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The BNL Lessons Learned Program

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The BNL Lessons Learned Program Powered By Docstoc
					            BNL Lessons Learned Workshop
                    Presented by Ed Sierra

Laboratory Lessons Learned Coordinator

                                June 27, 2008

               Quality Management Office

Brookhaven Science Associates
  U.S. Department of Energy           1
        Agenda




Brookhaven Science Associates
  U.S. Department of Energy     2
Brookhaven Science Associates
  U.S. Department of Energy     3
   Assessment of BSA Contractor Assurance Program

   It’s good business practice!




    Brookhaven Science Associates
      U.S. Department of Energy     4
What is a Lesson Learned?
   A lesson learned is the knowledge acquired from an innovation or an adverse
    experience that causes a worker or an organization to improve:

     • a process

     • an activity

     • worker safety

     • efficiency

     • quality


   In short, a change in behavior occurs.
   LL Example:
    Brookhaven Science Associates
      U.S. Department of Energy             5
DOE Order 210.2 DOE Corporate Operating
Experience Program
   Participate in Corporate OPEX Program

   Share BNL Developed LLs (DOE Database)
       – Required for Type A & B Accidents, Signficance
         Category 1 and R Occurrences
       – Optional for all other OPEX

   Screen DOE Corporate and External OPEX



    Brookhaven Science Associates
      U.S. Department of Energy     6
DOE Order 210.2 DOE Corporate Operating
Experience Program
   Distribute applicable OPEX to Personnel for review, analysis,
    internalization and corrective action implementation

   Designate an Operating Experience Program Coordinator – who will be
    a member of the Operating Experience Committee

   Implement Required Actions of Corporate OPEX Documents (e.g.,
    SORs, SAs, SBs, etc.) and Formally respond as required

   Trend Contractor Operating Events for Lesson Learned from Recurring
    Issues

   Establish Metrics


    Brookhaven Science Associates
      U.S. Department of Energy       7
What are the Lessons Learned Coordinator
Responsibilities?
   Organization’s point of contact

   Inform organization staff

   Apply Lessons Learned information to their programs,
    projects, or activities

   Generate and disseminate Lessons Learned

   Report on Lessons Learned status for organization as a part
    of the organization’s Self Assessment program
    Brookhaven Science Associates
      U.S. Department of Energy     8
Title of the Lesson Learned
Must Get The Reader’s Attention
    Make it short . . . but tell the whole story;

    Make the reader sense that this is something they
     need and want to know.

    Be specific to the incident or the situation, avoid
     using generic phrases;

    The Title is what is displayed in the subscription
     service e-mail notice and in references to the LL
     document.
 Brookhaven Science Associates
   U.S. Department of Energy     9
Tips for Writing a Lesson Learned Document
   Use the readers language
       – Don’t use technical language if not necessary;
       – Don’t use slang inappropriate for written documents;
       – Don’t assume your reader knows all your acronyms.

   Speaks directly to the reader in an informal, conversational
    style.

   An emphasis on explaining and interpreting causal analysis
    results rather than on methodology.


    Brookhaven Science Associates
      U.S. Department of Energy     10
Lessons Published 3rd Qtr FY 08
   Beware: A Safety Analysis Cannot be Viewed as a Static Historical Document (BNL)
   Team Review of Management Concern Related to the Acquisition of Equipment
   Minor Fire in Non-NRTL Listed HEPA Filter and Fan Assembly (BNL)
   Closed-Top Funnels are Compliant and Safe (BNL)
   Material Handling Events at Hanford
   Loss of Breathing Air - Importance of Three-Way Communication
   Do You Conduct Screening for Hypersensitivity (Allergic) Reactions When Planning
    Field Work? (BNL)

In Review Process
 Include an Instructional Designer when Embarking on a new Training Initiative (BNL)

   A top heavy, five drawer, lateral filing cabinet tips over and injures a worker (BNL)



    Brookhaven Science Associates
      U.S. Department of Energy                11
Is the Lesson Learned Program Effective?
 The system can be measured for value only on the
 basis of the prevention benefits it provides to BNL.




 Brookhaven Science Associates
   U.S. Department of Energy     12
Lesson Learned Metrics

                  No. of internal LL submissions/distributions
                  No. of external LL submissions/distributions
                  LL Sources reviewed
“Bean
counting”         Most viewed Lessons
                  Timeliness of distribution of internal and external LL
                  User data (unique user, user searches, user organization)

                  Feedback – (applicability, corrective actions, procedure revision,
                   training revisions, etc.)
                  Data stream trending for LL
 KPIs             Work Control (pre- and post-job LL)
                  LL origin (Occurrences, operating experience, assessments, critiques,
                   etc.)


