1. Bechtel National Inc. 1 Engineering Maintains Quality by Using Error Precursors Presented September 12, 2006 DOE Integrated Safety Management Best Practices Workshop Jim Hummer Configuration Management Bechtel National, Inc. Hanford Waste Treatment and Immobilization Plant

2. 2 53 million gallons radioactive waste 149 single-shell tanks built from 1943-1964 28 double-shell tanks built from 1968-1986 67 are presumed to have leaked Hanford Site Cleanup is an Unprecedented Challenge

3. 3 Vitrification offers the best solution for immobilizing Hanford’s high-level radioactive waste and preventing an environmental catastrophe The Solution: Immobilize the Waste in Glass Sturdy waste form – impervious to the environment Proven Technology – used at other DOE sites and internationally Requires significant infrastructure – several large facilities constructed to nuclear standards See www.waste2glass.com for additional information on WTP

4. 4 Pretreatment Building HLW Vitrification Building LAW Vitrification Building Analytical Laboratory Hanford’s Waste Treatment Plant will be the world’s largest chemical-radioactive waste treatment plant to treat Hanford’s underground tank waste WTP is the Cornerstone of Hanford Tank Waste Cleanup Pretreatment Facility Low-Activity Waste Vitrification Facility High-Level Waste Vitrification Facility Analytical Laboratory Balance of Facilities – Utilities, Operations Facility, and Offices

5. 5 Current Focus of Design Activities Process and Layout DefinitionEquipment and Controls DefinitionDetail Design Process Flow Diagrams 3-D Model and General Arrangement Drawings Equipment Location Software Specifications Supplier Submittals Concrete Drawings Steel Drawings Support Drawings Raceway Layout Circuit Routing DCS Software Development HVAC Orthographic Instrument Location Drawings Pipe Isometric Drawings Design Criteria: Contract Safety Envelope Basis of Design Permits Functional Specification Operational Requirements Flowsheets R&T Risk Issue Resolution          Plot Plan Single Line Diagrams Ventilation and Instrumentation Diagrams Mechanical Handling Diagrams Piping and Instrumentation Diagrams Material Specifications Equipment List

6. 6 Error Precursors are Used to Maintain Engineering Quality Error precursors, adopted from the Institute for Nuclear Power Operations (INPO), promote a human performance approach to error prevention. 80 % Caused by Human Error 20 % Equipment Failure and Other Causes All Error Occurrences Human Error Occurrences 70 % Latent Organizational Weaknesses 30 % Individual Errors

7. 7 Human Performance Error Precursors (Short List) Task Demands Time pressure (in a hurry) High workload (memory requirements) Simultaneous, multiple tasks Repetitive actions (monotonous) Irrecoverable acts Interpretation requirements Unclear goals, roles, responsibilities Lack of, or unclear, standards Work Environment Distractions / Interruptions Changes / Departures from routine Confusing displays or controls Workarounds Hidden system response Unexpected equipment conditions Lack of alternative indication Personality conflicts Individual Capabilities Unfamiliarity with task / First time performed Lack of knowledge (mental model) New technique not used before Imprecise communication habits Lack of proficiency / Inexperience Indistinct problem solving skills “Hazardous” attitude for critical task Illness / Fatigue Human Nature Stress (limits attention) Habit patterns Assumptions (inaccurate mental picture) Complacency / Overconfidence Mindset (“tuned” to see) Inaccurate risk perceptions (“Pollyanna”) Mental shortcuts (biases) Limited short-term memory

8. 8 The ISM Model for Engineering Quality Scope of Work: Engineering Procedures and Guides Identify/Analyze Hazards: EQA Chart for identification of common themes Develop/Implement Controls: Action Plans ISMS Model for Engineering Improvement Perform Work Within Controls: Procedure Compliance Checklists Feedback / Improvement: Leading Indicator Metrics, Assessments, Identification of Error Precursors

9. 9 Engineering Procedures and Guides Procedure topics include General Information Organization Planning and Control Design Execution Personnel Qualification Procurement SCOPE OF WORK

