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Operated by Los Alamos National Security, LLC for DOE/NNSA Contractor Assurance Office (CAO) U N C L A S S I F I E D Learning About Learning Progress in.

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Presentation on theme: "Operated by Los Alamos National Security, LLC for DOE/NNSA Contractor Assurance Office (CAO) U N C L A S S I F I E D Learning About Learning Progress in."— Presentation transcript:

1 Operated by Los Alamos National Security, LLC for DOE/NNSA Contractor Assurance Office (CAO) U N C L A S S I F I E D Learning About Learning Progress in Lessons Learned at Los Alamos National Laboratory presented to the DOE Operating Experience Coordinators Workshop May 5, 2010 Bob Stuewe Operating Experience Coordinator Contractor Assurance Office – Performance Feedback Los Alamos National Laboratory Bob Stuewe Operating Experience Coordinator Contractor Assurance Office – Performance Feedback Los Alamos National Laboratory

2 Operated by Los Alamos National Security, LLC for NNSA U N C L A S S I F I E D Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Office U N C L A S S I F I E D Bottom Line Results Take About Three Years to Manifest End of CY processed per year Pass preliminary screening Nearly all DOE/HSS Safety 10 internal per year 200 web users/month 250 in searchable archive ?? document accesses per month ?? searches/month Trend Occurrences Track Communications 2 FTEs 1 FTE on the Trending FY 2010 (Now) 800 processed per year Pass preliminary screening Multiple pre-planned sources All program/function areas internal per year web users/month >2100 in searchable archive >30,000 document accesses per month searches/month Analyze/Trend Occurrences, Causes Track Actions (risk-based) 2.5 FTEs 1.2 FTE on Analysis Slide 2

3 Operated by Los Alamos National Security, LLC for NNSA U N C L A S S I F I E D Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Office U N C L A S S I F I E D Learning About Learning Lessons About Effective Lessons Learned Programs Champion Learning, Not Lessons Reliable Processes Build Trust and Use Clarify Roles to Eliminate Redundancy Support Work Processes Enable Risk Management More Focused Equals More Effective Build and Use Indicators of Effectiveness Encourage Innovation Slide 3

4 Operated by Los Alamos National Security, LLC for NNSA U N C L A S S I F I E D Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Office U N C L A S S I F I E D Champion Learning Not Lessons Operating Experience Programs are Key to Knowledge Management Slide 4 Operating Experience Program World of Possible Knowledge Learning happens in the work unit in many, many ways (Required reading, training, requirements updates, work team meetings, plan of the day, procedure updates, learning teams, process improvement teams, corrective action teams etc.)

5 Operated by Los Alamos National Security, LLC for NNSA U N C L A S S I F I E D Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Office U N C L A S S I F I E D Champion Learning Not Lessons From the Criteria for Performance Excellence (MBNQA) Learning is one of the three pillars of organizational performance. Learning is referenced 103 times in 88 pages The term performance excellence refers to an integrated approach to organizational performance management that results in (1) delivery of ever-improving value to customers and stakeholders, contributing to organizational sustainability; (2) improvement of overall organizational effectiveness and capabilities; and (3) organizational and personal learning. To be effective, learning should be embedded in the way an organization operates. Slide 5

6 Operated by Los Alamos National Security, LLC for NNSA U N C L A S S I F I E D Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Office U N C L A S S I F I E D Champion Learning Not Lessons Know How Your Organization Learns and Support the Methods Nuclear and High Hazard Facilities Conduct of Operations: required reading, procedures, FLM weekly meeting, critiques, facility lessons learned coordinators, etc. Subject Areas Electrical Safety Committee, Chemical Safety Committee, Glovebox Safety Committee, Security Incident Analysis, etc. Lower Hazard Organizations Worker Safety and Security Teams, Learning Teams, Management Meetings, mentoring, on-boarding, etc. Institutional Management review boards, requirements updates, training updates, institutional web pages, etc. Slide 6

7 Operated by Los Alamos National Security, LLC for NNSA U N C L A S S I F I E D Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Office U N C L A S S I F I E D Slide 7 Reliable Processes Build Trust and Use Trust Requires Relationships – With Products/Services Used Operating Experience and Lessons Learned Process – Collects, screens, risk-prioritizes, and distributes operating experiences and lessons learned from key external and internal sources using timely communications. – Three risk-priority levels with different disposition/communication pathways Lessons Learned and Operating Experience Archive – Captures relevant lessons and best practices reported by the Laboratory managers and workers, contractors, subcontractors, and from other DOE sites and external sources. – Knowledge base Mirror Mirror : Translating Events into Actionable Information – Communicates high-leverage actions, lessons learned and best practices associated with operating experience patterns and trends.

