are theidentifiers missing,inaccurate,confusing ordifficult to detect? Do tagouts obscureother information?

labeled orimproved theinformationlabelingsatisfactorily?Provided evidencethat warnings andpostings areinadequate? Improved theidentifierprogram toeliminateproblems?

0700 -1.1, 1.2,1.3

confusing Is the informationas presentedconfusing? What isthe source of theconfusion?

taken steps toeliminate theconfusion?

0700 -1.1, 1.2,1.3

accessibility LTA

Why is theinformationdifficult to access?

improved theaccessibility ofthe information?

0700 -1.1, 2.5

navigationLTA (methodof movingthroughdisplays)

Is it difficult orcumbersome accessingthe desired display?

taken steps toimprove displayaccess?

0700 - 2.

Issue Date: 12/12/00 - 7 - 71841

conflicting Are there conflictsbetween multiplesources of the sameinformation?

corrected thesource of theinformationconflict?

0700 - 1.4

unstable Is there a mismatchbetween theparameter beingmeasured and thedisplayedinformation for thatparameter?

identified thesource of the mismatch(e.g.,display,signal, sensor)? Corrected thesource of theinformationmismatch?

0700 - 1.4

Control Function/Control Device

(1)Causal

Factors:(Root Cause

orcontributing cause)

(2)For each of theitems provide theevidence used toidentify the rootcause

(3)For the

immediatecondition as

well as for anyother relatedapplicable

conditions hasthe licensee:

(4)References

missing What specificcontrol function ismissing?

provided thenecessarycontrol functionwhere needed?

accessibility/locationfor hard-wiredcontrolsLTA

Is the control toohigh? Too low? Toofar from associated displays? Is itblocked/covered byother equipment?

moved thecontrol to asatisfactorylocation orremoved impedingequipment?

0700 -3.1, 3.3,3.4

accessibility of softcontrolsLTA

Is the controlaccessible? Why isthe controlinaccessible?

improved theaccessibility ofthe control?

0700 -2.1, 3.1,3.2, 3.4

movement/motion LTA

Is the direction ofmotioncorrect/intuitive? Is it difficult tooperate (tension toogreat, range ofmovement too great,too small?). Is thecontrol size/shapeuncomfortable?

corrected thecontrolmovement/motion/feel?

0700 -3.1, 3.2,3.3

functionLTA

Is the function ofthe controlappropriate? Doesit do what isrequired of thetask/action?

corrected thecontrol toprovide therequiredfunction?

0700 -2.1, 2.2,2.3, 2.5,2.6, 2.7

71841 - 8 - Issue Date: 12/12/00

too manyconcurrentactions

Does the operatorhave to perform toomany control actionsconcurrently orwithin too short ofa time period?

corrected theconcurrentaction problemsatisfactorily?

0700 - 2.1

response/feedbackLTA

Is theresponse/feedbacksatisfactory? Canthe operatorunderstand what thecontrol action hasaccomplished? Isresponse/feedbacktimely?

provided asatisfactory andtimelyresponse/feedback?

0700 -2.4, 3.4

identification (labelsandtagouts)LTA

Is the controlfunction not labeledor labeled poorlysuch that it is noteasily identified?

labeled orimproved thecontrol functionlabelingsatisfactorily?

0700 -2.1, 3.1,3.2, 3.3,3.4

Alarm/annunciation

(1)Causal

Factors:(Root Cause

orcontributing cause)

(2)For each of theitems provide theevidence used toidentify the rootcause

(3)For the

immediatecondition as

well as for anyother relatedapplicable

conditions hasthe licensee:

(4)References

missing What specific alarmis missing? Whatfunction needs to bealarmed thatcurrently is not?

provided theneeded alarmsatisfactorily?

0700 - 4.2

toomany/notprioritized

Do too many alarmsactivatesimultaneously suchthat the operatordoes not know how torespond? Are thealarms notprioritized?

reduced thenumber of alarmssuch that theoperator canrespondproperly? Hasthe licenseeimplemented aneffective alarmprioritizationsystem?

