1. 11/27/20071 DOE Corporate Operating Experience Program, DOE O 210.2 Briefing to the Operating Experience Committee Meeting And the ISM Champions Workshop November 27 & 29, 2007 ----------------------------------------------------------- Eugenia L. Boyle Occurrence Reporting & Operating Experience Program Manager Office of Analysis (HS-32), Office of Corporate Safety Analysis Office of Health, Safety and Security 301-903-3393 Eugenia.Boyle@hq.doe.gov

2. 11/27/20072 Contents Current Status of DOE O 210.2 Implementation – Contractor, Field, HQ, and Lead Office Related OPEX Commitments to DNFSB 2004-1 and Status Lead Office OPEX Initiatives Lessons Learned Program Survey Results Formation of an Operating Experience Committee

3. 11/27/20073 DOE O 210.2 Status DOE Order 210.2, DOE Corporate Operating Experience Program – Issued June 12, 2006. Order required the Contractor Requirements Document (CRD) to be incorporated into affected contracts by December 12, 2006. The CRD requires Contractors to incorporate the CRD into affected sub-contracts by June12, 2007. Four Regional Implementation Workshops were held in October and November 2006.

4. 11/27/20074 DOE O 210.2 - Contractor Implementation Status 62% in contracts now 31% implemented now PSO # CONTR.# IN CONTRACTS# IMPLEMENTED COORDINATORS IDENTIFIED Now End of YearLaterUnknownNow End Of YearLaterUnknown EE1010000001 EM221100 5211420 FE1100001001 NA7410220145 NE33 0012003 RW1010010001 SC1512102623411

5. 11/27/20075 DOE O 210.2 - DOE Field Implementation Status 36% implemented now PSO # FIELD SITES# IMPLEMENTED COORDINATORS IDENTIFIED Now End Of YearLaterUnknown EE100011 EM911165 FE110001 NA820067 NE100011 RW110001 SC12402610

6. 11/27/20076 DOE HQ Implementation Status The Office of Energy Efficiency has implemented DOE Order 210.2, "DOE Corporate Operating Experience Program" as part of a tailored, graded approach under the Integrated Safety Management System. They are currently in the process of updating and revising their HQ Functions, Responsibilities and Authorities Manual (FRAM). The Office of Science is developing documentation to define and implement its Operating Experience and Lessons Learned Program through its web-based Science Management System (SCMS). Implementation at the PSO level is expected in the next few years. Science laboratories are generally strong in their use of operating experience information and do not rely on the existence or performance of a Headquarters-based system to effectively use operating experience information to improve their safety performance.

7. 11/27/20077 DOE HQ Program Implementation Status (cont’d) The Office of Fossil Energy is involved in the following OPEX implementation activities: 1.Representation on the Operating Experience Committee. 2.Monitoring ORPS reports relative to FE HQ or sites and conducting investigations as required. 3.Reviewing best practices, where applicable. 4.Monitoring and dissemination of all total recordable cases, lost workday cases, near misses, etc.. 5.Active involvement in the CAIRS system.

8. 11/27/20078 DOE HQ Program Implementation Status (cont’d) The National Nuclear Security Administration is involved in the following OPEX implementation activities: 1.Requested that all NNSA organizations HQ/sites appoint coordinators and that sites incorporate DOE O210.2 into M&O Contracts - August 8, 2007. 2.Issued expectations for OPEX programs after a survey of the Field - November 26, 2007. 3.Is developing HQ Procedure for implementation of OPEX program - target November 2007. 4.Planning self-assessment of HQ OPEX programs implementation - target December 2007. 5.Planning assessment of two NNSA sites to validate OPEX program implementation - target January / February 2007.

9. 11/27/20079 DOE HQ Program Implementation Status (cont’d) The Office of Civilian Radioactive Waste Management (OCRWM) has a formal lessons learned process that is part of our Corrective Action Program (CAP). The CAP program tracks to closure identified issues and the corrective actions that are developed to prevent recurrence. In addition, the OCRWM Trending Program identifies monitoring, emerging, and adverse trends and requires line management actions to address the trends. Formal quarterly reports on the trends and corrective actions are provided to senior management. The OCRWM CAP is a key requirement for the License Application that will be evaluated by the U.S. Nuclear Regulatory Commission in the licensing of the Yucca Mountain Repository and status reports are periodically provided during the public quarterly management review meetings. The Director and senior management team routinely review operating safety metrics and metrics from the CAP during their Monthly Program Reviews.

