Re: procedures for procedures?

[LIPTONW@detroitedison.com]

You bring up a very important finding.  There's a tendancy in the nuclear 
industry to respond to a behavior problem (eg., a faulty procedure or an 
incident due to human error) by adding additional layers of reviews.  As
just 
about anyone who's been through this can testify, this soon becomes not only
a 
waste of time, but also, in fact, counterproductive.  What happens is that 
everyone in the review chain assumes that, with so many reviews, someone
else 
is sure to catch any errors, and, hence, being pressed for time with so many 
reviews, every review is cursory. The process becomes known as a
"signathon", 
especially if a long checklist is involved.  It thus turns out that the
error 
rate tends to increase. 
 
The opinions expressed are strictly mine. 
It's not about dose, it's about trust. 
 
Bill Lipton 
liptonw@detroitedison.com  
 
You wrote: 
 
In a previous life, when TVA's nuclear power program was shut down to heal 
itself, a consultant was brought in to "fix" the procedure system. 
 
The cure proved to be far worse than the disease, however. The system 
imposed on the nuclear power program required the use of a very specific 
writing technique, the usual document reviews we all think of as part of 
the procedure development/revision process, and also required that the 
process described in the procedure be diagramed (as in software 
flowcharting). There was a review checklist that was 10-12 pages thick to 
be completed by everyone reviewing the document. There was also a "test 
drive" of the procedure to carried out by a qualified person with a 
specific checklist to complete. There was a final review and concurrence by 
a person previously certified as a subject matter expert and qualified as 
an "independent reviewer," meaning this reviewer could not be part of the 
writer's chain of command. This process was applied to all procedures. Each 
feature of the system had its merits, but together they brought procedure 
development and revision process to a halt. (a government tradition: 
anything worth doing is worth overdoing.) 
 
After learning the hard way (the way I learned most of what I know), the 
system was simplified to include the usual review and the test drive using 
the checklist. The independent review was retained for plant safety-related 
procedures. 
 
The test drive process was probably the most useful part. It meant that 
someone who would have to use the procedure actually tried to execute the 
procedure as-written. A great way to find flaws. 
 
--------- 
Bob Flood 
Dosimetry Group Leader 
Stanford Linear Accelerator Center 
(650) 926-3793 
bflood@slac.stanford.edu