0700 -4.2, 4.3,4.4, 4.5

Issue Date: 12/12/00 - 9 - 71841

auditorywarning LTA

Auditory warning tooloud? Too soft? Wrong pitch? Notsufficientlydiscriminable fromother alarms orbackground?

corrected theauditorydeficiencies?

0700 -4.5.6.3

organization/ formatLTA

Are the alarmslocated and groupedin a way that makesit difficult toquickly locatealarms that arerelated to eachother and to thesystems that triggerthem?

correcteddeficiencies inlocation andorganization ofalarms?

0700 -4.1, 4.5

content LTA Is the informationpresented by thealarm insufficientto quickly andclearly understandthe condition whichit is intended toconvey?

corrected thealarmpresentation toconvey theintendedinformation?

0700 -4.1, 4.2,4.5

visibility/conspicuityLTA

Why is the alarmdifficult to see ordiscern? Is it in apoor location? Isit obscured by otherequipment? Is ittoo small? Does itvisually standoutfrom its background? Is the informationpresented on thealarm difficult toread do to size,color, contrast,font, number ofcharacters, etc.?

relocated orredesigned thealarm or removedobscuringequipment?

0700 -4.5, 4.10

continuouslyilluminated

Is an alarmconditioncontinuouslyilluminated, if thecontinuousillumination is notnecessary foroperator informationor action?

corrected allinappropriatelyilluminatedalarms?

0700 - 4.2

continuously repeated

Does an alarminappropriatelycontinue to activateeven after it hasbeen acknowledged?

corrected alarmsthatinappropriatelyrepeat afteracknowledgment?

0700 - 4.2

disabled Has an alarm beeninappropriately beendisabled? Has thelicensee determinedwhy?

corrected thisproblem?

71841 - 10 - Issue Date: 12/12/00

alarmprocedureavailability/accessibility LTA

Are the alarmprocedures readilyavailable andaccessible?

adequatelyimprovedprocedureavailabilityand/oraccessibility?

0700 -4.5, 4.9

computerprintoutand controlroom logdiffer

Are the alarm listand control room logconsistent?

determined thesource of thedifference andresolved theproblem?

navigationLTA

Are computer-basedalarms accessiblewithout excessiveneed to search thrunumerous computerscreens?

adequatelyimproved thenavigation foralarm systems?

0700 -4.6.1

alarmresponseLTA

What was inadequateabout the alarmresponse controls,methodology orprocedure?

adequatelyimproved theresponse?

0700 -4.5.3,4.6, 4.9

Environment

(1)Causal

Factors:(Root Cause

orcontributing

cause)

(2)For each of the itemsprovide the evidenceused to identify theroot cause

(3)For the

immediatecondition as

well as for anyother relatedapplicable

conditions hasthe licensee:

(4)References

too hot What is the evidencethat the workingenvironment was toohot for sustained safetask performance? What is the evidencethat support tools andequipment (coolers),protective gear (ColdSuit), or appropriatework practices andprocedures (exposurelimits) wereunavailable or notused.

taken steps toreduce thetemperature?

0700 -7.3.1,7.3.2,8.5.1

NUREG/CR-5680,Para.(5680) -4.2, 4.3,4.5

Issue Date: 12/12/00 - 11 - 71841

too cold What is the evidencethat the workingenvironment was toocold for sustainedsafe task performance? What is the evidencethat support tools andequipment (heaters),protective gear(insulated clothing),or appropriate workpractices andprocedures (exposurelimits) wereunavailable or notused.

taken steps toincrease thetemperature?

0700 -7.3.1,7.3.2,8.5.1

5680 -5.2, 5.3,5.5

too humid What is the evidencethat the workingenvironment was toohumid for sustainedsafe task performance? What is the evidencethat support tools andequipment (fan), orappropriate workpractices andprocedures (exposurelimits) wereunavailable or notused.

taken steps toreduce thehumidity?

