Hazardous Energy Work Control Presented September 13, 2006 DOE Integrated Safety Management Best Practices Workshop

1. 1 Hazardous Energy Work ControlPresented September 13, 2006DOE Integrated Safety Management Best Practices Workshop Mike LewisConstruction Bechtel National, Inc.Hanford Waste Treatment and Immobilization Plant

2. 2 Hazardous Energy Work Control � A Life Critical Process Important elements of working safely Work Planning � consistent, thorough, with worker involvement Work Control � clear roles and responsibilities and stop work authority Work Authorization � management and supervision engagement for hazardous energy work A trusting environment where people will ask questions and provide feedback These are a great fit into our new Nuclear Safety & Quality Culture

3. 3 The Old Way of Controlling Hazardous Energy Work Multiple areas each implementing requirements as they deemed applicable � often reliant upon a single individual�s decision for applicability of LOTO and Hazardous Work Permits No high level involvement in determining need for and authorization of hazardous energy work control Multiple LOTO Tagging Authorities in different areas running the LOTO program a little different in each area A mixture of processes and tools that were not always used consistently Organization quick to find fault with participants when events occurred, but mostly failed to recognize the organizational weaknesses that led to the events

4. 4 Awareness of an Adverse Trend Eight hazardous energy incidents at WTP in 2005 No obvious commonality between incidents Corrective Action Report issued � Seven compensatory actions: Management Suspension of Work � Suspended all LOTO work Investigate incidents with help from Building Trades Unions interview incident participants Investigate assured grounding features for buried cables Management interview incident participants Safety Assurance to investigate LOTO violation Develop interim work control process for hazardous energy

5. 5 Investigations and Assessments Root Cause Analysis 14 recommendations fed into RITS program Work Control Assessment 22 recommendations fed into RITS program (not all related to hazardous energy) Human Performance Investigation 3 recommendations mostly focusing on workplace culture and organizational weaknesses

6. 6 Key Recommendations from Investigations Fix the organizational weaknesses! Build defense in depth into the work control process Provide rumble strips to keep people within the parity zone Improve and integrate hazard analysis into the work control process Increase worker involvement in work planning Provide consistent supervision and management involvement in work planning, authorization and execution Incorporate knowledge based testing into hazardous energy work training Centralize hazardous energy work planning

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8. 8 Construction Utilities Group Established To help address organizational weaknesses relating to hazardous energy work, Construction Management established the Construction Utilities Group (CUG) CUG scope: Develop a new work process for hazardous energy work control Provide work planning and authorization Establish hazard controls Configuration management and system status Design/modifications of construction utilities and facilities Manage the beneficial use of permanent facilities Primary interface with maintenance group for systems and facilities maintenance

9. 9 Previously Existing Tools Improved Upon Planning (P), Control (C), Authorization (A) Job Hazard Analysis (JHA) process (P & C) Electrical arc flash calculations (P & C) Safe to work instructions (zero energy checks) (P, C,& A) LOTO Permits � identification of boundaries (P, C,& A) Pre-job Briefings (P & C)

10. 10 New Tools and Processes Summary Planning (P) Control (C), Authorization (A) New Hazardous Energy Packages (P, C, & A) Integration of previously existing tools into new packages Web accessible database for package processing (P) New configuration management approach (P & C) System Status boards (P) New approach to training (A) LOTO Independence from Construction (Defense in Depth)

11. 11 New Hazardous Energy Packages Consistent format for Hazardous Energy Packages Formal management authorization and supervision release to work for each package Standardized control points for �safe to work checks� Hazard Identification Checklist with defense in depth Integration of existing tools into overall process Standard feedback mechanism � (trusting environment)

12. 12 New Hazardous Energy Packages 14 sections for every package Typically 10-12 sections applicable, those that are non-applicable are positively identified as such Involvement of Craft, Supervision, Safety, Field Engineering, and Management in every package LOTO Tagging Authority involvement for all LOTO packages New packages provide planning, authorization, control and feedback in line with expectations for conduct of operations

13. 13 Typical Hazardous Energy Package

14. 14 Front Sheet Positive identification of applicable sections Work Authorization and release � (defense in depth)

15. 15 Section 1 Work Scope Description Four formats typically used depending upon type and complexity of work Standard format under development (using CUG database)

16. 16 Section 2 Drawing List Mostly for permanent plant work �Construction Viewer� print outs normally used

17. 17 Section 3 Work Instructions Standard format under development (using CUG database) Key work steps, safety steps and mandatory sequencing identified

18. 18 Section 4 Inspection Reports The section mostly applicable to permanent plant work (minority of packages) Various forms used according to types of inspection Other procedures drive type of forms to be used

19. 19 Section 5 Work Area Drawings Any legible identification of the work area Typically a marked up site plan or building plan

