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<h1><b> Human Performance Improvement - If It Does Not Feel
Right, Stop and Discuss It with Your Work Group</b></h1>
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<b>Statement:</b> When evaluating work assignments remember the
STAR process - <b>Stop, Think, Act and Review. </b><br>
<p>-Stop and take a step back. <br>
-Think about the work scope; can it be safely achieved?<br>
-Act on your assessment of the work; does the proposed work need
to be evaluated by a more experienced or knowledgeable person or
group?<br>
-Review and discuss with your work peers what your evaluation
has indicated. </p>
<p><b>Discussion:</b> A maintenance work package had been written
to make adjustments on the Swipe Delivery System (SDS) Transfer
Table while the table was controlled in the manual mode using a
laptop computer. As adjustments were being made, the transfer
table unexpectedly activated and began to close. Mechanical
Craftsmen working on the adjustments called an immediate stop to
the evolution. No one came in contact with the transfer table. </p>
<p><b>Analysis:</b> Although the work package credited the laptop
computer to mitigate the mechanical hazard, personnel involved
in the planning, development, and work execution later stated
they were unfamiliar with the manual operating mode of the
system. The personnel individually recognized their
unfamiliarity but did not stop the work and discuss their
individual concerns with their work group prior to beginning the
evolution. <br>
<br>
The groups of personnel participating in this event were highly
skilled and experienced in their individual fields, but there
was very little knowledge of the design of the system, the
software controls, or the manual operating mode. The group
shared available knowledge during the planning and pre-job
activities, but the interviews revealed that as the field work
progressed, each individual became less certain about the
operation but did not share their individual concerns of how
this particular work evolution was being controlled. </p>
<p><b>Actions:</b> <br>
<br>
-Through either group meeting(s) and/or required reading
reinforce the responsibility to stop work when work scope is
unfamiliar, work quality has not been met, or personnel are
uncertain of work assignments. <br>
-Perform a Cognizant Engineer equipment walk down to focus on
developing an understanding of the sequence of operations of the
SDS, manual mode operations, and how to enter into the manual
control mode. <br>
-Extent of Condition Perform review of waste handling automated
equipment to verify that the sequence of operations and control
modes are understood by the responsible engineer(s) so that
control over the equipment is maintained for each configuration
implemented. </p>
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<pre class="moz-signature" cols="72">--
Henry Robertson
DSO, Engineering Division
Safety Systems Group
PH# - 757.269.7285
FAX - 757.269.7352
<a moz-do-not-send="true" class="moz-txt-link-freetext" href="http://www.jlab.org/accel/ssg/">http://www.jlab.org/accel/ssg/</a>
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