0700 -7.3.1,7.3.2,8.5.1

5680 -4.2, 4.3,4.5

too dark What is the evidencethat the workingenvironment was toodark for safe taskperformance? What isthe evidence thatsupport tools andequipment (temporarylighting) orappropriate workpractices andprocedures wereunavailable or notused.

taken steps toimprove thelighting?

0700 -7.3.3,7.3.4,8.5.3

5680 -6.2, 6.3,6.5

too bright What is the evidencethat lighting in theworking environmentimpeded safe taskperformance orpersonnel safety? What is the evidencethat brightness, aim,location, glare orbeam angle adverselyeffected visualperformance?

taken step toreduce thebrightness,glare, etc.?

0700 -7.3.3,7.3.4,8.5.3

5680 -6.2, 6.3,6.5

71841 - 12 - Issue Date: 12/12/00

too noisy What is the evidencethat the workingenvironment was toonoisy for sustainedsafe task performanceor masks necessaryauditory signals andcommunications? Whatis the evidence thatprotective gear(hearing protectors)or appropriate workpractices andprocedures (exposurelimits) wereunavailable or notused?

taken steps toreduce thenoise?

0700 -7.3.5,8.5.2

5680 -3.2, 3.3,3.5

cramped/inaccessibleworkplace

What is the evidencethatcramped/inaccessibleworkplaces detractsfrom sustained safetask performance? What is the evidencethat support equipment(creeper, ladder),training, labels, orappropriate workpractices andprocedures wereunavailable or notused?

taken steps toenlarge theworking areaand/or improveaccess?

0700 -7.4, 8.2,8.5.2

dangerouswork place

What is the evidencethat the workenvironmentcontributes to slips,falls or otherphysical injuries? What is the evidencethat poor housekeepingcontributed to thesituation? What isthe evidence thatwarnings and cautionsare not present?

taken steps tocorrect thedangerousworkingconditions?

distractionsprevalent

What is the evidencethat distractionsimpede safe taskperformance? What arethe distractions?

taken steps toeliminate thedistractions?

Issue Date: 12/12/00 - 13 - 71841

highradiation/toxicity

What is the evidencethat excessiveradiation or toxicityin the workingenvironment adverselyeffected sustainedsafe task performanceor personnel safety?What is the evidencethat support equipment(alarming dosimeter),protective gear (radprotection suit), orappropriate workpractices andprocedures (exposurelimits) wereunavailable or notused.

taken steps tocorrect thesituation?

vibrationimpedes work

What is the evidencethat there wasexcessive vibration inthe workingenvironment whichimpeded sustained safetask performance? Whatis the evidence thatequipment wasinsufficientlybalanced, damped orisolated, protectivegear, or appropriatework practices andprocedures (exposurelimits) wereunavailable or notused.

taken steps toreduce thevibrations?

5680 -2.2, 2.3,2.5

71841 - 14 - Issue Date: 12/12/00

Communication

The factors below apply to (1) both written and/or verbalcommunications, (2) both intra- and inter- departmentalcommunications and (3) all situations e.g. control room, workstations, pre-job briefings, shift turnover, etc.

(1)Causal

Factors:(Root Cause

orcontributing cause)

(2)For each of theitems provide theevidence used toidentify the rootcause

(3)For the

immediatecondition as

well as for anyother relatedapplicable

conditions hasthe licensee

taken steps toensure that:

(4)References

missing/lack ofinformation

Did the sender sendand the receiverreceive thenecessaryinformation?

the necessaryinformation issent andreceived?

NUREG-1545,Para.(1545) -2.3, 2.4,2.5, 2.6

content LTA Was the informationcorrect? Was themessage appropriatefor the workenvironment, thejob at hand, and thereceivers level ofknowledge? Was theterminology familiarto the receiver?

the proper,accurate andconciseinformation isprovided?