20. 20 Section 6 Hazard ID Checklist Tying in existing work processes to the package Engaging the right SMEs Dual verification (defense in depth)

21. 21 Section 7 JHA (s) JHA procedure integrated in package Forms driven by JHA procedure New Hazardous Energy Work Control process ensures worker involvement in JHA development

22. 22 Section 8 LOTO Permit Application LOTO procedure integrated in package Forms driven by LOTO procedure Workers often consulted on boundary options

23. 23 Section 9 Arc Flash Calc Developed and signed by Electrical Engineers Identified boundaries and PPE Similar labels will eventually be placed on the actual equipment

24. 24 Section 10 Electrical Zero Energy Check Step by step instructions Developed and signed by Electrical Engineer STOP WORK hold point � (rumble strip)

25. 25 Section 10 Non-Electrical Zero Energy Check Step by step instructions Developed and signed by Field Engineer STOP WORK hold point � (rumble strip)

26. 26 Section 11 Hazardous Work Permit Hazardous Work Permit procedure integrated in package Forms driven by Hazardous Work Permit procedure

27. 27 Section 12 Pre-Job Briefing Pre-determined applicable topics All job associated crew will attend Sign in sheet provided

28. 28 Section 13 Training Requirements Specific safety training needs for package Identify the crew Verify the training

29. 29 Section 14 Work Closure and Feedback Close out the work Identify punch list items Provide feedback (continuation sheets provided in each package) In a just culture we hope to identify errors and error precursors before we have events

30. 30 When Needed, Further Sections can be Added Examples: Confined Space Permit Excavation Permit MSDS Sheets

31. 31 Electricians in Proper PPE for Zero Energy Check

32. 32 Web Accessible Database Web accessible database to request and process hazardous energy packages Streamlined process that provides consistent format Auto population of data between sections in the package Ability to stay electronic until final need to print Ability to run a variety of reports for process management

33. 33 Configuration Management Identified the need to improve accuracy of configuration management to enable safe work planning Temporary installations will be used for several more years, accurate as-built P&IDs, Single Lines and Panel Schedules essential Field labeling to match drawings greatly improved Configuration management improvements more in line with expectations for conduct of operations

34. 34 Construction Power Distribution Rack

35. 35 Standardized Orange and Black ID Labels

36. 36 Configuration Management � System Status Boards System Status boards for electrical and piping systems introduced Started with pin boards and have since introduced color coded system status images on large LCD screens System status more in line with expectations for conduct of operations Colored dots indicate valve/breaker positions, LOTO and Defective equipment.

37. 37 LCD Partial Screen Shot

38. 38 LCD Partial Screen Shot

39. 39 New Approach to Training Everyone at site needs basic training to know when to use a Hazardous Energy Package More detailed training for those that will prepare and work under a hazardous energy package Two training modules developed and both include a written knowledge-based test All training is classroom delivered Procedure reading, alone, is not deemed adequate Training rolling out to direct hire, subcontractors and service reps

40. 40 LOTO Independence LOTO group separated from Construction LOTO group reports to Project Director LOTO completely independent from Construction production pressures LOTO staffed by experienced Startup personnel familiar with LOTO in an operating plant environment

41. 41 Subcontractors and Service Reps Clear recognition that subcontractors and service reps do not have sufficiently robust programs for hazardous energy work control Flowdown of procedure requirements to subcontractors and service reps greatly improved Subcontractors and service reps included in new training Compensatory Action Service reps performing service work escorted and screened to ensure work process compliance

42. 42 Managing the Process Key metrics to monitor effectiveness during Implementation Phase Safety � hazardous energy incidents/near misses Quality* � inspection success / rejections Timeliness* � meeting the customer need dates Effectiveness* � reporting of errors not resulting in events (feedback section of hazardous energy packages) * Tracked in CUG database

43. 43 Hazardous Energy Incident Metrics

44. 44 Conclusion There are more CARs for hazardous energy in the past nine months than the previous four years, but these recent CARs are mostly without safety consequences � people have the courage to speak up The recent ORPS reports are mostly management concerns and administrative violations � we are not afraid to share a critical look at ourselves The improved �Just� culture is encouraging people to identify and address errors before events occur, there is less fear of blame, and more confidence in contributing to a safe work process Recent instances of stop work authority being used for hazardous energy activities demonstrates the questioning attitude we are striving for

45. 45 Conclusion (continued) We need to continue to manage hazardous energy work with a conduct of operations approach We have significantly improved PLANNING, CONTROLS, AUTHORIZATION & FEEDBACK Craft are typically an under-utilized resource for work planning � get them involved! People will make mistakes, don�t automatically blame them. Look for and eliminate or mitigate our organizational weaknesses and strengthen our defenses