ISMS Best Practices Workshop Just Culture Panel Workshop Hanford Contractors DOE Office of River Protection DOE Richland Operations Office

ISMS Best Practices Workshop

Just Culture Panel Workshop

Hanford ContractorsDOE Office of River Protection

DOE Richland Operations Office

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Just Culture Definition

• Definition: An environment that clearly defines acceptable behavior and recognizes human potential for error 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

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Just Culture Background

• EPRI study on power plant leading indicators of human performance identified 7 themes▪ Executive commitment▪ Awareness of hazards▪ Preparedness for errors and events▪ Flexibility to meet operational demands▪ Just culture ▪ Learning culture▪ System opacity

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Organizational Elements Related to Just Culture

• Organizational Attributes▪ Trust, respect, and fairness▪ Communication that can affect performance highly valued▪ Management communication and reinforcement of desired behaviors

• Process Contributors▪ Processes eliminate human performance weaknesses▪ Procedure deficiencies promptly corrected▪ Root cause analysis identifies organizational process, and individual

contributors to human performance events• Individual Values and Behaviors

▪ Deficiencies and suggested improvements are promptly reported and openly evaluated

▪ Personnel use questioning attitude and don’t proceed in face of uncertainty

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Why is Just Culture Important?

• Encourages participation at all levels of an organization in the identification of problems and continuous improvement

• Minimizes the probability of an event with consequences by maximizing organizational awareness of non consequential problems

• Promotes a learning culture and honest investigation of true weaknesses

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What Do Contractors Need From DOE Foster a Learning Environment

Avoid judgment, blame, & punishment for non-consequential events if right actions are being taken to address the issue. Introduce the analog of culpability matrix

Recognize errors will occur in implementation of 10 CFR 851. PAAA and 851 enforcement approach inhibits, rather than encourages reporting

Positively reinforce right preventive actionsRecognize and Promote reporting Recognize & Promote HPI Concepts of Identifying Error-

Likely Situations & Strengthening DefensesFocus on Lessons Learned Rather than Number of

Errors. Rationalize approach to recurrenceSPC => Every process has defectsSuccess lies in changing frequency and severity

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What Do Workers Need in a Just Culture• Trust - What’s Said Gets Done by Management• Respect for the Individual• Zero tolerance for HIRD • Worker involvement in ISMS• A Belief that Discipline is Fairly Administered• Use of coaching process• Respect for the Labor Contract• Multiple Avenues to Communicate• Worker participation in event investigations• Confidence in broader organizational cause

investigations

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What the Field Needs from HQ

• Focus on Setting DOE policy and high level expectations• Identify HQ, Field, and contractor R2A2 and work to

drive consistent performance• Establish consistent corporate metrics that draw from

established sources (e.g. ORPS, CAIRS, ORPS performance analysis) to monitor performance

• Resist the need for instant identification of root causes, consequences, and final actions for events

• Allow Field to address inconsequential events and precursors

• Recognize Field office attempts to foster self-reporting of lower level events without punishing for increased volume of minor events

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What HQ can do to fosterJust Culture

• Continue to support and sponsor HPI across the complex

• Identify and Celebrate success

• Incorporate HPI into the Corporate Performance Metrics (e.g. Discovery Clock)

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What is RL Doing?

• Developed a joint HPI Strategic Plan• Training Key RL staff on HPI Principles (36 for 8 hr

and 7 for 4-day course through 7/7/06)• Striving to celebrate performance (e.g. HEC R

response, SWSD safety day, others…)• Consideration of HPI aspects in contract actions• Direct communication of RL perspective on key

performance areas (HEC, elec, near miss)• RL acceptance of non-traditional corrective actions

to strengthen barriers/defenses to address latent organizational weaknesses

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What is ORP Doing?

• Developing a safety conscious work environment for all personnel (Feds and Contractors)

• HPI Training for Fed Staff (all in ORP will be trainied in 8 hr and about 40% in 4 day)

• Encouraging Contractor implementation of HPI principles• Promoting VPP to our Contractors• Encouraging personnel (Fed & Contractor personnel) to

report at below event levels so lessons can be learned without the cost of an event

• Using HPI tools to investigate events


Just Culture Panel Workshop – Hanford Experience

CH2M HILL Hanford Group, Inc.

