ORP-06-033

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 TrainingIf you want to watch the video clip, click on the box below. Otherwise continue the slideshow.

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

Review from the perspective of the people involved in the event (context)

Evaluate the organization as event unfolds

The event is the effect or symptom of deeper trouble in the organization, thus not random

Old methods

Review from hindsight point of view – judging each critical step in view of the final outcome

Investigate to find where personnel went wrong

Often look at events as a problem with people, procedures and training

ORP-06-033

Investigations using HPI Tools

Event

ErrorPrecursors

Vision, Beliefs, &

Values

LatentOrganizationalWeaknesses

Mission

Goals

Policies

Processes

Programs

FlawedDefenses

InitiatingAction

Vision, Beliefs, &

Values

Root Cause Analysis

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