Lessons Learned from Implementing Human Performance Improvement in Hanford

1. HanfordHuman Performance ImprovementLessons LearnedReportBrian Harkins – DOE ORP John McDonald – CH2M HILL Hanford GroupDave Jackson – Fluor Hanford

2. Purpose • Implement HPI by DOE ORP, RL and Hanford prime contractors • In response to a DOE EM initiative to improve ISMS • HPIhas been very successful in commercial nuclear power • DOE ORP and RL senior management received initial HPI training at the Nuclear Executive Leadership Training Course in the fall of 2005 • Integrate HPI into ISMS Report Link: http://www.hanford.gov/orp/uploadfiles/HPI%20LL.pdf

3. HPI Focus Areas • Just Culture • Steering Committee • Self Assessment • Training • Work Planning and Control • Procedures • Event Investigation/Cause Analysis • Culpability Matrix

4. Benefits From HPI • Reduced events with consequences • Improved problem identification • Improved identification of latent organizational weaknesses before they cause events • Simpler procedures and work packages • Improved identification and control of critical steps and hazards • Improved event investigation • Consistent and fair treatment of individuals

5. DOE Role with their Contractors • Recognize that DOE is part of the “Organization” • Support Contractor implementation of HPI • Recognize significant commitment • Encourage and reward implementation and use of HPI • Facilitate process changes • Joint DOE/Contractor commitment

6. Just Culture Lessons Learned • Perception that HPI doesn’t hold people accountable • Effective training helps establish just culture • Free flow of information • Prevention of harassment and retaliation • Fair and consistent treatment of individuals • ISMS Expectations • Communication and listening skills to foster problem identification • ISMS safety culture implementation accelerated HPI implementation • Emphasis on event prevention helped field implementation • Consistent and fair implementation of existing disciplinary process is consistent with just culture • Worker representatives helped build trust and foster lessons learned approach in event investigations

7. Steering Committee Lessons Learned • Stability is important – Stick to the plan • Focus on issues at least six months out • A long term focus accelerates the overall rate of change • Formally tracking improvement actions provides needed structure • Lots of little changes equal a big change in the organization • Event reviews from HPI perspective were valuable • Gap analysis participation ensured follow through on actions

8. GAP Analysis Methodology

9. Training Lessons Learned • Training is the biggest investment required to implement HPI • Initial training took about 6 months to develop and present • Emphasis on event prevention and ISMS integration • Entertainment examples enhance training experience • GAP Analysis and training needs analysis effective in determining training content and durations • Facility specific, practical applications allows for immediate application • Facility trainers adds credibility and sustainability

10. HPI Training Lessons Learned • Various training modules were used with resource estimates • 4 hour (up to 50-75% of work force) • 8 hour (5-100% of work force) • 24/32 hour (5-40% of work force) • Medium class size best, e.g. 15 – 20 people • Facility trainers teamed with contracted trainers added credibility • Emphasis on ISMS integration • An abundance of HPI resources and tools available to enhance training • Training effectiveness is improved by using mentors (HSS, other contractors, consultants, INPO)

11. HPI Concepts in Work Planning • Workers are the key in identifying hazards and controls of tasks • Just culture enabled workers to feel freer to raise issues • The workforce was trained in critical tasks, error precursors, and error likely situations • Certain tasks are more critical than others • Some actions/tasks are irrecoverable; once the action is taken, the reverse action cannot recover • Some steps have more chances for error • Critical tasks help focus attention on potential consequences so appropriate defenses and contingencies can be put in place

12. HPI in Work Planning Planning the Work Walkdown How we Identify General hazards and tasks Job Hazards Analysis How we Identify Critical Tasks & Error Precursors Safety Plan For the Critical Tasks we Define defenses against Error Precursors Work Instruction Precautions Warnings WorkSteps How we Implement the defenses

13. HPI in Performing Work Performing the Work Pre-job Briefing Communicate the scope , Critical tasks hazards, and controls Walkdown Work site Verify conditions are as expected looking for Error Likely Situations and that Instructions can be worked to as written Perform the work Perform work to instructions applying additional defenses at critical tasks Post Job Briefing Feedback Lessons Learned Document the work

14. Work Planning Lessons Learned • Theoretical concepts must be converted to opportunities for practical implementation • Prioritize which concepts will fit into organizational processes • Keep facilities and organizations involved in the process • Significant management attention required to make change • Expect a total of two years before changes are institutionalized • Workers and managers need to be mentored regularly

15. HPI vs. Standard Event Investigation Standard event investigation • 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 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

16. Root Cause vs HPI in Event Investigation

17. HPI Event Investigation/Cause Analysis Lessons Learned • HPI enhances root cause analysis in identification of organizational performance on human performance • Buy in by line organizations that own corrective action management, event investigation and root cause analysis is necessary • In the beginning, HPI investigations should be done in addition to the traditional investigation to demonstrate: • Value of ‘context’ • Role error likely situations and organizational weaknesses have on errors • Evaluate both error precursors and organizational performance • Focus on failed defense/barrier, not just the error precursors

18. HPI Culpability Evaluation Flowchart No No Were actions as intended? Knowingly violate expectation? Pass substitution test? (see note) History of human performance problems? Yes Yes No Yes No No Self-Reported Were expectations reasonable, available, workable, intelligible, and correct? Were the consequences intended? Deficiencies in training and selection or inexperience? No No Yes Yes Yes Yes Yes No Organization induced violation System induced error Blameless error Intentional act (not an error) Possible reckless violation Possible negligent error Corrective training or other intervention may be warranted Evaluate organizational processes and management/supervisory methods Note: Would other employees have made the same error?

19. HPI Lessons Learned On Culpability Matrix • HPI Culpability Matrix is easily understood and seen as a benefit by workers & supervisors. • 1st Impression by management is it’s a path to ‘blameless’ acts and a lack of accountability. • Old views & ‘Strong Rules’ exist in HR, Legal and Unions on consistency in disciplinary actions. • Agreements must be secured in moving forward. • Benefits near the end of an investigation in order to establish ‘context’ of event. • Output is used in ALL corrective actions, even those focused on individual (disciplinary review boards).

20. Conclusion • Pilot participants have continued on using HPI after the Pilot • An EFCOG initiative is expanding on the Pilot • We continue to learn more and are building better defensives to human error • In general, workers perceive HPI as a positive ISMS enhancement