January 28, 2020 | Mark Paradies

Practical, Efficient, Effective Human Performance Tools for the Nuclear Industry

Problems with Human Performance in the Nuke Industry

Human Performance (Hu) History

Back in the 1980s, INPO decided that the nuclear plants needed better human performance. They started the development of their first human performance (Hu) tool – HPES (or the Human Performance Evaluation Systems). I was just leaving the Nuclear Navy with an MS in Nuclear Engineering with an emphasis on Human Factors and interviewed with INPO to help develop HPES. I didn’t take the job, but I ended up working with the guys at INPO by reviewing and suggesting improvements to HPES including the Management System portion of the tool.

The years passed and additional tools were developed. More and more until the list of tools included:

  • Procedure Use
  • Procedure Adherence
  • Place Keeping
  • Independent Verification
  • Three-Way Communications
  • Pre-Job Brief
  • Post-Job Brief
  • Personal Safety Assessment
  • Observation and Coaching
  • Concurrent Verification
  • Questioning Attitude
  • STAR
  • Time Out (Stop When Unsure)
  • Attention to Detail
  • Management of Change
  • Error Traps and Precursors
  • Validate Assumptions
  • Do Not Disturb Sign
  • Conservative Decision-Making

This isn’t a standard list. There really isn’t a standard. The techniques were modified by the Department of Energy for their plants. Various consultants added and subtracted from this list as they brought the techniques to other industries. Also, the techniques may vary depending on the teacher you learned them from and the version you learned (yes, since the start of the development of these techniques in the 1990s, they have been “improved” and revised). Therefore, the techniques may vary in their names and complexity.

In the last few years, the Nuclear Industry has been challenged to cut costs by reducing the complexity of the performance improvement tools that they use. And one thing that had grown quite complex was the Hu programs at nuclear plants.

In addition to the complexity of the large number of tools listed above, some managers in the nuclear industry started to realize that at least some of the Hu Tools might not be as effective as they were advertised to be. Some tools seemed to result in blame. They got a bad name because after and incident, investigators could always spot the lack of the use of a tool that would have prevented the incident.

None the less, once a tool like Hu is adopted across an industry, it develops true believers. I’ve found that it is difficult to get them to look at the tool critically even if one of their “tools” is to “Challenge Assumptions” and another is “Questioning Attitude.”

The Time Has Come to Revisit Hu Programs

Therefore, we believe that the time has come to critically assess Hu and address the problems with Hu Programs in the Nuclear Industry. This critical look may provide a more effective group of Human Performance Improvement Tools that are based on human factors research and best practices.

What have we done? Researched the Hu Programs and studied the tools’ human factors basis. We could then understand which tools worked and why. Also, which tools were not tools but rather management philosophy. Also, what additional ideas from human factors should be included in Human Performance Improvement Programs. And finally, what Hu Tools should be avoided (or perhaps we should say discarded).

To document our work, we wrote a book:

Stopping Human Error

which will be out by mid-March.

Then, we decided to develop a course to help people understand the theories behind human performance improvement and how to put together a custom, efficient, effective, human performance improvement plan.

What Should Nuclear Plant Hu Managers Do?

Portrait of young engineer at control room

If you are ready to challenge the status quo Hu programs in the Nuclear Industry, you need to attend our new course – Stopping Human Error – and get ideas to improve your approach to improving human performance.

When is the new course? On March 9-10, 2020.

Where is the new course? At the Horseshoe Bay Resort near Austin, TX.

Of course, you will have to come with an open mind (a questioning attitude) and be ready to challenge some assumptions.

Why do I say that you need an open mind? I was talking to a safety/human performance manager just last week and he got mad. He said his Hu Program was working great and didn’t need to be tampered with. I tried to explain just one of the potential faults with just one tool – Error Traps and Precursors – and he told me that he did his job just fine without my help.

I could see that he was insulted. That certainly wasn’t my intent. I was criticizing the tool and not his application of the tool. He maintained that his company’s safety performance was proof that the tools worked great. I had asked how he knew that. There I go, challenging assumptions.

So, if you can’t look at your program with a critical eye with a vision to improve things, then you probably SHOULD NOT attend this course.

If, on the other hand, you are ready to make your Hu Program more efficient and effective, this course comes with a guarantee:

Attend this course, go back to work, and use the techniques you have learned to stop human error. If you don’t find new ways to improve human performance and if you and your management don’t agree that your efforts to improve human performance are much more effective, just return your course materials and we will refund the entire course fee.

What’s in the New Stopping Human Error Course?

