Human Performance Assessment of BNL Arc-Flash Even…….ppt

Human Performance Assessment of BNL Arc-Flash Event Rob Fisher, President Fisher Improvement Technologies, LLC 802-233-0760 Rob@ Abstract and Team The team was requested to provide an independent assessment of the human performance related issues that may have existed surrounding the arc-flash event at CAD on April 14, 2006. The specific portion of the event being assessed by this team were the injuries received by a BNL employee. A DOE Type-B investigation is in progress to determine the root and contributing causes of the arc-flash. The team consisted of: Keven Butler, INL Office of Human Performance Bill Brown, BNL EENS Team Lead – Rob Fisher, President, Fisher Improvement Technologies, LLC The team used human performance event analysis tools and comparison to human performance best-practices to identify areas where this event may have had human performance related contributors. The team conducted interviews, reviewed documents, consulted with the DOE Type-B team, and reviewed issues with management. Human Performance Fundamentals Three Tenets: The things that cause the small things are the same as the things that cause the big things; 85% - 90% of significant events have their roots in something OTHER than just the individual; and Errors and Events are different things. Once these three tenets are understood – assessment begins at what the individual was doing, thinking and feeling at the time of the event – and why they were doing, thinking and feeling those things. Human Performance assessment looks at the individuals, environment, situation, barriers, procedures, processes, rules, organizational impacts and other possible contributing or influencing factors. If we believe that people come to work to do a good job every day, then we have to also believe that there were reasons individuals did what they did when they did it. Errors should START the investigation process – not END it. Human Performance Assessment Path Very quickly, the assessment moved away fr