10. 11/27/200710 DOE HQ Program Implementation Status (cont’d) The Office of Nuclear Energy has a designated OPEX Program Coordinator and a lessons learned database (called NEATS - NE Action Tracking System) for the past 3 years. NEATS is used to forward Lessons Learned (LLs), good practices, and information about relevant issues to our sole field office (DOE-ID) at the INL for their information, use, and to solicit feedback on actions taken, as appropriate. DOE-ID receives HSS LLs daily, generates its own LLs, and prepares a daily summary that includes LLs for distribution to all INL contractors. NE will also be expanding its OPEX implementation activities as it receives further guidance/direction from HSS and/or the OPEX committee.

11. 11/27/200711 DOE HQ Program Implementation Status (cont’d) The Office of Environmental Management continues to utilize the DOE Corporate Lessons Learned Database, (maintained and managed by HSS), to report and disseminate lessons learned. The Office of Acquisition and Project Management (EM-50) will lead the coordination with EM/HQ and Field sites for submission of lessons learned in project management to the HSS database and the EM Communications Portal. In addition, the Chief Operating Officer (EM-3) established an EM Operations Lessons Learned Program in 2006 to promote sharing of operational experiences throughout the EM complex. Based on factors including risk and costs, operational facilities and projects are selected to share lessons learned in: Safety; Acquisition Strategy & Contract Management; Regulatory Compliance; Technology; Engineering Design & Construction; Funding & Resources; and Communications. EM has completed more than 10 operations lessons learned, including Rocky Flats Closure Project, River Corridor Cleanup Project, Hanford Waste Treatment Plant, Savannah River Salt Waste Processing Facility, etc. EM Operations Lessons Learned are presented at the monthly EM Field Managers Video Conferences and the presentations are posted on the EM Communications Portal.

12. 11/27/200712 Lead Office Implementation Status Lead Office: Office of Health, Safety and Security -Operating Experience Committee has been Chartered. -HSS Functions Responsibilities and Accountabilities (FRA) has been updated to Reflect Functions. -Office of Corporate Safety Performance is formalizing procedures that describe the processes used by the Office of Analysis in conducting the program. - Working in conjunction with the EFCOG ISM Working Group – ORPS, Electrical Safety Improvement Project, Feedback and Improvement, HPI. -HSS Continues to Establish Contacts with External Agencies and Review of External Experience.

13. 11/27/200713 Commitments from DNFSB 2004-1 Three Operating Experience Program-Related Commitments Commitment 17: Complete Department-wide formal review of Columbia and Davis-Besse events, and develop consolidated Department-wide Action Plan. DOE Action Plan – issued July 2005 identified Ten DOE Lessons Learned, Five with 20 unique Actions. Complete – July, 2005. Commitment 18: Develop a Comprehensive Operating Experience Program. DOE O 210.2 fulfilled this commitment. Complete – June, 2006. Commitment 19: Demonstrate Performance of DOE Operating Experience Program. Due by December 12, 2007. DNFSB has continued interested in implementation progress. Not complete.

14. 11/27/200714 DNFSB 2004-1 Commitment 17 Progress Report: Commitment was Met, Actions Ongoing While the formal review of the Columbia Shuttle and Davis Besse Nuclear Reactor events has been completed, additional actions remain as defined in the Department-wide Action Plan. Complete Department-wide formal review of Columbia and Davis-Besse events, and develop consolidated Department-wide Action Plan.

15. 11/27/200715 DNFSB 2004-1, Commitment 17 Columbia / Davis-Besse OPEX Related Actions Action #1.c. - Memo to Establish DOE Operating Experience Committee – Completed. Chartered as a subgroup of the ISM Champions Council. DOE program office and DOE and Contractor field representatives will serve on this committee. Action #1.e. - Sponsor Periodic Safety Forums for Sharing Lessons Learned – First Operating Experience Committee (OEC) Meeting to be held November 27, 2007 at BNL. – Future OEC Meetings/Workshops will continue to coincide with ISM Champions Council Meetings Action Plan, Lesson Learned #1 : Operating Experience.

16. 11/27/200716 Lead Office OPEX Initiatives DOE has Implemented a Corporate Safety Indicator Process - DOE's Corporate Safety Indicator process has been modified to include Corporate Sustainability. The concept of Corporate Sustainability, along with the analysis of other corporate safety indicators, has been briefed to the Deputy Secretary for the last three quarters. BP Fire Lessons Learned HSS issued ES&H Advisory 2007-02, Safety Culture Weakness Cited in BP Accident, based on the findings and recommendations of the independent safety review of BP U.S. refineries. HSS is determining whether to convene a DOE-wide review team to identify other DOE Lessons Learned from this report.