1545 -2.3.1,2.4.1,2.5, 2.6

untimelyinformation

Was the message sentat the correct timeto be useful?

information istransmitted ina timelymanner?

1545 -2.4.1

misunderstood/misinterpreted

Did the receiverinterpret themessage consistentwith the sender’smeaning?

message contentis clear andunderstandable?

inconsistentinformation

Was the informationconsistent withother informationabout performing thetask?

transmittedmessagescontainconsistentinformation?

repeat-backLTA

Did the receiverconfirm receipt andunderstanding ofinformation byrepeating what washeard in appropriatesituations.

the properrepeat-backprocedure isunderstood andimplemented?

1545 -2.4.1

Issue Date: 12/12/00 - 15 - 71841

verification LTA

Did the senderensure that theinformation wasreceived andunderstood? Did thereceiver confirm thecorrectinterpretation ofthe message?

messageverificationprocedures arein place andproperlyimplemented?

1545 -2.4.1

mode/communication devicesLTA

Was the messageproduced so that itwas easy to hear orread?

allcommunicationdevices areavailable andin properworking order?

0700 -6.1, 6.2,6.31545 -2.4.1

logbookmaintenanceLTA

Are entries accurateand timely? Do theyreflect plantactivities andstatus?

logbooks areproperlymaintainedaccording toplantprocedure?

workpackage LTA

Is the informationcomplete? Is itaccurate?

work packagesare properlyfilled out, andcontaincomplete andaccurateinformation?

documentmanagementLTA

Were there omissionsand/or technicalinaccuracies indeveloping andmanaging technicaldocumentationresulting incommunicationerrors?

the documentmanagementsystem iseffective andis implementedproperly?

standardterminologyLTA

Was standardterminology used?

standardterminology isin place and isused in allappropriatecommunications?

informationaboutsystem/equipmentLTA

Were deficiencies orstatus changesreported/recorded?

system/equipment status isproperlyunderstood,reported andrecorded?

informationnot sought

Did the receiverseek out theinformation neededto perform the job?

necessaryinformation isrequested asappropriate?

informationnot used

Did the receiver usethe necessaryinformation?

necessaryinformation isused whenreceived?

Coordination of Work/Supervision

71841 - 16 - Issue Date: 12/12/00

(1)Causal

Factors:(Root Cause

orcontributing

cause)

(2)For each of the

items provide theevidence used toidentify the root

cause

(3)For the immediatecondition as wellas for any other

relatedapplicable

conditions hasthe licensee

taken steps toensure that:

(4)References

supervisoryavailabilityLTA

Were supervisorsavailable to theworkers asnecessary?

the propersupervisors areavailable whenrequired?

NUREG/CR-5455, Vol.2, Sec.(HPIP) -16

taskdescription/explanationLTA

Did the supervisorsensure that theworkers understoodthe assigned tasks? Did the supervisorscoordinate betweendepartments asnecessary?

workers fullyunderstand whatthey are to doand how toaccomplish it?

coordinationof teamactivitiesLTA

what was theevidence that therewas insufficientcoordination of teamactivities

team coordinationis understood andbeingimplemented?

HPIP - 16

assignmentsof roles andresponsibilities LTA

Did the supervisorsmatch tasks to theappropriatepersonnel?

assignments areappropriate tothe skills andavailability ofpersonnel?

HPIP - 16

taskprogressmonitoringLTA

Were the workactivities tracked?

work activitiesand progress areappropriatelymonitored?

chain ofcommand LTA

Were reportingresponsibilitiesclear?

reportingresponsibilitiesare clear and arebeing implementedproperly?

oversightLTA

Did the supervisorprovide appropriateoversight of allwork activitieswithin theirorganizational unit?

oversight isbeingappropriatelyimplemented?

HPIP - 16

staffworkinghoursprogram LTA

Was circadian cycleconsidered duringscheduling work? Was overtimeconsidered duringwork scheduling?**** See fitness forduty for additionalquestions.

the Commission’spolicy statementwas taken intoconsideration inthe overtimeplanning andimplementation?