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Our ISMS strategy is based on an open work Our ISMS strategy is based on an open work environment where everyone feels free to raise environment where everyone feels free to raise

issues without fear of HIRDissues without fear of HIRD

ISMS at CH2M HILL

Event Prevention

Employee involvement

Problem identification and

resolution

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CH2M Prime

Contractor

1999 2000 2001 2002 2003 2004 2005 2006

Tank Farm Acceleration

StrategyProblem

Evaluation Report System ESTARS

Integrated Mission

Acceleration Plan (IMAP)

Vapor Issues

Organi-zational

Readiness

Safe Work Environment

(SWE) Culture

Assessment

Released Sub-

Contracted Staff

Augmentation

Mandatory Respirator Usage in

FarmsISMS/

CONOPS Improvement

Training

ISMS Expectations

4/15/05

Vapor Resolution

WFO VPP Star Status

Human Performance Improvement

Training

Management Changes

Integration of SWE, ISMS &

HPI

Follow-up SWE Survey

GAP

CH2M HILL Improvement Cycle

Accident Injury Rate

PIP Addressing OA Vapor

Issues

A-Prefix Farms –

Mask Cessation

244-CR Vault Event

7/22/04

CAP Completed for 244-CR

Event

Project Delivery System

Mission Alignment Process (MAP)

SWE Mentoring

Involuntary Reduction of

Force

ISMS PIP

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CH2M HILL ECP Requests

2002 2003 2004 2005 2006

Number ECPRequests

16


Frequency of PER Initiations

0

100

200

300

400

500

600

700

800M

ay

-01

Ma

y-0

2

Ma

y-0

3

Ma

y-0

4

Ma

y-0

5

Ma

y-0

6

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5 Year DART and Recordable Injury Rates

DART RatesFive Year Summary

3.64

2.82

0.11

1.83

1.02

0.0

1.0

2.0

3.0

4.0

5.0

Cas

es/2

00,0

00 H

rs

Recordable RatesFive Year Summary

3.08

5.39

3.78

1.54

3.14

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

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Conduct of Operations Index Frequency

0

10

20

30

40

50

60

70

80

90

100

A) Skin and clothing Contaminations 8 8 2 2 0

B) Procedure Not Folllowed 11 2 0 0 0

C) Procedure Problem 15 3 8 3 2

D) Training Issues 3 2 1 1 0

E) Management Issues 40 19 12 7 5

F) Lockout/Tagout 5 1 1 0 1

G) Work Control Issues 9 11 7 2 1

FY2002 FY2003 FY2004 FY2005 FY2006 (Year to date)

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CH2M HILL Actions Taken to Implement Just Culture

• Alternative avenues expanded – more union safety representatives; Hanford concerns council

• All employee surveys conducted• Improved IROF process communication and fairness• Cause analysis process changed to identify

organizational contributors to human performance events

• Single, web based problem identification process • Trust, respect, and fairness expectations issued• HPI Training conducted• Discipline process revised to improve fair treatment

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2004 Employee Survey Process Improvement Issues

• Accountability Issues▪ Improve consistency in holding everyone

accountable for their behavior▪ Improve fairness and consistency of

disciplinary process▪ Improve timeliness of disciplinary process

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Comparison of Disciplinary Actions by Employee Group

2003 2004 2005

Non Exempt 1 (3%) 0 2 (5%)

Exempt 8 (27%) 6 (29%) 20 (45%)

Bargaining Unit 21 (70%) 15 (71%) 22 (50%)

Total 30 21 44

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Response Time From Event to Review

Discplinary Action Response Time

3629

19

0

10

20

30

40

2003 2004 2005

DaysDays

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99% of respondents say they will take action if potentially unsafe conditions, work practices, or products are seen

99 100

2005 HILL All Employee Survey

Question 10: Do you take action if you see potentially unsafe

conditions, work practices, or products?

98

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ISM Best Practice WorkshopAurora, CO

Sept 12-13, 2006

Safety Excellence-Creating a Just Culture

Fluor Hanford Inc.

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ISMS Best Practices WorkshopSafety Excellence-Just Culture

How’s Fluor Hanford Promoting a Just Culture

• Path to a Just Culture began in August 1996▪ Fluor’s Zero Accident Program

• Provided a Firm belief that Injuries are not the cost of progress.

▪ Presidents’ & Employee Zero Accident Councils• Provided voice in program & ownership of work area

▪ HAMTC Safety Rep. Program• Provided the Communication, Built Trust, Win-Win• STOP Work Responsibility

▪ Pursuit of VPP• The avenue to worker involvement in work planning & execution.