17. 11/27/200717 Lead Office OPEX Initiatives (cont’d) External Operating Experience: HSS has made formal contacts with several External Agencies and routinely searches External OPEX Sources. U.S. Chemical Safety and Hazards Investigation Board Nuclear Regulatory Commission National Aeronautics and Space Administration Naval Safety Center Institute of Nuclear Power Operations Additional Contact Efforts Continue.

18. 11/27/200718  Separate and clarify the Criteria for Fires and Explosions.  New Criteria for Hazardous Electrical Energy Control using the Electrical Severity Measurement Tool and for Other Hazardous Energy Control.  Technical Safety Requirements (TSR) - revised to remove criticality  Criticality Safety revised to capture TSR violations  Facility Operations revised  Management Concerns revised Lead Office OPEX Initiatives (cont’d) Proposed Revision of DOE M 231.1-2, Occurrence Reporting Criteria: HS-30 is reviewing and finalizing proposed changes to the occurrence reporting criteria. Will submit for REVCOM review in early 2008.

19. 11/27/200719 Near Misses - Revised Definition: 10 (3) 1-3†A near miss to an otherwise ORPS reportable event, where something physically happened that was unexpected or unintended and significant consequences were avoided only by chance because either: a) no controls or protective equipment were in place to prevent more severe consequences, or b) the controls or protective equipment were ineffective. The significance category assigned to the near miss should be based on an evaluation of the potential risks and planned or anticipated corrective actions. The proposed changes are intended to correct known reporting problems and enhance the Corporate Safety Indicator Process. Lead Office OPEX Initiatives (cont’d) Proposed Revision of DOE M 231.1-2, Occurrence Reporting Criteria (cont’d):

20. 11/27/200720 1.Safety Bulletins - 5 2.Safety Advisories - 5 3.Operating Experience Summary – 7 Issues containing 22 Articles 4.Suspect/Counterfeit Data Collection Sheets – 131 5.Lessons Learned – 200 approved 6.Facility Call Sheets – 86 In CY 2007, HS-30 published the following OPEX products: Lead Office OPEX Initiatives (cont’d)

21. 11/27/200721 1. Safety Bulletin 2007- 01, Compressed - Gas Cylinder Safety 2. Safety Bulletin 2007- 02, Hexavalent Chromium Update 3. Safety Bulletin 2007- 03, Lead Safety Awareness 4. Safety Bulletin 2007- 04, Thoriated Weld Rods 5. Safety Bulletin 2007- 06, Unwanted Chemical Reactions Safety Bulletins Lead Office OPEX Initiatives (cont’d)

22. 11/27/200722 1. Safety Advisory 2007- 01, Valley Fever 2. Safety Advisory 2007- 02, BP Safety Culture 3. Safety Advisory 2007- 03, OSHA Revises Electrical Safety Standards 4. Safety Advisory 2007- 04, Startup Reviews 5. Safety Advisory 2007- 05, Substance Abuse Safety Advisories Lead Office OPEX Initiatives (cont’d)

23. 11/27/200723 Operating Experience Summary Articles Lead Office OPEX Initiatives (cont’d) 1. In the Event of Fire, Follow Emergency Procedures 2. Excavator Accidents can be Deadly 3. Safety XChange Reports on Best Practices of 2006 4. Fluor Hanford Develops Training Material on Hazards Involving Neutral Conductors 5. Ladders: What Goes Up Must Come Down — Safely 6. Valley Fever Cases Reported at Lawrence Livermore National Laboratory 7. Operating Vehicles or Equipment while Fatigued can be Fatal 8. Failure to Verify Voltage Results in Electrical Near Miss 9. Aerosol Can Explodes Inside a Hot Truck and Damages Windshield 10. PPE and Engineered Controls can Prevent Welding Exposure to Hexavalent Chromium 11. Inadequate Industrial Job Planning has Unintended Consequences

24. 11/27/200724 Operating Experience Summary Articles (cont’d) Lead Office OPEX Initiatives (cont’d) 12. Is There a Fire Hazard Underneath Your Desk? 13. Always Consider Potential Electrical Hazards in Non-Electrical Work 14. Preventing Heat-Related Illness 15. Poor Job Planning Results in Electrical Worker Fatality 16. Lessons Learned from Leak at British Reprocessing Plant 17. Damaged Powered Air Purifying Respirator Hoses 18. Safe Use and Installation of Fall Protection Anchors 19. NRC Identifies Recurring Operability Issues with Emergency Diesel Generators 20. Near Miss - Roll Bar on Riding Mower Knocks Down Window Air Conditioner 21. Are Proper Cold Weather Protection Measures in Place at Your Site? 22. OSHA Issues New Instruction on Combustible Dusts

25. 11/27/200725 In October, 2007, a Lessons Learned Program Survey was distributed to key contractor personnel across the complex. There were 25 respondents from more than 21 sites. The following slides show some of the results from the survey. Lessons Learned Survey Results

26. 11/27/200726 According to the survey, the top five sources used to generate organizational Lessons Learned Notices were: DOE Corporate Operating Experience LL Database 72% Critiques and Investigations68% Occurrence Reporting and Processing System (ORPS)64% Accident, Incident, Injury Reports52% Daily Operational Experiences44% Lessons Learned Survey Results (cont’d)

27. 11/27/200727 The following is the stated percentage of contractors who routinely submit internal Lessons Learned to the DOE Corporate Operating Experience Lessons Learned Database. Yes: 56% No: 44% Lessons Learned Survey Results (cont’d) Question: What can we do to increase this percentage?

