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Office of Quality and Best Practices

Fermilab Lessons Learned Program - When to generate a Lessons Learned - Attributes of good Lesson Learned - What data to include - When to s ubmit a lesson into the DOE System. Office of Quality and Best Practices.

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Office of Quality and Best Practices

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  1. Fermilab Lessons Learned Program - When to generate a Lessons Learned - Attributes of good Lesson Learned - What data to include - When to submit a lesson into the DOE System Office of Quality and Best Practices

  2. Lessons learned shall be developed, at a minimum, after any of the following occurrences: A Type A or Type B accident investigation. A significant category 1 or recurring event. A significant category 2, 3 or 4 occurrence. A specific operating experience derived from other operating events including: General emergencies Site area emergencies or alerts NTS injury or illness reported in CAIRS Assessment findings (independent or self), when a finding: provides significant new information; or has direct relevance to other facilities, sites or programs; or the information has potential to be the basis for significant improvements or cost savings. A project’s Critical Decision step reaches completion, as defined by DOE O 413.3B A complex corrective action plan is completed. The best practices found during an activity would pass the DOE criteria. See the later slides concerning the DOE Lesson Learned database criteria. Lessons Learned – When a LL is Required

  3. A lesson must be… significant in that it has real or assumed impact on operations; provides new information, or the information has potential to be the basis for improvements - waste reduction, cost avoidance, or cost savings. valid in that it is factually and technically correct; and applicable in that it identifies a specific design, process, or decision that reduces or limits the potential for failures and mishaps, or reinforces a positive result. Note – Applicability also assumes there is potential for use by Fermilab. Lessons Learned – Significant, Valid and Applicable?

  4. Does Fermilab perform work affecting facilities that utilize the same equipment (safety, production, monitoring, etc.) described in the document being screened? Does Fermilab perform work affecting facilities that employ the same designs described in the document being screened? Does Fermilab utilize an administrative or management control system similar to that described in the document being screened? Does Fermilab perform work affecting facilities that use, store, or produce the same or similar chemicals/products described in the document being screened? Are the same activities or operations described in the document being performed by Fermilab? Does Fermilab implement the same regulations/codes/standards described in the document being screened? Is there the opportunity for a similar problem or situation to affect Fermilab work? Lessons Learned – Screening Criteria

  5. Lessons Learned – Attributes of a Good Lessons Learned

  6. When bringing forth lessons learned, the information should include, as appropriate: The source of the information. Who, OEM manual, witness, etc. If an event, the summary of the event, causes, and corrective and preventive actions taken, if available. If not an event, the information itself (summarized, if appropriate). Relevance Additional guidance on the impact to Fermilab or others (i.e. how you might gain or experience loss). Other possible scenarios Supportive documentation and references. Description of facts impacting the situation. Materials, work environment, timeframe, etc. Lessons Learned – What data to include?

  7. Guidance for submitting a Best Practice to the DOE: Does the practice have broad applicability across the DOE Complex as opposed to being more specific to one site? Can the conditions needed for adoption by others be adequately defined? Can the benefits and value be clearly and quantitatively defined? Can the cost and resource expectations (needs) for adoption be sufficiently defined? Can or does the proposing site have senior management support to share the "Best Practice"? Is the proposing site willing to mentor adopting sites? Can a recommended implementation scenario and support structure be properly defined? Lessons Learned – Criteria to Submit a Lesson Learned to DOE

  8. Guidance for submitting a Lesson Learned from an undesirable event: The lesson shall provide significant, new information. The experience has direct relevance to other facilities, sites, or programs. The information has the potential to be the basis for significant improvements or cost savings. And, separately consider… The risks or potential impact is high or urgent. An “Alert” may be in order. See your line manager for raising an issue to this level. Lessons Learned – Criteria to Submit a Lesson Learned to DOE

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