▪ ISMS• Standardized the process & program• Provided a consistent process for projects & workers

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Safety Excellence-Just Culture Furthering the Fluor Hanford Culture

• Continuing to Build on Union Safety Reps. , EZACs & VPP• Initiating Human Performance Improvement

▪ Over 700 trained in HPI Fundamentals▪ 40 HPI Practitioners Trained to Implement at Project Level▪ Learning that Errors will happen, and building defenses to mitigate

consequences.• Investigating Incidents using HPI techniques

▪ Looking deeper into the organization for errors & conditions▪ Greater chance of fixing more than just the immediate event

• Integrating Culpability Matrix into decisions on discipline ▪ Understanding better why good people make mistakes▪ Removing the latitude of poor performers to hide in the organization

• Focusing on Early Conflict Resolution• Supervisor Leadership Training on Mediation• Trained Intervention Mentors• Outside Consultants As Necessary

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ISMS Best Practices WorkshopCulpability Evaluation Flowchart

Were actions as intended?

Knowingly violate expectation?

Pass substitution test?

(see note)

History of human performance problems?

Were expectations reasonable, available, workable, intelligible,

and correct?

Were the consequences

intended?

Deficiencies in training and selection or inexperience?

Self-Reported

Organization induced violation

System induced

error

Blameless error

Intentional act (not an

error)

Corrective training or

other intervention

may be warranted

Possible reckless violation

Possible negligent

error

No

Yes Yes

Yes Yes Yes Yes

No

No No Yes

Note: Would other employees have made the same error?

Evaluate organizational processes and management/supervisory methods

No No

No

No Yes

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Safety Excellence – Just CultureFluor Hanford Results

• Metrics Tell the Story▪ VPP Culture Survey Chart▪ Employee Safety Concern Chart▪ Total Injury Rate Chart▪ Number of Safety Related Grievances Chart

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Contacts

George Jackson, Executive Vice PresidentFluor Hanford(509) 372-1050 [email protected]

Tony Umek, Vice President Safety & Health (509)373-5983 [email protected]

Dave Jackson, Deputy Vice President Safety & Health (509)376-0082 [email protected]

John Jeskey, HAMTC Safety Rep DirectorFluor Hanford(509) 396-1009 [email protected]

P.O. Box 1000 H8-67, Richland, WA 99352

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River CorridorClosure Project

Safety • People • Results

U.S. Department of EnergyRichland Operations Office

HPI Just CultureWorkshop Panel On Hanford Experience

Phillip KeuhlenDirector, Safety, Health & Quality

September 12, 2006

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Achieving “Just Culture” During Transition To A New Contract

• Special situation:▪ Contract in public domain, often in public discussion,

before transition▪ New management = new means & methods▪ Uncertainty about future in work force▪ Rumors about intentions precede you

• WCH approached as part of establishing strong industrial and nuclear safety culture

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INPO Principles for a Strong Nuclear Safety Culture as a Blueprint

• Everyone is personally responsible for nuclear safety• Leaders demonstrate commitment to safety• Trust permeates the organization• Decision making reflects safety first• Nuclear technology is recognized as special and unique• A questioning attitude is cultivated• Organization learning is embraced• Nuclear safety undergoes constant examination

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How WCH Approached Development of a Just Culture (1)

• Embraced ISMS as the integrating umbrella• Instituted robust communication process

▪ Conveyed “Zero is the only goal” for employee injuries▪ Actively promoted “Time Out for Safety”▪ Management highly visible and approachable at work sites

• Trained FLS as the critical interface with the craft▪ How do we convey by our actions that people are our most

valuable resource?▪ Tools and exercises in FLS Leadership Workshop

• Incentivized safety performance for all employees

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How WCH Approached Development of a Just Culture (2)

• Instituted Local Safety Improvement Teams (LSIT)▪ Employee led (often by union stewards), management supported▪ Prompt action & feedback are key elements

• Strengthened HAMTC Safety Representative Program▪ Weekly drive builds mutual trust & confidence

• Built supporting processes▪ HPI event investigation▪ Culpability matrix considered in constructive discipline

• Cultivated employee leadership for pursuit of VPP

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WCH Metrics Indicate Just Culture is “Taking”

• Employee Concerns

• Grievances

• Safety Performance


Questions and Answers

Documents

ISMS Best Practices Workshop Just Culture Panel Workshop Hanford Contractors DOE Office of River Protection DOE Richland Operations Office