GenericLetter 82-12,CommissionPolicyStatement

10 CFR26.20

Issue Date: 12/12/00 - 17 - 71841

pre-jobbriefing LTA

Did the supervisorensure adequacy of pre-job briefings? Was a pre-jobbriefing held ifnecessary?

pre-job briefingscontain completeand accurateinformation,including allnecessarycautions andwarnings, and areconductedproperly?

HPIP - 16

shiftturnover LTA

Did the supervisorensure adequacy ofshift turnover?

shift turnoverprocess has beenimproved toprovide completeand accuratestatusinformation?

planning andschedulingwork LTA

Was work plannedadequately e.g. sitevisits, jobwalkthru, specialrequirements andconstraintsidentified? Werepersonnel workloadand workflow wellmanaged? Was workprioritized? Werepossible conflictsidentified?

the work planningand schedulingprocess has beenimproved tomitigate theproblemsidentified?

HPIP - 16

resourceallocationLTA

Were sufficientworkers assigned,appropriatematerials availableand sufficient timeallocated for thejob?

sufficient resources havebeen madeavailable toaccomplish theplannedactivities?

Work Practices

(1)Causal

Factors:(Root Cause

orcontributing

cause)

(2)For each of theitems provide theevidence used toidentify the rootcause

(3)For the immediatecondition as wellas for any other

relatedapplicable

conditions hasthe licensee:

(4)Referenc

es

formalization of workpracticesLTA

Are work practicesformalized? Howwere work practicesformalized?

developed aformal workpractice?

self-checking LTA

Was there evidenceof self-checking? Was there adequateself-checking?

emphasized selfchecking intraining?

71841 - 18 - Issue Date: 12/12/00

independentverificationLTA

Was there evidenceof independentverification? Wasthere adequateindependentverification?

supplied adequatestaffing forindependentverification?

walkdownsLTA

Did a walkdown occurduring turnover? Was the walkdownconductedadequately?

improved thewalkdown process?

HPIP -16

inattentionto detail

What evidence doesthe licensee havethat the root causewas inattention todetail? Why wasinattention todetail selected asthe root cause?

fixed the problemto preventrecurrence?

lack ofquestioningattitude

What evidence wasthere of aquestioningattitude? Was thereevidence of ageneral lack ofquestioningattitude?

put into effectprograms that arelikely to improvequestioningattitude amongstaff?

addressed anygeneric findings?

Lack ofawareness ofequipmentstatus

What evidence wasthere of a lack ofawareness ofequipment status?

taken theappropriate stepsto assure thatstaff is aware ofequipment status?

Lack ofawareness ofplantcondition(situationawarenessLTA)

What evidence wasthere of a lack ofawareness of theplant condition?

address anygeneric findings?

lack safeworkpractices

What is the evidencethat supports thatstaff is not usingsafe work practices? Does the evidencesupport the finding?

address thefinding with anappropriatecorrectiveaction? Does thecorrective actionaddress anygeneric findings?

impropertools/materialsused

Why was improperequipment used?Availability? Didthe work controlsystem indicate theappropriate toolsneeded?

addressed thisissue?

Issue Date: 12/12/00 - 19 - 71841

teamwork LTA What is the evidenceof lack of properteamwork?

taken steps toimprove teamwork? Are these stepsadequate?

HPIP -16

housekeepingLTA

What is the evidenceof poorhousekeeping?

taken steps toimprovehousekeeping? Are these stepsadequate?

too manytaskinterruptions

What is the evidencethat taskinterruptions had animpact on jobperformance?

taken steps toeliminate orreduce theinterruptions?

too manyconcurrenttasks

What is the evidencethat working toomany concurrenttasks wasresponsible for/orcontributed to humanperformance error? Did the licenseecomplete a check ofwork request recordsas soon as possibleafter the event? Did the licenseeinterview personnelinvolved with theevent concerningtheir perception oftheir workload assoon as possibleafter the event?

redistributedworkresponsibilities?

excessiveworkload

What is the evidencethat excessiveworkload wasresponsible for/orcontributed to humanperformance error? Did the licenseecomplete a check ofwork request recordsas soon as possibleafter the event? Did the licenseeinterview personnelinvolved with theevent concerningtheir workload assoon as possibleafter the event?

taken action toreduce excessiveworkload?