8 Operated by Los Alamos National Security, LLC for NNSA U N C L A S S I F I E D Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Office U N C L A S S I F I E D Reliable Processes Build Trust and Use Process Management is Proven To Create Reliable Products/Services 1.Establish Process Management Lean Six Sigma - Champion and Yellow Belt Process Team (Weekly - Operations) Integration Team (at least Annually - Integration and Strategy) 2.Benchmark (inside and outside DOE) 3.Define Product/Service Quality Specifications Purpose -> Products/Services-> Customers-> Requirements -> Controlling characteristics Defined processes (steps and roles) for each product (mapping) 4.Set up Process Controls and Improvement Program Description, Procedures, Checklists, Tools Use Contractor Assurance System: Goals, Measures, Assessments, Issues Mgt, Process Improvement Establish Task Roles (daily, weekly, monthly, quarterly, annual) Annual Improvement Plan (effectiveness and efficiency) 5.Execute and Innovate Slide 8

9 Operated by Los Alamos National Security, LLC for NNSA U N C L A S S I F I E D Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Office U N C L A S S I F I E D Reliable Processes Build Trust and Use Reliable Processes Requires Reliable Operations Slide 9 Monday Process Team Updates Upcoming Communications Plan Operations Improvement Plan Wednesday MIRROR Team Organized by sections of the publication Quality review and improve key messages and actions Design year-end and next issue Thursday Screening Team Process Team and occasionally the site office Finalize screening Determine dispositions Write headlines Publish Weekly Summary Daily intake and preliminary screening Work on products and services (MIRROR, lessons, support customers) Work on Communications Plan and Improvements Plan Tuesday Integration CAS Management Team Institutional Management Review Board As Needed Friday Week Close Out In case extra time is needed to complete the weeks deliverables Backlogs are deadly

10 Operated by Los Alamos National Security, LLC for NNSA U N C L A S S I F I E D Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Office U N C L A S S I F I E D Clarify Roles to Eliminate Redundancy Functional Approaches Increased Costs, Decreased Effectiveness LL requirements embedded in many directives, guides Alignment and Integration can save taxpayer money LANL approach OPEX program supports multiple functions – use an integration team to plan annual improvement ( Safety, Security, Env Mgt, Project Mgt, Facilities, HPI, Training) Issue & Corrective Action Management - handles extent of condition for institutional/local, OPEX program helps with whats in between QA/SCI – handles work-related suspect, counterfeit and defective items, OPEX serves as knowledge base, get directly involved at Urgent level Planned integration with internal security LL and Security Lessons Learned Center Organizational and Subject Area LL Knowledge Bases and Process align with and link to Institutional Contractor Assurance System: Measures, Assessment Planning, Issue Effectiveness Evaluation Site office uses LANL screening and disposition process, oversight of higher risk Slide 10

11 Operated by Los Alamos National Security, LLC for NNSA U N C L A S S I F I E D Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Office U N C L A S S I F I E D Slide 11 Support the Work Processes Easy to Think About the Push

12 Slide 12 Support the Work Processes Work is Always Underway – Dont Try to Change Cars While Moving

13 Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Offoce (CAO) U N C L A S S I F I E D Support the Work Processes Beware of the Adverse Unintended Consequences of the Push Common Lesson from OPEX: Not Thinking Through a Change Nuclear Facilities Procedures control the quality Modifying procedures include many steps, for good reason Conservation of Attention Law Only so much time in a day Rushing to implement a lessons learned can create rework Resource Allocation is Not an OPEX Role Acting on a lesson competes for resources OPEX Coordinators do not know the daily priorities on the work floor 13

14 Operated by Los Alamos National Security, LLC for NNSA U N C L A S S I F I E D Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Office U N C L A S S I F I E D Slide 14 Support the Work Processes Hard to Think about the Pull – But Equally Important

15 Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Offoce (CAO) U N C L A S S I F I E D Support the Work Processes Supporting Work Processes Requires a Knowledge Base Slide 15 MS Sharepoint Reduced Cost IT Costs Process Costs Aligns with Work Processes Topical Libraries (key systems) Alerts (individual and topical groups) How-To Tools Full PDF search capability

16 Operated by Los Alamos National Security, LLC for NNSA U N C L A S S I F I E D Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Office U N C L A S S I F I E D Hazard inventory is pretty stable at the sites Sharing known or low hazards provides little value to management New and Significant Hazards important and valued Risk Management About reducing consequence or probability Risk Management What is the risk? (to the mission) How large are the potential adverse consequences? What are you doing to handle it? How likely are you to succeed? Should you do more? Requires knowledge of organizational processes Russian Hydro as an Example Enable Risk Management To Engage Senior Management – Help Reduce Risk Slide 16 Where Lessons Learned can add the most value to management.

17 Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Offoce (CAO) U N C L A S S I F I E D Slide 17 Work Planning Processes (Line ) Training Development (Support) Requirements Development (Support) Enable Risk Management Risk-based Prioritization Matrix derived from O210.2 with Security from IMI levels Urgent and Caution matrix essentially identical to Order – will add Best Practice un future Communicate URGENT Caution Informational ClarifyScreen Monitor Sources Urgent = Immediate action is needed to ensure that the Laboratory is in a safe, secure, and environmentally sound mode relative to the information identified in the alert. Active engagement of relevant manager(s). Formal issues and corrective action tracking. Caution = Timely action may be needed. Routine notification through Lessons Learned and Operating Experience Weekly Summary s and LANL Home Page. LANL managers determine relevance and take needed action. Informational = Future action may be needed. Posted to LANL Home Page if broadly applicable and actions clear. Important to knowledge base.

