6 / / U. S. Department of Energy (DOE) Corporate Operating Experience Program Presented on 6/21-25/2010 at the Human Performance/Root Cause/Trending/ Self Assessment/Operating Experience (HPRCT) Conference Baltimore, MD Eugenia Boyle, DOE HQ, HS-32 Occurrence Reporting & Operating Experience Program Manager LL URL:

6 / / Contents U.S. Department of Energys Sites, Mission & Vision Office of Health, Safety and Securitys Mission DOEs Corporate Operating Experience Program Primary DOE HQ OE Products, Websites & Availability Public Analysis Tool for Occurrence Reporting DOE Corporate Lessons Learned Database Blogs and Wikis Operating Experience Committee (OEC) Questions

6 / / U.S. Department of Energy DOEs Mission Statement Discovering the solutions to power and securing Americas future DOEs Vision DOEs vision is to achieve results in our lifetime ensuring: Energy Security Nuclear Security Science-Driven Technology Revolutions One Department of EnergyKeeping our Commitments.

6 / / A Bad Day at DOE

6 / / DOEs Specific Missions Science and Discovery: Invest in science to achieve transformational discoveries Clean, Secure Energy: Change the landscape of energy demand and supply Economic Prosperity: Create millions of green jobs and increase competitiveness National Security: Maintain nuclear deterrent and prevent proliferation Lower Green House Gas Emissions: Position U.S. to lead on climate change policy, technology, and science

6 / / DOE Sites Across the US

6 / / Office of Health, Safety and Securitys Mission The Office of Health, Safety and Security (HSS) is DOEs central organization responsible for health, safety, and security providing corporate-level leadership and strategic vision to coordinate and integrate these activities. HSS is responsible for policy development, technical assistance, safety analysis, corporate safety and security programs, education and training, DOE-wide independent oversight, and enforcement. The Chief Health, Safety and Security Officer advises the Secretary and the Deputy Secretary on all matters related to health, safety, and security across the complex. HSS provides clear policy guidance, assistance in policy implementation, and a focused and integrated corporate-level analysis of Departmental operating experience that identifies existing and potential problem areas to provide line managers with a solid foundation for implementing effective Department-wide activities and solutions in the areas of health, safety, [environment] and security.

6 / / DOEs Corporate Operating Experience Program The Department of Energy's (DOE) Corporate Operating Experience Program (OE) - Helps prevent the recurrence of significant adverse events/trends by sharing performance information, lessons learned and good practices across the DOE complex. A DOE Directive, DOE Order 210.2, DOE Corporate Operating Experience Program, was issued on June 12, Its purpose is: To institute a Department of Energy (DOE) wide program for the management of operating experience to prevent adverse operating incidents and to expand the sharing of good work practices among DOE sites.

6 / / To provide the systematic review, identification, collection, screening, evaluation, and dissemination of operating experience from U.S. and foreign government agencies and industry, professional societies, trade associations, national academies, universities, and DOE and its contractors. To reinforce the core functions and guiding principles of DOEs Integrated Safety Management (ISM) to enhance mission safety and reliability. Order Objectives ISM Core Functions

6 / / Order Objectives (contd) Summary: To combine the disparate operating experience (OE) elements into one program that includes requirements for event reporting, safety related statistics, and lessons learned. The Requirements of the Directive include DOE entities, contractors, and subcontractors.

6 / / Order Requirements Prescribe a Formal Process that: Evaluates DOE Internal and External Operating Experiences (OE) to assess trends, safety, and program issues and to promote sharing of Good Work Practices that may affect safety and success of DOE missions OE Clearing House Function: collection, storage, retrieval OE Screened for Significance – by all stakeholders Timely Communication of Screening Results and Insights DOE Corporate Communication thru Actionable or Informational Products Effectiveness Evaluated thru Periodic Safety Meetings and Metrics

6 / / Operating Experience Information Sources DOE Internal Sources – Databases and Reports External Sources – Other Government Agencies, Industry, and Foreign Sources Interagency Sharing Agreements formal or informal - URL: a/analysis/ll/. a/analysis/ll/ Primary Sources of OE Information:

6 / / DOE Internal OE Sources: DOE Corporate Lessons Learned Database - A central clearinghouse used to collect and share lessons learned and best practices pertaining to all DOE activities Occurrence Reporting and Processing System (ORPS) – The database of occurrence reports from across the DOE complex Type A and B Accident Investigations (AI) – In-depth analysis reports of serious events Computerized Accident Injury/Illness Reporting System (CAIRS) – OSHA Reportable statistics Radiation Exposure Monitoring System (REMS) – Rad dose info. Corrective Action (CA) Tracking System (CATS) – A system for tracking and closing CAs from Accident Investigations Non-Compliance Tracking System (NTS) – Price Anderson Amendment Act (PAAA) info Operating Experience Information Sources (contd)

6 / / Principle External OE Sources: Institute of Nuclear Power Operations (INPO) Nuclear Regulatory Commission (NRC) U.S. Chemical Safety and Hazards Investigation Board (CSB) Occupational Safety and Health Administration (OSHA) Government Industry Data Exchange Program (GIDEP) National Aeronautics and Space Administration (NASA) Department of Defense Atomic Energy of Canada, LTD - Chalk River Laboratories Sellafield, Ltd. National Operating Experience & Learning Group (OELG) of England Operating Experience Information Sources (contd)

6 / / Using internal and external OE sources, the following OE products, most of which are publically available, are produced: Primary OE Products Operating Experience Summary – A monthly publication containing a series of articles on events with lessons to be learned. The individual OES articles are posted immediately upon completion at and as publications at Public ORPS - Searchable information on DOE's Final Occurrence Reports since 2005, updated daily, posted at ORPS Weekly Summary of Occurrences - A weekly summary of current occurrences determined to be of significant interest to help prevent the recurrence of similar events/trends posted at