71841 - 20 - Issue Date: 12/12/00

timepressure tocompletetasks

What is the evidencethat working underexcessive timepressure to completetasks wasresponsible for/orcontributed to humanperformance error? Did the licenseeinterview personnelinvolved with theevent concerningtheir perception oftime pressure tocomplete tasks assoon as possibleafter the event?

reduced theeffects of timepressures?

cognitiveoverload

What is the evidencethat task complexitywas responsiblefor/or contributedto human performanceerror? Did thelicensee interviewpersonnel involvedwith the eventconcerning theirperception of thecomplexity of thetasks they wereperforming as beinga contributor to theevent?

taken steps torelieve thecognitiveoverload?

cognitiveunderload(boredom)

What is the evidencethat boredom wasresponsible for/orcontributed to humanperformance error? Did the licenseeinterview personnelinvolved with theevent concerningtheir perception ofthe complexity ofthe tasks they wereperforming as beinga contributor to theevent?

taken steps torelieve bordom?

Issue Date: 12/12/00 - 21 - 71841

Procedure use/adherence (for procedure quality use IP42001 orIP42700)

(1)Causal

Factors:(Root Cause

orcontributing cause)

(2)For each of theitems provide theevidence used toidentify the rootcause

(3)For the immediatecondition as wellas for any other

related applicableconditions has the

licensee takensteps to:

(4)References

noprocedure/unavailable

Why did theprocedure notexist or wasunavailable?

ensure a procedurewas madeavailable?

procedure/referencesnot used

What is theevidence that aprocedure/reference was not used?

ensure thatprocedures/references will be usedin the future?

SECY-90-337

procedureprerequisites not met

Why wereprerequisites notmet?

ensure allprocedureprerequisites willbe met in thefuture?

SECY-90-337

procedurestepscircumvented

Why were procedurestepscircumvented?

ensure that stepswill not becircumvented inthe future?

SECY-90-337

proceduremodification processLTA

What is theevidence that theproceduremodificationprocess is LTA? What is wrong withthe process?

correct thedeficiency?

SECY-90-337

incorrectprocedureused

What is theevidence that anincorrectprocedure wasused? Why was anincorrectprocedure used?

ensure thatincorrectprocedures willnot be used in thefuture?

procedurebelieved tobeincorrect

What is theevidence tobelieve that theprocedure was incorrect? Was itincorrect?

restore confidencein the correctnessof procedures?

71841 - 22 - Issue Date: 12/12/00

TRAINING AND QUALIFICATIONS (USE IP41500 AND NUREG-1220)

FITNESS FOR DUTY:

(1)Causal

Factors:(Root Cause

orcontributing cause)

(2)For each of theitems provide theevidence used toidentify the rootcause

(3)For the

immediatecondition as

well as for anyother relatedapplicable

conditions hasthe licensee:

(4)References

substanceabuse(chemicalandalcohol)

What is the evidencethat substance abusewas responsiblefor/or contributedto human performanceerror? Did thelicensee completefor-cause testing assoon as possible inaccordance with 10CFR 26.24 (3) incases of suspectedsubstance abuse?

assured thatsubstance abusewould not betolerated at theplant?

correctly andfullyimplemented allelements oftheir FFDprogram andproceduresincludingtraining and FFDtesting.

10 CFR26.20,26.24

illness What is the evidencethat Illness/injurywas responsiblefor/or contributedto human performanceerror? Did thelicensee complete amedical recordscheck of personneldirectly involved assoon as possibleafter the event?

adequatelyimplemented itsbehaviorobservationprogram andassured thatsick employeeswould not beassigned tosafetysignificantjobs?