Mark Paradies, human factors expert and Board Certified Ergonomist (certificate #85) and Alex Paradies, experienced TapRooT® Instructor and Lean Transformation leader, will help you understand these concepts:

  • The causes of human error
  • Human factors design best practices
  • Methods to find error likely situations
  • Techniques to help supervisors and workers prevent human errors
  • CHAP (Critical Human Action Profile)
  • Human Performance improvement Technology
  • Designing your human performance improvement program.

Here is the course outline:

Day 1 (8:00am to 5:00pm)

  • Foundations of Improving Human Performance
  • Resilience and Safeguards
  • Using TapRooT® Root Cause Analysis for Reactive Problem Analysis
  • Using TapRooT® Human Performance Best Practices Proactively
    • Human Engineering
    • Procedures
    • Training
    • Communications
    • Management System
    • Work Direction
    • Quality Control
  • Stopping Normalization of Deviation
  • Pre-Job Hazard Analysis
  • Pre-Job Briefs
  • Personal Safety Assessment

Day 2 (8:00am to 5:00pm)

  • Applying Critical Human Action Profile Proactively
  • Human Performance Improvement Technology
    • Procedure Use/Adherence
    • Place Keeping
    • Independent Verification
    • Three-Way Communication
    • Pre-Job Brief
    • Personal Safety Assessment
    • Observation and Coaching
    • Post-Job Brief
    • Concurrent Verification
    • Questioning Attitude
    • Stop-Think-Act-Review
    • Time Out
    • Attention to Detail
    • Management of Change
    • Error Traps and Precursors
    • Validate Assumptions
    • Do Not Disturb Sign
    • Conservative Decision Making
  • Admiral Rickover and “Facing the Facts”
  • Applying Safeguard Analysis to Stop Human Errors
  • Which Tools Will Work Best for You?
  • Sample Plan/Suggested Plan
  • Customizing Your Plan
  • Present Your Plan, Benchmarking, and Feedback

With the exercises built-in to try some of the techniques, this will be an active, quick-moving 2-day course.

You will leave this course with a clear understanding of methods to improve human performance and a custom plan to apply the best of those methods at your company to achieve great gains in safety, quality, or operational and maintenance performance (all of which depend on human performance).

Participants will also receive the new book, Stopping Human Error, a $99.95 value, as part of the course materials. In addition, participants will receive a certificate of completion and a 90-day subscription to TapRooT® VI Software, our dynamic cloud-based software that computerizes the Equifactor® and TapRooT® Techniques.


To register for the new Stopping Human Error Course, click on the button below…


About the Instructors


Mark Paradies

Mark Paradies has 40 years of experience in high-reliability organizations, process safety, incident investigation, and root cause analysis. His career started as a leader in Admiral Rickover’s Nuclear Navy (where he earned Engineer Qualification). He also worked for DuPont in the areas of human factors, process safety, and performance improvement management before he started System Improvements in 1988. Mark was one of the co-creators of the TapRooT® System and worked with Heinz Bloch on the original development of the Equifactor® Technique. He has a BS in Electrical Engineering and an MS in Nuclear Engineering (with an emphasis on human factors), both from the University of Illinois.

His human factors and human error analysis experience includes:

  • Masters Degree with Emphasis on Human Factors from the University of Illinois
  • Research on the proper role of automation in the next generation of nuclear power plants (1983-1985)
  • Member, Human Factors & Ergonomics Society, 1983-Present)
  • Developing a Human Performance Improvement Program at DuPont (1985-1988)
  • Contributed to INPO’s HPES (1986)
  • Co-Developer of the TapRooT® Root Cause Analysis System (1990-Present)
  • Co-Developer of the NRC’s Human Performance Investigation Process, HPIP (1990-1993)
  • The 85th Certified Professional Ergonomist, the first human factors professional certification (1993)
  • IEEE Human Factors Committee Member and Co-Author: IEEE Root Cause Analysis Standard (2010-2017)
  • Committee Co-Author: Recognizing and Responding to Normalization of Deviation, CCPS
  • Committee Co-Author: Guidelines for Investigating Chemical Process Incidents, 2nd & 3rd Editions, CCPS


Alex Paradies has a BS in Materials Science from the University of Tennessee where he also studies Human Factors and Business. He then joined Timken and held various management-level positions in manufacturing bearings including manufacturing operations manager, quality manager, and helping implement a Lean process in a bearing manufacturing plant. Alex joined System Improvement in 2019, is a TapRooT® Instructor, and helped develop the Stopping Human Error Course.

But There’s More

If you attend the course, you should also think about attending the 2020 Global TapRooT® Summit. It is being held on March 11-13 at the same location. In the Summit there is a track on Improving Human Performance. That’s a great place to network and get even more great ideas.

See the speakers and sessions at https://summit.taproot.com/schedule.

Summit Attendees

Courses & Training, Human Performance
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