1. Hanford Human Performance Improvement Lessons Learned Report Brian Harkins – DOE ORP John McDonald – CH2M HILL Hanford Group Dave Jackson – Fluor Hanford

2. Purpose Implement HPI by DOE ORP, RL and Hanford prime contractors
In response to a DOE EM initiative to improve ISMS
HPI has been very successful in commercial nuclear power
DOE ORP and RL senior management received initial HPI training at the Nuclear Executive Leadership Training Course in the fall of 2005
Integrate HPI into ISMS
Report Link:

3. HPI Focus Areas Just Culture Steering Committee Self Assessment
Training
Work Planning and Control
Procedures
Event Investigation/Cause Analysis
Culpability Matrix

4. Benefits From HPI Reduced events with consequences
Improved problem identification
Improved identification of latent organizational weaknesses before they cause events
Simpler procedures and work packages
Improved identification and control of critical steps and hazards
Improved event investigation
Consistent and fair treatment of individuals

5. DOE Role with their Contractors
Recognize that DOE is part of the “Organization”
Support Contractor implementation of HPI
Recognize significant commitment
Encourage and reward implementation and use of HPI
Facilitate process changes
Joint DOE/Contractor commitment

6. Just Culture Lessons Learned
Perception that HPI doesn’t hold people accountable
Effective training helps establish just culture
Free flow of information
Prevention of harassment and retaliation
Fair and consistent treatment of individuals
ISMS Expectations
Communication and listening skills to foster problem identification
ISMS safety culture implementation accelerated HPI implementation
Emphasis on event prevention helped field implementation
Consistent and fair implementation of existing disciplinary process is consistent with just culture
Worker representatives helped build trust and foster lessons learned approach in event investigations

7. Steering Committee Lessons Learned
Stability is important – Stick to the plan
Focus on issues at least six months out
A long term focus accelerates the overall rate of change
Formally tracking improvement actions provides needed structure
Lots of little changes equal a big change in the organization
Event reviews from HPI perspective were valuable
Gap analysis participation ensured follow through on actions

8. GAP Analysis Methodology

9. Training Lessons Learned
Training is the biggest investment required to implement HPI
Initial training took about 6 months to develop and present
Emphasis on event prevention and ISMS integration
Entertainment examples enhance training experience
GAP Analysis and training needs analysis effective in determining training content and durations
Facility specific, practical applications allows for immediate application
Facility trainers adds credibility and sustainability

10. HPI Training Lessons Learned
Various training modules were used with resource estimates
4 hour (up to 50-75% of work force)
8 hour (5-100% of work force)
24/32 hour (5-40% of work force)
Medium class size best, e.g. 15 – 20 people
Facility trainers teamed with contracted trainers added credibility
Emphasis on ISMS integration
An abundance of HPI resources and tools available to enhance training
Training effectiveness is improved by using mentors (HSS, other contractors, consultants, INPO)

11. HPI Concepts in Work Planning
Workers are the key in identifying hazards and controls of tasks
Just culture enabled workers to feel freer to raise issues
The workforce was trained in critical tasks, error precursors, and error likely situations
Certain tasks are more critical than others
Some actions/tasks are irrecoverable; once the action is taken, the reverse action cannot recover
Some steps have more chances for error
Critical tasks help focus attention on potential consequences so appropriate defenses and contingencies can be put in place

12. HPI in Work Planning Planning the Work Walkdown Job Hazards Analysis
How we Identify
General hazards and tasks
Job Hazards
Analysis
How we Identify
Critical Tasks &
Error Precursors
Safety Plan
For the Critical Tasks we Define defenses against Error Precursors
Work Instruction
Warnings
Precautions
Work Steps
How we Implement the defenses

13. HPI in Performing Work Performing the Work Pre-job Briefing
Communicate the scope , Critical tasks hazards, and controls
Walkdown Work site
Verify conditions are as expected looking for Error Likely Situations and that Instructions can be worked to as written
Perform the work
Perform work to instructions applying additional defenses at critical tasks
Post Job Briefing
Feedback
Lessons Learned
Document the work

14. Work Planning Lessons Learned
Theoretical concepts must be converted to opportunities for practical implementation
Prioritize which concepts will fit into organizational processes
Keep facilities and organizations involved in the process
Significant management attention required to make change
Expect a total of two years before changes are institutionalized
Workers and managers need to be mentored regularly

15. HPI vs. Standard Event Investigation
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
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

16. Root Cause vs HPI in Event Investigation

17. HPI Event Investigation/Cause Analysis Lessons Learned
HPI enhances root cause analysis in identification of organizational performance on human performance
Buy in by line organizations that own corrective action management, event investigation and root cause analysis is necessary
In the beginning, HPI investigations should be done in addition to the traditional investigation to demonstrate:
Value of ‘context’
Role error likely situations and organizational weaknesses have on errors
Evaluate both error precursors and organizational performance
Focus on failed defense/barrier, not just the error precursors

18. HPI Culpability Evaluation Flowchart
Were actions as intended?
Knowingly violate expectation?
Pass substitution test?
(see note)
History of human performance problems? No No
Yes
Yes No
Yes No No
Were the consequences intended?
Were expectations reasonable, available, workable, intelligible, and correct?
Deficiencies in training and selection or inexperience?
Self-Reported
Yes
Yes No No
Yes
Yes
Yes
Organization induced violation No
System induced error
Blameless error
Intentional act (not an error)
Possible reckless violation
Possible negligent error
Corrective training or other intervention may be warranted
Evaluate organizational processes and management/supervisory methods
Note: Would other employees have made the same error?

19. HPI Lessons Learned On Culpability Matrix
HPI Culpability Matrix is easily understood and seen as a benefit by workers & supervisors.
1st Impression by management is it’s a path to ‘blameless’ acts and a lack of accountability.
Old views & ‘Strong Rules’ exist in HR, Legal and Unions on consistency in disciplinary actions.
Agreements must be secured in moving forward.
Benefits near the end of an investigation in order to establish ‘context’ of event.
Output is used in ALL corrective actions, even those focused on individual (disciplinary review boards).

20. Conclusion
Pilot participants have continued on using HPI after the Pilot
An EFCOG initiative is expanding on the Pilot
We continue to learn more and are building better defensives to human error
In general, workers perceive HPI as a positive ISMS enhancement