10 CFR26.20

fatigue What is the evidencethat fatigue wasresponsible for/orcontributed to humanperformance error?

adequatelyimplemented itsbehaviorobservationprogram andassured thatfatiguedindividuals areremoved fromduty?

10 CFR26.20

GenericLetter 82-12

Issue Date: 12/12/00 - 23 - 71841

excessiveovertime

What is the evidencethat excessiveovertime wasresponsible for/orcontributed to humanperformance error?Did the licenseecomplete a check ofthe shift logs andtimekeeping recordsas soon as possibleafter the event?

taken action toreduce excessiveovertime?

10 CFR26.20

GenericLetter 82-12

working toolongwithoutresting/workingcontinuously withoutbreaks

What is the evidencethat personnelworking excessivetime without restbreaks wasresponsible for/orcontributed to humanperformance error? Did the licenseecomplete a check ofthe shift logs andtimekeeping recordsas soon as possibleafter the event? Did the licenseeinterview personnelinvolved with theevent concerningtheir work periodsas soon as possibleafter the event?

assured thatfatigue wouldnot result fromworking toolong?

10 CFR26.20

too manydistractions

What is the evidencethat beingdistracted wasresponsible for/orcontributed to humanperformance error? Did the licenseeinterview personnelinvolved with theevent concerningtheir perception ofdistractions asbeing a contributorto the event?

reduceddistractionsfrom criticalwork situations?

71841 - 24 - Issue Date: 12/12/00

night work What is the evidencethat working undernighttime workconditions wasresponsible for/orcontributed to humanperformance error? Did the licenseecomplete a check ofthe shift logs andtimekeeping recordsas soon as possibleafter the event? Did the licenseeinterview personnelinvolved with theevent concerningtheir work periodsas soon as possibleafter the event?

reduced theeffects of nightwork?

called intoworkoutsideregularschedule

What is the evidencethat workingirregularhours/hours outsideregularly scheduledhours wasresponsible for/orcontributed to humanperformance error? Did the licenseecomplete a check ofthe shift logs andtimekeeping recordsas soon as possibleafter the event? Did the licenseeinterview personnelinvolved with theevent concerningtheir work periodsas soon as possibleafter the event?

reduced theeffects ofunscheduled workhours?

adequately andcorrectlyimplement itsFFD proceduresfor call-ins?

71841-04 RESOURCE ESTIMATE

It is estimated that this procedure will take between 8 and 40staff-hours to complete for each human performance issue. Theinspector or inspectors assigned should be familiar with thediscipline associated with the subject of the licensee’s evaluationand should have had training in one of the appropriate root causeanalysis methods. The resource determination should be at thediscretion of regional management depending on the number of topicareas that have been identified as related to the human performanceissue. For planning purposes, a resource estimate near the lowerend of the scale should be used for licensees with correctiveactions programs that have been determined to be thorough duringthe annual inspection for the identification and resolution ofproblems. For licensees with corrective action programs that havebeen previously determined to be ineffective, a resource estimatenear the higher end of the scale should be used.

71841-05 REFERENCES

10 CFR Part 26, Fitness for Duty Programs

Issue Date: 12/12/00 - 25 - 71841

SECY-90-337, Procedural Adherence Requirements

Generic Letter No. 82-12, Nuclear Power Plant Staff Working Hours

NUREG-0700, Rev. 1, Vol. 1 - Human-System Interface Design ReviewGuideline

NUREG-1220, Rev. 1, Training Review Criteria and Procedures

NUREG-1545, Evaluation Criteria for Communication-RelatedCorrective Action Plans

NUREG/CR-5680, The Impact of Environmental Conditions on HumanPerformance

NUREG/CR-5455, Vol. 2, Development of the NRC’s Human PerformanceInvestigation Process (HPIP), Investigator’s Manual

END