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2. Hazardous Energy Work Control ? A Life Critical Process. Important elements of working safelyWork Planning ? consistent, thorough, with worker involvementWork Control ? clear roles and responsibilities and stop work authorityWork Authorization ? management and supervision engagement for hazar
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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
7. 7
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