1 / 33

Lessons Learned May 2005 Revision

Lessons Learned May 2005 Revision. 12T 12L 9M. LESSONS LEARNED Sources & Subjects. Each Report has Lesson Learned (LL) Section EH ORR/RA Web Site has LL Section (handout) Team Leaders Handbook has LL section LL topics include: Achieving Readiness;

dewey
Download Presentation

Lessons Learned May 2005 Revision

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Lessons LearnedMay 2005 Revision 12T 12L 9M

  2. LESSONS LEARNEDSources & Subjects • Each Report has Lesson Learned (LL) Section • EH ORR/RA Web Site has LL Section (handout) • Team Leaders Handbook has LL section • LL topics include: • Achieving Readiness; • Considerations before proceeding with the ORR/RA; • Logistics and Support; • Managing the team and the process; • Developing the Implementation Plan; • Conduct of Drills and Evolutions; • Development of the Report and CAPs; • Individual Specific ORR/RAs; • LL DOE/NNSA Site and Field Office Concerns and Issues. 12T 12 L 9M May 2005 Revision

  3. ACHIEVING READINESS • Management Line preparation . . . • Premature ORR/RA Start . . . • AB Implementation . . . • Inadequate MSA . . . • DOE/NNSA Line Oversight not prepared . . . • Lack of Operational Proficiency . . . • Procedural problems . . . • Flowdown of requirements . . . • Not Validated and Verified (V&V) . . . • “Not yet implemented,” usually new facilities . . . 12T 12 L 9M May 2005 Revision

  4. MANAGEMENT LINE PREPARATIONS • Objective should be successful startup/restart not “passing” Readiness Review: - Passing the ORR/RA is just a by-product . . . • Establish guidance/procedures for Subject Matter Experts (SMEs who are contractors and Federal personnel) involvement during MSA/preparation phase . . . 12T 12 L 9M May 2005 Revision

  5. MANAGEMENT LINE PREPARATIONS • Flexibility needs to be incorporated into procedures for: • First-time-use including hold points for verifying assumptions and actions to take if assumptions are incorrect . . . • Management oversight during startup preparations to adjust level of oversight based on performance . . . 12T 12 L 9M May 2005 Revision

  6. MANAGEMENT LINE PREPARATIONS • For systems or mockups not capable of operating under real conditions or with real material: • Establish requirements for the surrogate material . . . • Integrate operator training with simulated conditions to identify differences . . . 12T 12 L 9M May 2005 Revision

  7. MANAGEMENT LINE PREPARATIONS • Lessons Learned adjustments include: • Mischaracterization of type, form, quantity is not uncommon for legacy material. Consider use of non-destructive techniques for better characterization and/or open a container in a controlled environment to help prepare for readiness planning. • Still be prepared and flexible for the unexpected. 12T 12 L 9M May 2005 Revision

  8. MANAGEMENT LINE PREPARATIONS • Some facilities by-pass readiness preparations by designating known deficiencies for post start repair, thereby getting through the readiness review easier but then are not ready for product production. • Limit the use of these designations to equipment that is not possible to function before readiness is declared. 12T 12 L 9M May 2005 Revision

  9. MANAGEMENT LINE PREPARATIONS • Use of a Joint Test Group has been proposed and being implemented successfully at some Sites, and they also are developing a process to capture knowledge from the test engineers to the system engineers that much of the time is lost. • Learn from others’ experiences. 12T 12 L 9M May 2005 Revision

  10. ISSUES BEFORE PROCEEDING • Team members not trained or ready to proceed . . . • Operational Demonstration schedule not defined . . . • Counterparts not assigned, available, or trained . . . • Documentation for review not identified or not available . . . • Example forms and report content not provided to team . . . • Evidence files not prepared . . . • Contractor does not communicate to DOE team until arrival that delayed start of ORR has resulted in new procedures, programs, references . . . 12T 12 L 9M May 2005 Revision

  11. LOGISTICS AND SUPPORT • Not adequate work space . . . • Not adequate computers, copiers, phones . . . • No arrangements for electronic document access . . . • No arrangements for classified support . . . 12T 12 L 9M May 2005 Revision

  12. MANAGE THE ORR TEAM • Workable review scope assignments . . . • Full time dedication to the review . . . • Team members stay focused, remain on schedule . . . • Document results; deliverables on schedule . . . • Performance based review vice a compliance audit . . . 12T 12 L 9M May 2005 Revision

  13. CONDUCT OF OPERATIONAL DEMONSTRATIONS • Conduct of Operational Demonstrations: • Team Leader to communicate drill/evolution expectation to facility with sufficient lead time . . . • See it all; pre-job brief to post-job debrief . . . • Team is not part of operational/drill team . . . • Avoid distraction or influence to operators . . . • Copious notes including times, and procedure steps . . . • Assign complete observer coverage of action sites . . . 12T 12 L 9M May 2005 Revision

