Safety Observation to Support Human Performance Improvement at Los Alamos National Laboratory

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

2. 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. 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 ATOMICS was previously designed and managed based on 1990s concepts: Success was limited due to inconsistent management involvement and minimum analysis of observation data for trends, patterns and systemic issues for actions. Corrective actions taken addressed mainly “symptoms”. Evolution in the design of ATOMICS is based on benchmarking with several best-in-class companies: Management and workers take joint ownership; success/sustainability is tied to individual and organizational performance measures. Data analysis is a critical part of our safety observation process. Effectiveness reviews will be conducted as needed to demonstrate follow-up in addressing concerns. 360 observation – peer observing peer, worker observing manager or manager observing worker – are all part of the process. Safety injury data, observation frequency, data analysis and corrective actions will all be considered in the performance appraisal process for everybody. Higher than expected injury rate does not automatically result in a poor performance rating. Manager’s action to direct more observations, analyze observation and other relevant data, and direct corrective actions will be considered collectively in the performance appraisal process. Our objective is injury and event prevention which is the most cost effective approach for human error reduction.ATOMICS was previously designed and managed based on 1990s concepts: Success was limited due to inconsistent management involvement and minimum analysis of observation data for trends, patterns and systemic issues for actions. Corrective actions taken addressed mainly “symptoms”. Evolution in the design of ATOMICS is based on benchmarking with several best-in-class companies: Management and workers take joint ownership; success/sustainability is tied to individual and organizational performance measures. Data analysis is a critical part of our safety observation process. Effectiveness reviews will be conducted as needed to demonstrate follow-up in addressing concerns. 360 observation – peer observing peer, worker observing manager or manager observing worker – are all part of the process. Safety injury data, observation frequency, data analysis and corrective actions will all be considered in the performance appraisal process for everybody. Higher than expected injury rate does not automatically result in a poor performance rating. Manager’s action to direct more observations, analyze observation and other relevant data, and direct corrective actions will be considered collectively in the performance appraisal process. Our objective is injury and event prevention which is the most cost effective approach for human error reduction.

4. 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 SMS’ objective is to Do Work Safely, consistent with DOE’s goal for Integrated Safety Management (ISM) ISM is the DOE framework for integrating all environment, safety, health and quality requirements into work planning and execution to enable mission accomplishment safely. ISM’s five core functions and eight guiding principles support SMS objectives and our partnership between managers and workers. 2. Facilitate Group Discussion of SMS objectives What are participants’ view of our Zero Injury and Zero Event objective? Discuss the intent of the statement-can we agree? Discuss the difference between a value and priority, i.e., unlike priority, value can not be traded. Who owns this value? 3. Facilitate Group Discussion of the partnership strategy What do we need to do to make this partnership a reality? Management demonstrate commitments by encouraging conduct of observations, analyzing observation data for issues, correcting identified deficiencies. ADSMS has established a NO SURPRISE program to report concerns and issues for management action. Worker demonstrate commitments by conducting observations, reporting concerns & near-misses, and having a healthy sense of uneasiness. 4. Is our Injury Free Career objective for all of our employees realistic?SMS’ objective is to Do Work Safely, consistent with DOE’s goal for Integrated Safety Management (ISM) ISM is the DOE framework for integrating all environment, safety, health and quality requirements into work planning and execution to enable mission accomplishment safely. ISM’s five core functions and eight guiding principles support SMS objectives and our partnership between managers and workers. 2. Facilitate Group Discussion of SMS objectives What are participants’ view of our Zero Injury and Zero Event objective? Discuss the intent of the statement-can we agree? Discuss the difference between a value and priority, i.e., unlike priority, value can not be traded. Who owns this value? 3. Facilitate Group Discussion of the partnership strategy What do we need to do to make this partnership a reality? Management demonstrate commitments by encouraging conduct of observations, analyzing observation data for issues, correcting identified deficiencies. ADSMS has established a NO SURPRISE program to report concerns and issues for management action. Worker demonstrate commitments by conducting observations, reporting concerns & near-misses, and having a healthy sense of uneasiness. 4. Is our Injury Free Career objective for all of our employees realistic?