10. 10 Procedures Maintain Quality using Error Precursors Task Demands ------------------------------ Work Environment ------------------------------ Individual Capabilities ------------------------------ Human Nature ------------------------------ SCOPE OF WORK Objective: Avoid using procedures to address performance gaps  Clarify requirements  Remove ambiguity  Provide alternatives  Use examples  Build in defenses, barriers, and safeguards  Analyze for error likely situations  Develop cost effective solutions  Apply lessons learned

11. 11 Engineering Quality Analysis Chart Features Relative significance and scope CAR binning according to topic Distribution by gap area Performance and process gaps Distribution by significance ANALYZE HAZARDS

12. 12 EQA Provides the Basis to Assess Error Precursors Task Demands ------------------------------ Work Environment ------------------------------ Individual Capabilities ------------------------------ Human Nature ------------------------------ Objective: Provide a statistical basis to analyze common themes  Communicate scope and relative significance of quality issues  Relate issues to common cause codes for analysis  Initiate discipline-specific assessment of error precursors  Trigger action plan development to address common themes ANALYZE HAZARDS Cross-discipline and cross- product assessment of quality issues for error precursors  Engineering products  Engineering processes

13. 13 Our Roadmap to Engineering Improvement Action Plans Monitor Results Analysis for Gaps Corrective Action Reports Management Assessments Surveillance Reports Checklists Checklist Metrics Engineering Quality Analysis Input Action Plan IMPLEMENT CONTROLS

14. 14 Action Plans Correct Organizational Weaknesses Task Demands ------------------------------ Work Environment ------------------------------ Individual Capabilities ------------------------------ Human Nature ------------------------------ IMPLEMENT CONTROLS Input from many sources  Corrective Action Reports  Self Assessments  Surveillance Reports  Checklists Objective: Address underlying causes of common problems  Clarify goals, roles, and responsibilities  Interpret and relate requirements to upper tier source  Improve performance on new techniques / tasks

15. 15 Procedure Compliance Checklists Purpose: Leading indicator to identify error precursor conditions Implemented by document checker as part of normal, pre-approval, document review Used for calculations, drawings, specifications, material requisitions, and supplier deviation disposition requisitions Metrics pinpoint actionable areas of improvement opportunity WORK WITHIN CONTROLS

16. 16 Procedure Compliance Checklists (Examples) WORK WITHIN CONTROLS

17. 17 Compliance Checklists Stop Errors in their Tracks Task Demands ------------------------------ Work Environment ------------------------------ Individual Capabilities ------------------------------ Human Nature ------------------------------ Objective: Improve organizational factors to prevent errors  Peer checking with timely documented feedback  Ensures product compliance to procedural requirements  Promotes a questioning attitude  Software compiles performance data as work progresses  Promotes teamwork – removes emotion form the process Checklists do away with human nature traps  Accurate mental model  Errors easy to recognize  No blame cycle WORK WITHIN CONTROLS

18. 18 The EQP Provides Feedback and Awareness Positive feedback Upcoming events Process changes Metrics Feedback / Improvement

19. 19 The EQP Focuses Attention on What’s Important Task Demands ------------------------------ Work Environment ------------------------------ Individual Capabilities ------------------------------ Human Nature ------------------------------ Objective: Influence values and behaviors through awareness  Reinforce priorities and expectations  Recognize and reward good performance  Openly discuss mistakes, near-mistakes, and lessons learned  Put value of error prevention in plain words  Feedback to get what we want, and avoid what we don’t want  Improvement information cycles back into scope of work FEEDBACK / IMPROVEMENT

20. 20 Error Precursor Assessment is Applied in Several Ways Engineering Corrective Action Report (CAR) management process includes an assessment of relevant error precursors to promote error reduction Action plans are used to address latent organizational weaknesses Employees post the potential error precursors (short list) in their workspace for review and application to their assigned work. Engineers are advised to discuss potential error precursor conditions with their supervisors and seek resolution. Engineering uses a monthly quality presentation to introduce quality topics and trigger detailed discussion among the staff. The EQP was used to introduce the concept to Engineering staff.

21. 21 In the Words of our Engineering Manager “In the fast-paced and challenging engineering and construction environment our engineers thrive in, error precursors like time pressures, high workloads, and simultaneous multiple tasks are the norm rather than the exception. What sets our engineers apart is not the environment they find themselves in, but how they find ways to adapt to their environment while maintaining quality and compliance with requirements.” Leon Lamm WTP Engineering Manager