6 / / Safety Advisories - Documents issued on an as-needed basis when analysis of operating experience data shows an event(s) or a trend(s) that warrants Senior Headquarters and field manager awareness but whose safety significance does not warrant a more immediate action posted at Safety Bulletins - Potentially actionable information that has a high potential to impact safety and health at DOE facilities posted at Electrical Safety Monthly Analysis – A monthly analysis of recent electrical occurrences in support of the Departments ongoing efforts to improve electrical safety posted at Primary OE Products (contd)

6 / / Public Analysis Tool for Occurrence Reporting

6 / / Public Analysis Tool for Occurrence Reporting (contd)

6 / / DOE Corporate Lessons Learned (LL) Database

6 / / DOE Corporate LL DB – Facts & Enhancements Available at Requires a user-id and password, but registration is open to the public. Project Management LL – Recently added Project Management LL to the existing Safety & Health LL and Security LL in the database. We are looking for other LL types to incorporate into the database. Autonomy Search Tool – Currently working to add Autonomy as a search tool to not only provide a better search capability for the LL database, including attachments, but also to expand searching to other Operating Experience information, as desired.

6 / / Operating Experience Summary (OES) Blog

6 / / OES Blog - Facts and Article Examples Available at Open to the public. Articles Posted – First article was posted in November, There are currently 15 articles published with a few in draft. Some OES Blog Article Titles - Nuclear Facility Construction Noncompliances: Part 1Overview Battery Explodes While Charging Haste Makes Waste Procurement Gone Wrong Russian Hydroelectric Plant Accident: Lessons to Be Learned Type A Accident InvestigationVehicle Fatality Type B Accident Investigation of Hanford Worker Fall from Catwalk

6 / / Highly Reliable Performance (HRP) Blog

6 / / HRP Blog - Facts and Article Examples Available at Open to the public. Articles Posted – First article was posted in February, There are currently 15 articles published. Some HRP Blog Article Titles - Performance and Safety: Convergence toward a Meta Model? The HPI Equation Deviations from Expectations; the Toyota Way? Sustaining a Culture of Safety in the V.A. Health Care System Narrowing the Gap Between the Work as Imagined and Work as Performed at SRS Narrowing the Gap Between the Work as Imagined and Work as Performed at SRS High Reliability; Similar Quests, Many Expressions – a short video

6 / / Electrical Safety Blog

6 / / Electrical Safety Blog - Facts and Article Examples Available at Open to the public. Articles Posted – First article was posted in November, There are currently 9 articles published. This blog contains current happenings, monthly summaries, and various other special topics all covering electrical safety. In addition it provides a feedback loop so readers can comment and discuss the information presented here. Some Electrical Safety Blog Articles - Monthly Electrical Safety Summary: April 2010 National Electrical Safety Month

6 / / Vehicle Safety Awareness (VSA) Wiki

6 / / VSA Wiki- Facts and Contents Available at Requires a user-id and password. Contents – This Wiki was recently pushed to production. It contains many items related to vehicle safety, including videos. Some VSA Wiki Topics include - Presidential Executive Order Banning Texting While Driving Distracted Driving Quarterly Newletter-NSC-FEB2010.pdf WAPA Vehicle Safety Incentive Program Website for setting a GM Tahoe truck parking brake. Motor Vehicle Study-Analysis-final ppt YouTube Lego Road Safety Video

6 / / Operating Experience Committee (OEC) 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.

The DOE Operating Experience Committee has been chartered as a subgroup of the Integrated Safety Management (ISM) Champions Council: To strengthen the feedback and improvement of the ISM core function and To provide increased Federal leadership and involvement in the review of operating experience. 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. The OEC currently consists of almost 300 members, within DOE and external to DOE (both domestic and foreign). 6 / / Operating Experience Committee (OEC) (contd)

6 / / 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 DOEs Office of Health, Safety and Security, and (3) Chief of Nuclear Safety (CNS) and Chief of Defense Nuclear Safety (CDNS), or their designated representatives. Associate membership in the Committee is open to: All DOE federal and contractor employees, as well as to external domestic and international representatives interested in sharing operating experiences and associated best practices. Operating Experience Committee (OEC) (contd)

6 / / Activities include: Semi-Annual Meetings across the DOE complex. Monthly conference calls. Task Team activities. Development of new OE sharing techniques (SharePoint, Wiki, Blogs). Current Task Teams are: Metrics/Program Effectiveness Tools/Resources External Events Criteria Review and Approach Document (CRADs) to Assess DOE Order Implementation Qualification Standards for OE/Lessons Learned Coordinators Procedures Operating Experience Committee (OEC) (contd)

6 / / Operating Experience (OE) Wiki with OEC Information

6 / / OE Wiki (with OEC Info) – Facts & Enhancements Available at Requires a user-id and password – available to OEC members now and others later. Contents – This Wiki was recently pushed to production. It currently houses all OEC information on meetings, conference calls, and operating experience items that have been shared with OEC members. Future Enhancements – We plan to add a lot more operating experience information to this Wiki. One near term enhancement will be to add event and training videos.

6 / / OE Wiki with OEC Conference Call Info

6 / / Questions to Consider What information do you call operating experience (OE) and what OE do you share (within your organization and external)? How can we obtain OE information from you? We are looking for high value OE, not high quantity: Accident Investigations Event/Training Videos Operating Experience Articles Alerts Suspect Counterfeit and Defective Items (SCI/DI) How do you measure OE effectiveness? Do you evaluate / use external OE? How is SCI / DI managed? How do you or your managers approach risk management?

6 / / Any Questions for Me? Thank You!