   Brookhaven Science Associates
     U.S. Department of Energy               13
Lesson Learned Feedback Prompt!
   Prompt/capture feedback of published LL Communications

    • Will adopt

    • Distributed for Information

    • Not applicable

    • Previously adopted

    • Reading for Interest only

    • Under investigation
    Brookhaven Science Associates
      U.S. Department of Energy     14
2nd Qtr FY 08 LL Feedback
                          Exhibit 8: Lessons Learned Feedback


                                                                          Distributed for Information

                                                30
                     80                         9%
                    25%                                         23
                                                                7%        Not Applicable



                                                                     27
                                                                     8%   Previously Adopted
      2
     1%

                                                                          Reading for Interest Only



                                          161                             Under Investigation
                                          50%



                                                                          Will Adopt



 Brookhaven Science Associates
   U.S. Department of Energy                       15
2nd Qtr FY 08 Lesson Learned Feedback
                                                                Exhibit 9: Lessons Learned Feedback

                      40
                                                                                                                     Distributed for Information
                                                                                                    37
                                                                                                                     Not Applicable
                      35
                                                                                                                     Previously Adopted
                                                                                                                     Reading for Interest Only
                      30                                                                                             Under Investigation
                                                                30                         30
                                                                                                                     Will Adopt                                                                  29
Number of Responses




                      25                                                                                                                                                 26
                                                                                                                     25

                                         22
                      20                                                                                                                         21


                      15
                                                                                                                                                                                  15
                                                                                                                                                                    13
                                                                              12
                      10
                                                                         10

                                                      7                                                                       7          7                                                                7
                       5     6                                                         6                     6
                                 5
                                                          4 4                                            4                                                4
                                     2        1 3                    0             2            0                3        1          2       0        0       3 2             0          2 2 1        1
                       0
                           Electrical Arc Results in Inadequate Hazard Re-    Exploding Battery          Radioactive Sealed        Inappropriate Sample    Be on the Lookout for            Activation of
                                  a Near Miss            evaluation and           Incident                 Source Events          Shipment to Off-site Lab  Potential Electrical       Emergency Operations
                                                       Recognition Causes                                                                                         Hazards               Center During Severe
                                                         Electric Shock                                                                                                                  Weather Conditions


                      Brookhaven Science Associates
                        U.S. Department of Energy                                                                16
Brookhaven Science Associates
  U.S. Department of Energy     17
A Sampling of BNL Lesson Learned Feedback
   This is the first lessons learned notice I received. If you were involved in adding me to
    the distribution list, I appreciate it. This will prove to be helpful. Thanks!

   This appears to be an excellent use of web media to convey/inform employees of
    pertinent safety information

   Not very illuminating!

   I have incorporated this Lesson Learned into a Work Instruction for removing
    combustible materials from the HFBR (Building 750).

   I try to get the big picture from lessons learned and incorporate any ideas, knowledge,
    and improvements into my work/life.

   This Lessons Learned is a jewel. As a sea going oceanographer that put big moorings
    in the ocean, I have given an "awareness" sermon a hundred times to those that
    helped me on deck.


    Brookhaven Science Associates
      U.S. Department of Energy                18
A Sampling of BNL Lesson Learned Feedback
   I find reading Lessons Learned helps me with my work planning to maybe stop future
    failure.

   The Lessons Learned format is clear and "inviting" information well-presented.
    Photographs added to understanding.

   Good info, most of what was discussed was deployed during the RSB and CFN
    Construction review. I like the idea of the on-site nurse station that can be used for the
    NSLS II project.

   This reinforces the critical importance of every driver being aware of their
    surroundings. You never know when someone's life will depend on it.

