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This report was prepared as an account of work sponsored by an agency of tl;e ',1r":? _ _:t"t.:,_,Government. Neither the United States Government nor any agency thereof, or any of their emp;o_,.,}_._ _ _,,_hes any warranty, expressed or implied, or assumes any legal liability of responsibility for any third party's use, or the results of such use, of any information, apparatus, product or process disclosed in this report, or represents that its use by such third party would not infringe privately owned rights.

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The three volumes of this report detail a standard investigation process for use by U. S. Nuclear Regulatory Commission (NRC) personnel when investigating human performance related events at nuclear power plants. The process, called the Human Performance Investigation Process (HPIP), was developed to meet the special needs of NRC personnel, especially NRC resident and regional inspectors. HPIP is a systematic investigation process combining current procedures and field practices, expert experience, NRC human performance research, and applicable investigation techniques. The process is easy to learn and helps NRC personnel perform better field investigations of the root causes of human performance problems. The human performance data gathered through such investigations provides a better understanding of the human performance issues that cause events at nuclear power plants. Volume III is a detailed documentation of the development effort and the pilot training program. iii ACKNOWLEDGEMENTS We would like to thank all of the NRC personnel who helped by providing their ideas, support, review, or other assistance. We would like to especially thank Ann Ramey-Smith, the initial project manager. HPIP would have never existed without her persistence getting this system developed and shepherding it through the testing and approval process. Also, we would like to thank Dolores Morisseau, the current project manager, for her helpful guidance of the project through the final revisions and implementation. Finally we would like to recognize the invaluable input to the system testing provided by NRC Region I. They willingly volunteered to pilot test the system in the field. Their feedback provided improvements in the process and training that made HPIP an even better system.

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