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Incorporating Human Performance Improvement Tools into DOE Processes by tjP2ikl

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									Incorporating Human Performance
Improvement Tools into DOE Processes


  Shirley J. Olinger, Deputy Manager, ORP
 Brian Harkins, ORP Facility Representative
             September 2006




                                              ORP-06-033
Point of View
Human Performance Improvement (HPI) tools are improving
 our work processes and strengthening ISM at the Office of
 River Protection (ORP). This presentation will present the
 process that we are using to incorporate HPI tools into our
 processes and some of the challenges and rewards
 involved.




                                                           ORP-06-033
  Building on our existing ISM System Description
Our ISM System Description attributes included HPI concepts in our
   processes. The concepts included;
 Each employee instinctively feels responsible for safety
 Leaders demonstrate commitment to safety
 Trust towards each other
 Decision-making reflects safety as the overriding priority
 An inquisitive attitude and behavior
 A disciplined authorization basis system is in place to ensure all
   hazards are identified and mitigated before work begins
 Organizational learning is embraced
 Openly examine our operations and solicit feedback
Incorporating HPI is strengthening our ISM system


                                                                       ORP-06-033
Process

HPI Training for ORP Staff
 All ORP personnel will receive 8 hours HPI training
 Personnel involved in direct oversight of Contractors’ activities will
   receive additional 32 hours HPI Training (~ 40 % of staff)
 Hands on refresher training for all ORP personnel to reinforce
   specific principles
    – Error Precursors
    – Latent Organization Weakness
    – HPI Training tailored specific to employees duties




                                                                           ORP-06-033
Hands on Refresher Training
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Total playing time: 08:29




                                                                                                 ORP-06-033
Process (continued)

Process Changes
       Investigations using HPI Tools
    –       Outside Independent
    –       DOE
    –       Joint DOE & Contractor
       Encourage and reward reporting at a low level (errors without
        consequences)
       Instilling “Just Culture”




                                                                        ORP-06-033
Investigations using HPI Tools

HPI event investigation               Old methods
 Review from the perspective of       Review from hindsight point of
   the people involved in the event      view – judging each critical step
   (context)                             in view of the final outcome
 Evaluate the organization as         Investigate to find where
   event unfolds                         personnel went wrong
 The event is the effect or           Often look at events as a
   symptom of deeper trouble in          problem with people,
   the organization, thus not            procedures and training
   random



                                                                    ORP-06-033
    Investigations using HPI Tools
                                  Root Cause Analysis
                                Flawed
                                Defenses
 Vision,                                                 Vision,
Beliefs, &                                              Beliefs, &
 Values                                                  Values




                        Event
   Latent
   Organizational
   Weaknesses                                      Initiating
                                                   Action



                               Error
                            Precursors

                    Anatomy of an Event
                                                                ORP-06-033
Investigations using HPI Tools

Outside Independent Investigation
 ORP decided to conduct an investigation using HPI
  because of the continual recurrence of events at the WTP
  construction site. Although we appeared to handle each
  event adequately, we continued to have similar events.
 ORP contracted with an expert in HPI to:
   – Review 10 events (occurrence & accident reports)
     (9 electrical & 1 LO/TO)




                                                         ORP-06-033
Investigations using HPI Tools
  DOE ORP Investigations
   Before giving DOE identified issues to the Contractor for
    resolution, some items are reviewed using HPI Tools in an
    effort to identify latent organizational weakness. When
    issues is given to the Contractor, if latent organizational
    weaknesses have been identified they are given to the
    Contractors as areas for improvement.
  Joint DOE & Contractor Investigations
   ORP has participated in joint reviews using HPI tool to
    identify areas for improvement. DOE involvement adds
    independent view and helps assure that weakness found will
    be viewed as opportunities for improvement not violations.

                                                                  ORP-06-033
Process (continued)

Process Changes
I.         Investigations using HPI Tools
       –       Outside Independent
       –       DOE
       –       Joint DOE & Contractor
II.        Encourage and reward reporting at a low level (errors without
           consequences)
III.       Instilling “Just Culture”




                                                                     ORP-06-033
Encourage and reward reporting at a low level (errors
     without consequences)

 ORP has encouraged our contractors to develop systems
  for their employees to report issues. Reporting levels are at
  a very low level.
   – CHM2Hill – Problem Evaluation Report (PER)
   – Bechtel National Inc – Project Issues Evaluation Reporting
     (PIER)
 ORP has a data base system for DOE personnel to report
  site observations (OA Database)


                                                              ORP-06-033
Process (continued)

Process Changes
       Investigations using HPI Tools
    –      Outside independent
    –      DOE
    –      Joint DOE & Contractor
       Encourage and reward reporting at a low level (errors without
        consequences)
       Instilling “Just Culture”




                                                                        ORP-06-033
 Instilling “Just Culture”
 Definition: An environment that recognizes human potential
  for error and clearly defines acceptable behavior in a
  consistent manner
 Attributes:
   – Recognition of fairness related to the identification and
     resolution of human performance problems
   – Distinction between honest mistakes and intentional
     shortcuts with respect to discipline
   – Free flow of plant information across all levels of an
     organization
   – High level of self-reporting

                                                                 ORP-06-033
Instilling “Just Culture”

 ORP ISM System Description
 HPI Focuses on the Organization not individuals or event
 Recognition that every one makes mistakes
 Encouragement/ reward personnel to disclose errors
  without consequences
   – Discovery Clock




                                                         ORP-06-033
Challenges
 Develop training specific to DOE employees that is
  applicable to their areas of responsibilities
 The timing of reinforcement training
 Instituting the mind-set change in the organization that HPI
  provides
 Instituting a “Just Culture” both with our contractors and
  Federal personnel




                                                               ORP-06-033
Rewards
 Reporting errors without consequences
   – Self-reporting error resulted in identification of a potential life
     threatening latent organizational weakness
 Employee Ownership — we have observed a increased
  involvement of staff in the effort to improve our processes
 Process improvements




                                                                     ORP-06-033
Path Forward
 Further institute HPI tools into our existing
   – Oversight reporting system
   – Just culture
   – Discovery clock
   – Critical Steps concept
 Start using HPI tools to evaluate DOE management
  Systems (e.g. CAM, PIP’s)
 Develop metrics to be able to gage improvement




                                                     ORP-06-033
Conclusions
 Implementing HPI tools into DOE’s process is taking us to a
  new level of performance
 HPI tools should be trained, reinforced, and rewarded
 Implementing HPI can seem like an overwhelming task.
  Evaluate your organizational needs and determine what
  HPI tools will benefit your organization the most and start
  with those tools
 Incorporate processes from others (RL, ORP, INPO,
  Nuclear Power) whenever possible to reduce the need to
  redevelop programs


                                                            ORP-06-033

								
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