   I'm trapped here. Every time I launch my web browser I get this feedback page




    Brookhaven Science Associates
      U.S. Department of Energy                19
Point to Ponder
   The more we stress only what we can measure, the
    more we need to remember that not everything that is
    measurable matters, and not everything that matters
    is measurable.”
                             - Elliot Eisner




    Brookhaven Science Associates
      U.S. Department of Energy     20
Lesson Learned Infrastructure
   https://sbms.bnl.gov/




    Brookhaven Science Associates
      U.S. Department of Energy     21
Brookhaven Science Associates
  U.S. Department of Energy     22
Brookhaven Science Associates
  U.S. Department of Energy     23
   Color blocks help identify work flow status




Brookhaven Science Associates
  U.S. Department of Energy      24
Brookhaven Science Associates
  U.S. Department of Energy     25
                    Recent Modifications/Path Forward
   Recruit new LL Coordinators

   Conduct/document an evaluation of the effectiveness of actions implemented from LL

   Revise subject areas to include steps that prompt the search for, and the application of
    LL

   Revise Laboratory-wide safety committee charter(s) to include responsibility to review
    value-added LL for possible improvements to institutional policies, procedures, work
    practices, training, and assessment activities

   Modify the “will adopt” LL feedback mechanism to capture the action(s) that will be
    taken in response to the Lesson.

   Revise the Lessons Learned (LL) subject area to require a formal response from
    Organizational LL Coordinators regarding evaluation/utilization of LL

    Brookhaven Science Associates
      U.S. Department of Energy               26
                    What are Traps, Triggers and Tools?
                                                       Demands of
   Traps                                                 Task
    • Conditions or situations that people may fall       Work
      into without recognizing it and cause and        Environment
      error, event or incident
                                                        Individual
   Triggers                                             Factors
    • observable actions or reactions,
    • a recognized thought or individual
      perception
    • or a “gut-feeling” that something isn’t right.
   Tools
    • Methods used to recognize and avoid traps
      and prevent errors, events and incidents



Brookhaven Science Associates
  U.S. Department of Energy                   27
Performance Modes
            This PERSON on this TASK at this TIME
                                             Key Words              Error
                                                                    Rate
 SKILL-BASED -- stored patterns             HABIT
 of pre-programmed actions.                 Familiar (> 50 times)     1 per
 Acting out of habit without                Not Thinking              1000
 conscious thoughts.
 RULE-BASED -- rules accumulated            There is a rule,
 via experience and training.               and I KNOW there          1 per
 Can be WRITTEN or VERBAL                   is a rule                 100


 KNOWLEDGE-BASED -- using                   You don’t Know            1 in 2
 analytical processes and stored knowledge.        what                  to
 Has NOTHING to do with how smart           You don’t know!!!!!       1 in 10 !!!!
 you are! You are uncertain how to proceed.
 Brookhaven Science Associates
   U.S. Department of Energy           28
Why is this important for
people to understand?
   Helps them keep from “proceeding in the face of
    uncertainty” which causes many accidents and injuries

   Makes them aware of the probable failure rate of a
    task or action

   Helps them apply the right TOOL to prevent an error,
    accident or injury

    Brookhaven Science Associates
      U.S. Department of Energy     29
Which Performance Mode Would You
Rather Be in?




        Skills-based
                                              Knowledge-based



                                 Rule-based


 Brookhaven Science Associates
   U.S. Department of Energy           30
Top 10 Error Traps…
                             Stress
                        High work load
                         Time pressure
                    Poor communications
               Vague or poor work guidance
          Overconfidence in work and/or abilities
   Infrequent or first time performing a task (new-to-job)
                          Distractions
       First working day following time off > 4 days
              The end of a shift or work cycle

 Brookhaven Science Associates
   U.S. Department of Energy     31
Time Pressure, Stress
& High Workload
   All feel the same to us
     • Feels like frustration
     • Muscles tighten
     • Deep breathing
     • Multiple minor errors
     • Sweating

   We cannot distinguish between them




    Brookhaven Science Associates
      U.S. Department of Energy     32
Poor Communications, Vague Guidance, First Time
or Infrequent task or Overconfidence
   All put the person in Knowledge–Based (KB) mode

    • Poor communications (Verbal) – The part of the communication left out
      is the part the receiver is in KB mode on and the quality of communication
      is the primary responsibility of the sender

    • Vague Guidance (Written) – The parts that are vague or missing keep the
      user in KB mode

    • First Time / Infrequent Task – The parts of the task that they have never
      done or don’t remember are KB mode

    • Overconfidence – Shrouds our ability to see when we enter KB mode

    Brookhaven Science Associates
      U.S. Department of Energy         33
Distractions, >4 Days off, End of or Extended Shift
   Distractions – Split the shared resources the brain needs – its like
    working with half a brain!

   >4 days off – Our brains disengage and we need time to re-engage

   End of shift or extended shift – Fatigue or distractions become
    additional problems




    Brookhaven Science Associates
      U.S. Department of Energy        34
                                Heaven Can Wait!




Brookhaven Science Associates
  U.S. Department of Energy           35

				
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