Human Performance Tool Spotlight: OOPS - Outside Of Procedure, Parameters, or Process - STOP

Holy cow, a Human Performance tool called, "OOPS?" Well, not really. It's only an addition (or interpretation) to Stop When Unsure and Questioning Attitude. Using a Questioning Attitude (holding off on my argument that SWU and QA are not even tools at all, because these should be used all the time, and tools only when they matter the most) while performing work and you find a reading or situation off normal, STOP. This seems pretty simple and to the point. Staying engaged and thinking about the work.

So, let's evaluate OOPS and why it's possibly more effective than Stop When Unsure. The keyword being "Unsure" - it sounds like the worker doesn't know what they're doing - lacking training or knowledge to perform the task. This sounds accusatory and perhaps even with a little blame. What I've come to learn about people and Human Performance Programs are that words matter, and more people participate in a Good Catch program, than in a Near Miss one... even if the rules and avenues of capturing them are identical. We humans are a fickle bunch.

So, do workers have the authority to STOP work?

Every place I've ever been or interacted with, people have told me that they don't always have this authority, yet one hundred percent of leadership team members I've spoken with have told me that everyone has the right to STOP work to resolve safety or potential Human Performance issues. If you are a leader, make it clear to your workforce that they have this authority and you expect them to use it. I am positive there is a disconnect in some companies on this point.

What is a Time Out?

Some workers and leadership team members do not like this verbiage, because it sounds childish. [Suggestion from a friend on LinkedIn: Jeffrey Meade, P.Eng. re: Time Out... If you use this, present it with sports imagery to remove the childish/punishment vibe.] Call it whatever you want, but make sure the job stops to get issues resolved. This is where the performance improvement happens. No need to rush through and get something wrong, or hurt someone. Here is the description:

• A time out is a brief stoppage of work to allow workers, their supervisor, or other knowledgeable persons to discuss and resolve the issue(s) such as uncertainty, doubt, confusion, or if questions persist before resuming the task.
• Every person has the responsibility and authority to STOP work when uncertainty exists, even if it seems simple and straightforward.
• Once the issue(s) have been resolved satisfactorily, it seems most pertinent if the person that called for a time out should be the one to then call time in so work may resume.

When to STOP

–When encountering conditions inconsistent with procedures–When outside bounds of key parameters–If conditions are different than expected from your pre-job brief–When inexperienced or lacking knowledge of task–When uncertain or confused–If beyond scope of the plan or process–When unexpected results or unfamiliar situations are encountered–When something expected does not happen–When someone else expresses doubt or concern

How to STOP

If you find yourself Outside of Procedures, Parameters or Processes – STOP – and CONTACT your supervisor. Errors can be prevented by properly using written procedures. OOPS is a strong method that can be used effectively to prevent errors due to proceeding in the face of uncertainty.

From this point on I’m going to share some nuclear procedure “Stop Work Criteria” which involves when to stop, the leadership approved response, and when to start work back up. This may seem like overkill, but when trying to explain this in a very regulated world, this helps it all make sense and also protects the sanctity of the worker’s authority to stop any job.

Stop Work Criteria:

Stop work and contact supervision whenever a stop work criteria condition is encountered. There are any number of things that should cause one to stop work and get help from supervision. The following are (a long list of) examples:

Job surrounding issues:

• Unusual noise, smell, heat; insufficient lighting, etc.
• Unexpected job hazard is present
• Unexpected configuration control bumping hazards are present

As-found equipment conditions:

• Components are not in expected condition
• Component labels are not applied or are confusing
• Component label does not match controlling document (ie: clearance,
procedure)
• EDT/EST or Danger Card on equipment to be tested/worked on
• Work can not be performed as planned/briefed
• Deficiencies are found in WO package (or instructions are unclear)
• Procedure can not be followed as written
• Plant drawings and components disagree

Work performance issues:

• Unanticipated energy (pressure, voltage, etc.) is encountered
• Equipment does not respond as expected
• Loss of pre-established communications
• Unusual component wear, FME, etc., is observed
• Need for expanded scope or manpower is identified
• Test equipment, tooling, parts, etc., do not perform as expected
• Deficiency identified during rounds on safety-related components

Changes occurring during work performance:

• Plant/radiological changes in the vicinity of the job
• Audio/visual alarms (Emergency Plan, Area/Plant Fire)

Event occurrence:

• Mispositioning of a component
• Clearance process issue
• Spill or significant housekeeping issue
• Vehicle accident
• Injury
• PMT performance issue
• PMT cannot be performed as specified
• Insufficient resources (including required observers)

Any time you find yourself outside of process or procedure (OOPS) or are uncertain

Supervisory Response:

The following guidance outlines expected actions for supervisors to help ensure an effective response to an OOPS notification.

Thank the individual for stopping work to ask for your help. Questioning attitude and involving supervision are two keys to preventing events should be positively reinforced.

Ask the individual:

• How did you discover the condition?
• Why did the condition occur? (Clarify goals)
• What does your controlling document state? Show me the document.
• What is your recommendation?

Ask yourself:

• Does the documentation need to be changed?
• What expertise do I need to help the condition? (Eng, Maint, etc.)
• Do I need to use the Operations Decision making model?
• If there is an equipment deficiency, should we just stop and get it fixed?
• Am I too close to the issue?
• What is my recommendation? Who will challenge me? (peer or SM)
• Do we need to stop and re-brief?
• Where will we document this?
• Are my standards high enough?

Consider positive reinforcement for the individual. It is important to reward the behavior of stopping if you want it to happen again. The positive reinforcement can offset the negative reinforcement of having to do more work to ensure events are prevented. 



Resuming Work:

Work/testing should not resume until authorized by supervision, which shall ensure the following:

• Any job surrounding issues have been corrected or addressed. Noise, heat, etc., issues explained satisfactorily and/or corrected. Bumping hazards removed or compensated for.
• Components which are not in expected condition (or which contain EDT/ESTs) are dispositioned by Operations. New labels are applied. Component label or controlling document is corrected, or supervision has approved continuing with work activity.
• WO's, procedures, drawings are corrected/clarified.
• Clearance is addressed as necessary. Operations/Engineering dispositions unusual equipment response, wear, or out-of-spec conditions, etc. Communications systems are corrected. Test equipment, tooling, parts issues are addressed. Work Management/Planning is notified of expanded work scope/manpower needs.
• Plant condition/radiological condition changes are reviewed with Operations/RP, and work is re-authorized/re-briefed, as required.
• Immediate help is acquired, as needed. Management is notified. IR's generated. Department head approval is obtained before resumption of task.
• PMT is corrected. All specified resources required to satisfy PMT requirements are on hand.
• All other open-ended issues related to the concern are addressed.

References:

I dug into some of my archived old Human Performance nuclear procedures and some of the training I've put together over the years to develop this post with no particular reference to anywhere other than commercial nuclear industry procedures. Thank you.

Click here for a pretty amazing safety video I found while doing research for this post. 

Click here for a video on Stop Work Authority.

Click here for another video on Stop Work Authority.