28. 11/27/200728 The following is the stated percentage of Lesson Learned Programs that have a system to track corrective actions made in response to a Lessons Learned Notice? Yes:52% No:48% Lessons Learned Survey Results (cont’d) Question: What can we do to increase this percentage?

29. 11/27/200729 The responses below were selected to complete the following sentence: We have implemented the new DOE Order.... YesNo...into our site Operations60%40%...into our site Maintenance and Work Planning60%40%...into our site Work Processes68%32%...into our site Training56%44%...into our site Design and Construction48%52% Lessons Learned Survey Results (cont’d)

30. 11/27/200730 The responses below were selected to complete the following sentence: Our site has established metrics that measure the... Strongly Disagree DisagreeNo Opinion AgreeStrongly Agree …Lessons Learned program performance. 20%4%24%48%4%...effectiveness of actions implemented from Lessons Learned Notices. 24%12%28% 8%...effectiveness of the Lessons Learned program. 20%4%24%48%4%...user feedback that documents the fact that a Lessons Learned Notice(s) was beneficial to the user and operations (e.g. application of a Lessons Learned resulted in process changes that made operations safer). 20%12%32%24%12% Lessons Learned Survey Results (cont’d)

31. 11/27/200731 The responses below were selected to describe the contractors’ opinion of the following sentence: Our site prepares and issues Lessons Learned reports, summaries and/or charts for Senior Management review. Strongly Disagree2% Disagree 4% No Opinion8% Agree64% Strongly Agree12% Lessons Learned Survey Results (cont’d)

32. 11/27/200732 The following is the stated frequency for issuing Lessons Learned reports, summaries, and/or charts. Monthly 44% Quarterly 40% Bi-annually 4% Annually 0% Not applicable 20% Lessons Learned Survey Results (cont’d)

33. 11/27/200733 The following is the stated overall satisfaction with the DOE Corporate Operating Experience Program. Very Dissatisfied0% Dissatisfied8% No Opinion16% Satisfied72% Very Satisfied4% Lessons Learned Survey Results (cont’d) Question: What can we do to increase the percentage of Satisfied and Very Satisfied?

34. 11/27/200734 The following is the stated overall satisfaction with the Society for Lessons Learned Sharing (SELLS) group. Very Dissatisfied0% Dissatisfied0% No Opinion4% Satisfied56% Very Satisfied40% Lessons Learned Survey Results (cont’d)

35. 11/27/200735 Operating Experience Committee (OEC) Establishment of a DOE Operating Experience Committee The purpose of the Department of Energy (DOE) Operating Experience Committee (OEC) is to support line management within DOE and the DOE community in developing and sustaining effective operating experience programs so that lessons from internal and external operating experience lead to improvement in future operational and safety performance. The OEC will facilitate management and worker communications to promote the sharing of operating experiences and associated best practices for using operating experience to improve future performance.

36. 11/27/200736 The DOE Operating Experience Committee has been Chartered as a Subgroup of the ISM Champions Council  Will meet Action 1.c of the Columbia-Davis Besse Action Plan  Will strengthen the feedback and improvement ISM core function  Will provide increased Federal leadership and involvement in the review of operating experience  The SELLS charter will be cancelled.  In order to realize the benefits of learning from external operating experience, the OEC will open its membership to other government agencies, contractors, and private sector companies and individuals Operating Experience Committee (OEC) (cont’d)

37. 11/27/200737 Designated members of the Committee consist of: (1) the designated DOE and Contractor Operating Experience Program Coordinators (as defined in DOE O 210.2), (2) the Director, Office of Analysis within DOE’s Office of Health, Safety and Security, and (3) Chief of Nuclear Safety (CNS) and Chief of Defense Nuclear Safety (CDNS), or their designated representatives. Operating Experience Committee (OEC) (cont’d) Associate membership in the Committee is open to: All DOE federal and contractor employees, as well as to external representatives interested in sharing operating experiences and associated best practices.

38. 11/27/200738 Thank you for your attention!