5. 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. 6 Safety Observation Process

7. 7 Industry Statistics on Causes of Events Of all the occurrences that take place within an organization, 80% can be attributed to human factors and 20% can be attributed to equipment failure or equipment related processes. Of the 80% human factors, 30% is due to individual errors (slips, trips, lapses), while 70% can be attributed to Latent Organizational Weaknesses. A latent organizational weakness is defined as an undetected deficiency in processes or values that create work place conditions that either provoke error or degrade the integrity of defenses. In a mature environment, people are very willing to discuss Latent Organizational Weaknesses—giving the organization an opportunity to proactively prevent something from happening. Of all the occurrences that take place within an organization, 80% can be attributed to human factors and 20% can be attributed to equipment failure or equipment related processes. Of the 80% human factors, 30% is due to individual errors (slips, trips, lapses), while 70% can be attributed to Latent Organizational Weaknesses. A latent organizational weakness is defined as an undetected deficiency in processes or values that create work place conditions that either provoke error or degrade the integrity of defenses. In a mature environment, people are very willing to discuss Latent Organizational Weaknesses—giving the organization an opportunity to proactively prevent something from happening.

8. 8 Common Error Precursors

9. 9 Lessons from Human Performance Basis: Human Performance = Behaviors + Results Our Strategy: Re + Md ? 0e [reducing error AND managing defenses LEADS TO zero events] This strategy was developed by the Institute of Nuclear Power Operations, and successfully demonstrated effectiveness at many nuclear power plants. Re - Errors can be reduced by discussions during the pre-job briefings, conducting behavioral observations during job performance. Learning from post-job reviews, observation data analysis will help avoid future errors. Md – Analysis of observation (behavior and condition) data will contribute to identifying potential weaknesses in our controls (defenses) for corrective actions. Remember, organizational & process weaknesses contribute to more than 50% of the events based on National Safety Council and INPO data. Emphasis is on fixing the system, not the worker. 0e – Zero event is our goal and it is achievable as demonstrated by many best-in-class operations (High Reliability Organizations). Working together as teams, we can achieve this goal. This strategy was developed by the Institute of Nuclear Power Operations, and successfully demonstrated effectiveness at many nuclear power plants. Re - Errors can be reduced by discussions during the pre-job briefings, conducting behavioral observations during job performance. Learning from post-job reviews, observation data analysis will help avoid future errors. Md – Analysis of observation (behavior and condition) data will contribute to identifying potential weaknesses in our controls (defenses) for corrective actions. Remember, organizational & process weaknesses contribute to more than 50% of the events based on National Safety Council and INPO data. Emphasis is on fixing the system, not the worker. 0e – Zero event is our goal and it is achievable as demonstrated by many best-in-class operations (High Reliability Organizations). Working together as teams, we can achieve this goal.

10. 10 Behavior observation serve to promote safe and consistent behavior, thus reduce the frequency of errors. Job context observation will identify facility and equipment issues that act as precursors to errors. While frequency reduction is highly desirable, defenses have to be in place to address severity of an event. We have to integrate reducing errors with management of defenses in order to reduce probability and severity of an event. Design of our safety observation process will assist in achieving our objective of zero events.Behavior observation serve to promote safe and consistent behavior, thus reduce the frequency of errors. Job context observation will identify facility and equipment issues that act as precursors to errors. While frequency reduction is highly desirable, defenses have to be in place to address severity of an event. We have to integrate reducing errors with management of defenses in order to reduce probability and severity of an event. Design of our safety observation process will assist in achieving our objective of zero events.