18 Operated by Los Alamos National Security, LLC for NNSA U N C L A S S I F I E D Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Office U N C L A S S I F I E D Enable Risk Management Risk Levels Differ from Site to Site Slide 18 Pre-ScreeningPost Screening# HSS - Green Informational21 HSS - Blue Caution4 Informational44 HSS - Red Caution4 Informational6 HSS - Yellow Caution38 Informational65 Urgent Lessons most commonly associated with DOE Safety Alerts and Advisories, defective safety items, and other sources

19 Operated by Los Alamos National Security, LLC for NNSA U N C L A S S I F I E D Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Office U N C L A S S I F I E D Slide 19 Enable Risk Management Select Sources to Support Risk Management – Might Change over Time Primary Routine Sources Monitoring Frequency DOE HSS Server/Web (LL, Alerts, OE Summaries, Security Lessons Learned Center (SLLC)) Daily Partner Alerts (Bechtel, BWXT, UC, etc.)As Issued ORPS (from Other Sites)Daily Suspect Counterfeit/Defective ItemsDaily U.S. Chemical Safety BoardMonthly Enforcement Actions and GAO ReportsQuarterly Consumer Products (CSPC, FDA)As Issued

20 Operated by Los Alamos National Security, LLC for NNSA U N C L A S S I F I E D Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Office U N C L A S S I F I E D More Focused Equals More Effective Tailor Communication Methods to Audience and Media Capability Slide 20

21 Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Offoce (CAO) U N C L A S S I F I E D More Focused Equals More Effective Weekly Summary – Management and LL Roles with Prioritization Recipients Division Leaders and above NNSA Site Office LL Roles and Upon Request Augments daily ORPS Slide 21 Specific = Relevant 1.Define Most Specific Customer 2.Select Words in Headline 3.Integrity Check 4.Order (First and Last Most Read) Scan-able (6 most important/actionable; > 6 has lower read rate)

22 Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Offoce (CAO) U N C L A S S I F I E D More Focused Equals More Effective LANL Homepage to Reach Workers Directly Some Communication Overlap Helps Effectiveness Main Users Workers Broadest lessons Includes worker home safety Specific = Relevant Even shorter headlines Pre-job brief is major customers Slide 22

23 Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Offoce (CAO) U N C L A S S I F I E D More Focused Equals More Effective Internal Lessons Learned Submission – Content over Format Adobe Fill-able Form Just the Facts Word Docs too slow, costly, hard to share with DOE Field Validation – reduce errors Fields support processing Screening and prioritizing Interface to DOE/HSS Includes picture objects Submit Button linked to LL Archive and Process Becoming standard at facility level Slide 23

24 Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Offoce (CAO) U N C L A S S I F I E D More Focused Equals More Effective LANL Mirror (Quarterly Publication) Translating Events into Actionable Information Events binned by systems and processes Patterns and trends (incidents, occurrences, causes) Year-End and Two-Year Running Reflection Use statistics to identify changes/trends High-leverage lessons/actions aligned with greatest performance gaps Recognition for developing and sharing lessons learned Slide 24

25 Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Offoce (CAO) U N C L A S S I F I E D More Focused Equals More Effective LANL Mirror: Events Causes Checklist for Improvements Slide 25

26 Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Offoce (CAO) U N C L A S S I F I E D Build and Use Indicators of LL Effectiveness Fact-based Improvement is the Objective Use CAS Dashboard LL Indicators Processing time performance Urgent within 24 hours Caution within 7 days Document Access Rate Search Rate Knowledge Inventory Internal LL Generation Rate LL Program Execution Routine Process Milestones Progress on Improvement Plan Corrective Actions Slide 26

27 Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Offoce (CAO) U N C L A S S I F I E D Build and Use Indicators of LL Effectiveness Need measures than can help understand Cause and Effect Slide 27

28 Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Offoce (CAO) U N C L A S S I F I E D Build and Use Indicators of LL Effectiveness Need measures than can help measure use for Work Planning Slide 28

29 Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Offoce (CAO) U N C L A S S I F I E D Encourage Innovation LANL Performance Communication Center Modernizing Communications Chat with an Expert Builds Knowledge Base Blog Role-based information Relevant Tools Relevant Requirements Best Practices (coming soon) Custom version of LL Form Recognition Slide 29

30 Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Offoce (CAO) U N C L A S S I F I E D Encourage Innovation Sub-Unit Approaches Evolve as their Learning Processes Mature R&D key lessons included in On-Boarding materials for new hires (might become a best practice) Local LL Archives Linked to Institutional Archive Project Management Engineering D&D Maintenance Facilities Learning Teams (linked to HPI implementation) Slide 30

31 Operated by Los Alamos National Security, LLC for NNSA Contractor Assurance Offoce (CAO) U N C L A S S I F I E D Learning About Learning Progress in Lessons Learned System at LANL Questions? Slide 31


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