1. ORP-06-033 Incorporating Human Performance Improvement Tools into DOE Processes Shirley J. Olinger, Deputy Manager, ORP Brian Harkins, ORP Facility Representative September 2006

2. ORP-06-033 Point of View Human Performance Improvement (HPI) tools are improving our work processes and strengthening ISM at the Office of River Protection (ORP). This presentation will present the process that we are using to incorporate HPI tools into our processes and some of the challenges and rewards involved.

3. ORP-06-033 Building on our existing ISM System Description Our ISM System Description attributes included HPI concepts in our processes. The concepts included;  Each employee instinctively feels responsible for safety  Leaders demonstrate commitment to safety  Trust towards each other  Decision-making reflects safety as the overriding priority  An inquisitive attitude and behavior  A disciplined authorization basis system is in place to ensure all hazards are identified and mitigated before work begins  Organizational learning is embraced  Openly examine our operations and solicit feedback Incorporating HPI is strengthening our ISM system

4. ORP-06-033 Process HPI Training for ORP Staff  All ORP personnel will receive 8 hours HPI training  Personnel involved in direct oversight of Contractors’ activities will receive additional 32 hours HPI Training (~ 40 % of staff)  Hands on refresher training for all ORP personnel to reinforce specific principles – Error Precursors – Latent Organization Weakness – HPI Training tailored specific to employees duties

5. ORP-06-033 Hands on Refresher Training If you want to watch the video clip, click on the box below. Otherwise continue the slideshow. Total playing time: 08:29

6. ORP-06-033 Process (continued) Process Changes  Investigations using HPI Tools – Outside Independent – DOE – Joint DOE & Contractor  Encourage and reward reporting at a low level (errors without consequences)  Instilling “Just Culture”

7. ORP-06-033 Investigations using HPI Tools 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 Old methods  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

8. ORP-06-033 Investigations using HPI Tools Event Error Precursors Vision, Beliefs, & Values Latent Organizational Weaknesses Mission Goals Policies Processes Programs Flawed Defenses Initiating Action Vision, Beliefs, & Values Root Cause Analysis Anatomy of an Event

9. ORP-06-033 Investigations using HPI Tools Outside Independent Investigation  ORP decided to conduct an investigation using HPI because of the continual recurrence of events at the WTP construction site. Although we appeared to handle each event adequately, we continued to have similar events.  ORP contracted with an expert in HPI to: – Review 10 events (occurrence & accident reports) (9 electrical & 1 LO/TO)

10. ORP-06-033 Investigations using HPI Tools DOE ORP Investigations  Before giving DOE identified issues to the Contractor for resolution, some items are reviewed using HPI Tools in an effort to identify latent organizational weakness. When issues is given to the Contractor, if latent organizational weaknesses have been identified they are given to the Contractors as areas for improvement. Joint DOE & Contractor Investigations  ORP has participated in joint reviews using HPI tool to identify areas for improvement. DOE involvement adds independent view and helps assure that weakness found will be viewed as opportunities for improvement not violations.

11. ORP-06-033 Process (continued) Process Changes I. Investigations using HPI Tools – Outside Independent – DOE – Joint DOE & Contractor II. Encourage and reward reporting at a low level (errors without consequences) III. Instilling “Just Culture”

12. ORP-06-033 Encourage and reward reporting at a low level (errors without consequences)  ORP has encouraged our contractors to develop systems for their employees to report issues. Reporting levels are at a very low level. – CHM2Hill – Problem Evaluation Report (PER) – Bechtel National Inc – Project Issues Evaluation Reporting (PIER)  ORP has a data base system for DOE personnel to report site observations (OA Database)

13. ORP-06-033 Process (continued) Process Changes  Investigations using HPI Tools – Outside independent – DOE – Joint DOE & Contractor  Encourage and reward reporting at a low level (errors without consequences)  Instilling “Just Culture”

14. ORP-06-033 Instilling “Just Culture”  Definition: An environment that recognizes human potential for error and clearly defines acceptable behavior in a consistent manner  Attributes: – Recognition of fairness related to the identification and resolution of human performance problems – Distinction between honest mistakes and intentional shortcuts with respect to discipline – Free flow of plant information across all levels of an organization – High level of self-reporting

15. ORP-06-033 Instilling “Just Culture”  ORP ISM System Description  HPI Focuses on the Organization not individuals or event  Recognition that every one makes mistakes  Encouragement/ reward personnel to disclose errors without consequences – Discovery Clock

16. ORP-06-033 Challenges  Develop training specific to DOE employees that is applicable to their areas of responsibilities  The timing of reinforcement training  Instituting the mind-set change in the organization that HPI provides  Instituting a “Just Culture” both with our contractors and Federal personnel

17. ORP-06-033 Rewards  Reporting errors without consequences – Self-reporting error resulted in identification of a potential life threatening latent organizational weakness  Employee Ownership — we have observed a increased involvement of staff in the effort to improve our processes  Process improvements

18. ORP-06-033 Path Forward  Further institute HPI tools into our existing – Oversight reporting system – Just culture – Discovery clock – Critical Steps concept  Start using HPI tools to evaluate DOE management Systems (e.g. CAM, PIP’s)  Develop metrics to be able to gage improvement

19. ORP-06-033 Conclusions  Implementing HPI tools into DOE’s process is taking us to a new level of performance  HPI tools should be trained, reinforced, and rewarded  Implementing HPI can seem like an overwhelming task. Evaluate your organizational needs and determine what HPI tools will benefit your organization the most and start with those tools  Incorporate processes from others (RL, ORP, INPO, Nuclear Power) whenever possible to reduce the need to redevelop programs