  14. PREPARE THE REPORT • Timely input of compliant forms and parts . . . • Draft complete and delivered before team leaves site. . . • Expeditious factual accuracy . . . • Classification review; Classification brief before ORR/RA starts . . . 12T 12 L 9M May 2005 Revision

  15. LESSONS LEARNED FOR DOE/NNSA FIELD OFFICES • Criteria and process for DOE/NNSA Field verification of contractor readiness lacking . . . • Criteria and process for DOE/NNSA Field verification of DOE/NNSA oversight readiness lacking . . . • Lack of adequate review of SNR determinations by Contractor . . . • Corrective Action closeout process lacking, or either acceptance criteria not communicated to contractor or not understood by DOE/NNSA line personnel . . . 12T 12 L 9M May 2005 Revision

  16. IFIT DWPF NWCF SNFP W-62 W-56 (Y-12) Wet Chemistry SRS TCON WETF W-56 (PANTEX) West Valley Demonstration Project F-Canyon Y-12 Disassembly / Assembly operations Supernate Process at TRU Y-12 Reduction Process AHCF WVPD Lessons LearnedReview Examples 12T 12 L 9M May 2005 Revision

  17. IFIT • DOE Oversight • Procedure Validity • Review Started before Readiness Achieved • DOE ORR suspended 12T 12 L 9M May 2005 Revision

  18. DWPF • TSR Implementation • Equipment Operability • RadCon Environment • Good Drill Program 12T 12 L 9M May 2005 Revision

  19. NWCF • All simulation • Midnight dose • Not trained on procedures • Generally not ready • Too many first-timers and/or no training • ORR exceeded scope in POA 12T 12 L 9M May 2005 Revision

  20. Spent Nuclear Fuels Project(Major Construction Project) • Include Schedule Time to Implement SAR • Flexible Scope to Support Readiness Status • Track ALL Open Issues to Resolution • Line Management Manage ORR Activities • Stay Connected • Deal with Emerging Issues • IP Must reflect Scope of POA • DOE Line Management Process Flawed 12T 12 L 9M May 2005 Revision

  21. W-62 Readiness Assessment • Inadequate Time for Observation • Team Member Qualification not Adequate • Too Few Team Members to Review all Core Requirements • Difficulty in Completion of Assessment Forms 12T 12 L 9M May 2005 Revision

  22. W-56 RA at Y-12 • Scope of CRA not consistent with new activity • Support systems and components not ready • Fire suppression • Glovebox Ventilation System • Past Modifications and commitments not completed • Some procedures did not work • MSA was not adequate • CRA did not stop • DOE RA stopped based on number and breadth of issues. • Recovery was long and difficult 12T 12 L 9M May 2005 Revision

  23. Wet Chemistry • Ten chemical process systems after 8 yr Shutdown • CORR Suspended and then failed • Schedule pressure drove readiness decisions • Project plan underestimated test program impacts • Procedure development and operational training time compressed to recover schedule • Closure of Change packages and Test Packages • MSA started late; Inadequate response to MSA indicators 12T 12 L 9M May 2005 Revision

  24. W-56 Readiness Assessment (PANTEX) • Premature Start - AB not Implemented • Inadequate Closure of CORR Findings • RA Suspended • Competent Team to Support Hard Choices • POA & IP Scopes Varied • POA not Timely 12T 12 L 9M May 2005 Revision

  25. West Valley Demonstration Project • Not Performance-Based • DOE Oversight - inadequate • Poor DOE understanding of ORR process 12T 12 L 9M May 2005 Revision

  26. F-Canyon • “Dream Team” • Phased startup • Linking database • Corrective Action Team 12T 12 L 9M May 2005 Revision

  27. Y-12 Receipt, Storage & Shipment • DOE validation of contractor ORR • Finding closure/Root cause • OSR Implementation/Bases • Procedure Implementation and Control 12T 12 L 9M May 2005 Revision

  28. SRS TCON • Poorly written POA can (will) reduce scope and effectivness of associated readiness reviews • NNSA TL change late in process 12T 12 L 9M May 2005 Revision

  29. Y-12 BLDG 9212 REDUCTION PROCESS • On-The-Floor workers not bought-in to ISM • Skill of the craft vs objective standards 12T 12 L 9M May 2005 Revision

  30. TRU Supernate Process at Oak Ridge • Privatized contracts tend to be highly schedule driven • One week for DOE ORR is not enough 12T 12 L 9M May 2005 Revision

  31. AHCF • Facility Hazard Category questionable • Repeat Findings from MSA • Facility procedures showed hasty revisions with missing steps 12T 12 L 9M May 2005 Revision

  32. WETF • Insufficient lead time given to NNSA Team for preparation • NNSA Line Management validation of contractor and Fed readiness was lacking 12T 12 L 9M May 2005 Revision

  33. WVPD • A sub-tem leader pulled off ORR team by his home management at 1600 on the Friday prior to start of ORR • A 1 week ORR schedule is not desirable 12T 12 L 9M May 2005 Revision

More Related