Presentation at the DOE ISM Workshop - 2007 by Chris Cantwell, Todd Conklin & John Tseng

1. Safety Observation to Support Human Performance Improvement at Los Alamos National Laboratory Presentation at the DOE ISM Workshop - 2007 by Chris Cantwell, Todd Conklin & John Tseng November 28, 2007 LAUR-07-7708

2. What Are We Doing? • Safety awareness and timely corrective actions as the first step in building an enduring safety culture • Safety observation tool enhanced with Integrated Safety Management (ISM) and Human Performance Improvement (HPI) principles and tools • Stockpile Manufacturing and Support Directorate (SMS) as the pilot for the Los Alamos National Laboratory (LANL)

3. Job-Site Condition & Behavior Observation Joint ownership by management & employees Management responsible for process sustainability Participation/safety results used as input to the performance appraisal process 360º observation Injury and event prevention Behavior Observation Employee owned & managed Management supported Voluntary participation Peer to peer Focus was on worker behavior Evolution of ATOMICS Safety Observation Process To From

4. SMS—Objectives Organization – A Safe and secure workplace that protects workers and enables efficient mission performance by: • Zero injury and zero events • Safety is a core value, not a priority • Performance = Behavior + Results Achieve these objectives in Partnership by: • Management will demonstrate commitment by providing the best possible safety training, processes and equipment. Managers commit to take meaningful action that supports: • No fault reporting • Valuing Error as leading data • Close Call / Good Catch reporting systems • Trending data to identify error prone conditions • Workers will demonstrate their commitment by being safe, making good decisions, and participating in safety initiatives

5. SMS Safety Observation Objectives At ADSMS: It is possible to work your entire career in our facilities without injury or event – DO WORK SAFELY To do this we must: • Learn the use of observation tools • Provide reinforcement / feedback for safe behaviors • Record observation data for analysis and to identify error-likely situations • Then we* fix these problems (systems, processes, procedure, conditions, behaviors, and trends) *First Line Managers, Supervisors, and Workers

6. Safety Observation Process Set Observation Parameters Implement Corrective Actions & Provide Feedback Conduct Observation Record Observation Data for Analysis • Hold Safety Conversation • Reinforce Safe Behaviors • Discuss reasons for • At-Risk Actions

7. Industry Statistics on Causes of Events Human Performance Occurrences 70% Organizational Weaknesses/ Errors 30% Individual Errors 80% Human Performance 80% Human Performance 20% Equipment Performance

8. Common Error Precursors

9. Lessons from Human Performance Basis: Human Performance = Behaviors + Results Our Strategy: Re + Md→0e [reducingerror AND managing defenses LEADS TO zero events] Organization & Processes 70% Performance Improvement = Individual 30% +

10. Serious Accident MD Severity Severity Near Misses Major Events Near Misses Non-consequential Errors Non-consequential Errors Frequency Frequency Re ZERO Reducing Errors + Managing Defenses  Zero Event

11. Safety Observation Process Set Observation Parameters Implement Corrective Actions & Provide Feedback Conduct Observation Record Observation Data for Analysis • Hold Safety Conversation • Reinforce Safe Behaviors • Discuss reasons for • At-Risk Actions

12. Approach to Develop Observation Cards Hazard- and task-oriented observation cards Analysis driven… Weaknesses in Defenses & Management Systems To Identify Collect Data at Individual Level Which leads to Prevention Target

13. Hazard/Task Oriented Observation Cards • Glovebox Work • Detonator Facility • Facility Conditions • Printed Circuit Fabrication • Standards and Calibration Lab • Administrative Work • Outdoor Activities • Good Catch / Near Miss

14. Job Analysis O B S E R V A T I O N S Pre-job Briefing Job Post-job Evaluation /Briefing Analysis Tools Active errors can be introduced in any phase of a job. The observation process identifies at-risk behaviors that could result in active-errors. Analysis of the observation data can identify latent weaknesses that produce at-risk behaviors which could contribute to the active-errors. Analyzing the characteristics of the latent weaknesses allows workers and managers to make changes to reduce the probability of an active-error.

15. Implementation Lessons Learned • Clear expectations on safety leadership • Tailoring implementation to programmatic/ facility conditions • Benefits of a user-friendly observation data system in conjunction with the LANL Issue & Corrective Action Management tool (LIMTS – LANL Issue Management Tracking System)

16. Safety Leadership – Current State at LANL • Safety is currently thought of as only a system of discipline. • Safety efforts are delegated to lower levels at LANL – we demand performance – and leaders have little or no involvement. • We have passively given safety leadership to employees. • There is a clear lack of participation in safety programs by leadership. • Safety as a value is never demonstrated – just talked about. • The organization is perfectly attuned to the performance it is getting.

17. What is Safety Leadership? • Safety Leadership is the degree to which we… • make organizational safety expectations clear, • support safety financially, • are present when key safety issues are decided, • are positive and supportive of other safety efforts… thus creating and insisting on a safe, healthy and caring culture. At LANL we prevent events. Safety Leadership = Time Money Communication

18. The Challenge The success of our safety program is entirely dependent upon leadership commitment, availability, and support in decision making in practice for employees in the field. • Leaders know and understand their role and expectation in managing the safety program in their work areas. • Leaders are able to reinforce and value subordinates. • Leaders visit their workplaces frequently. • Leaders facilitate workgroup participation in decision making. • Leaders know and understand how to effectively communicate safety in their work areas.

19. Where are we going? We Never Reduce… We Always Prevent... If you can predict an event... You can prevent an event

20. Summary