11. 11 Safety Observation Process

12. 12 Approach to Develop Observation Cards Hazard- and task-oriented observation cards Analysis driven… The expanded scope of the process necessitated the use of multiple observations cards that cover a broader and more accurate focus on job context behaviors and specific hazard content. As an example, the scope of operations in SMS has increased to include high explosive work in addition to radioactive work and the observation sheets are designed to capture the similarities and specific individual differences. The process is analysis driven that directs both observation focus areas and corrective actions. We will continue to improve these observation cards based on experience and suggestions from participants. The expanded scope of the process necessitated the use of multiple observations cards that cover a broader and more accurate focus on job context behaviors and specific hazard content. As an example, the scope of operations in SMS has increased to include high explosive work in addition to radioactive work and the observation sheets are designed to capture the similarities and specific individual differences. The process is analysis driven that directs both observation focus areas and corrective actions. We will continue to improve these observation cards based on experience and suggestions from participants.

13. 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. 14 Analysis Tools There are many activities required to get a job done. This is a simplified activity diagram. The requirements for a particular job have to be identified. This could include specifically what work needs to be done, what material sill be needed, what tools and machinery will be needed, how many people will be needed, how much time is available to do the work, …. This all goes into the job analysis. The pre-job briefing lets the people involved know requirements of the job such as the material involved, the location it is to be performed, the time allotted, machinery, … This allows the workers to get a mental picture of the job. The pre-job evaluation occurs when the workers arrive on-site and determine the actual conditions within which they will be doing the job. This allows them to get a more accurate mental picture of the job, identify actual hazards, determine if the job can be done as required. The job is the work involved. The post-job evaluation looks at the worker’s and the facility’s condition after the job has been completed. Was machinery moved? Were tools worn? Does trash need to be picked up? Are the workers tired? This is data that could be taken away from the job. The post job briefing lets the job analyst know how well the job was planned. This could include what the actual pre-job site conditions were; how many workers should assigned to the job; unanticipated problems experienced during the job; what the post-job site conditions are; lessons learned; … The observation process spans all these phases. It identifies behaviors that could/did cause events.There are many activities required to get a job done. This is a simplified activity diagram. The requirements for a particular job have to be identified. This could include specifically what work needs to be done, what material sill be needed, what tools and machinery will be needed, how many people will be needed, how much time is available to do the work, …. This all goes into the job analysis. The pre-job briefing lets the people involved know requirements of the job such as the material involved, the location it is to be performed, the time allotted, machinery, … This allows the workers to get a mental picture of the job. The pre-job evaluation occurs when the workers arrive on-site and determine the actual conditions within which they will be doing the job. This allows them to get a more accurate mental picture of the job, identify actual hazards, determine if the job can be done as required. The job is the work involved. The post-job evaluation looks at the worker’s and the facility’s condition after the job has been completed. Was machinery moved? Were tools worn? Does trash need to be picked up? Are the workers tired? This is data that could be taken away from the job. The post job briefing lets the job analyst know how well the job was planned. This could include what the actual pre-job site conditions were; how many workers should assigned to the job; unanticipated problems experienced during the job; what the post-job site conditions are; lessons learned; … The observation process spans all these phases. It identifies behaviors that could/did cause events.

15. 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. 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. 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.

18. 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. 19 Where are we going? We Never Reduce… We Always Prevent... If you can predict an event... You can prevent an event

20. The centerpiece of the process is Injury Free Career All SMS employees are entitled to expect an Injury Free Career! 1. Managers exhibit behaviors that reinforce Human Performance principles 2. Managers support SOP through involvement in the process 3. Safety conversation encourages employee involvement 4. First line supervisors are the primary managers of SOP 5. SOP is one of the managers’ safety management tools 6. Employee Safety Teams review all observation data; use LIMTS to record issues 7. The SOP process is managed and monitored with leading indicators and injury data 8. Communicate performance to everybody, including use of SMS Website 9. DESC continuing review of critical behaviors and status performance as part of monthly meetings 10. SOP Facilitator assists the Directorate in sustaining the process The centerpiece of the process is Injury Free Career All SMS employees are entitled to expect an Injury Free Career! 1. Managers exhibit behaviors that reinforce Human Performance principles 2. Managers support SOP through involvement in the process 3. Safety conversation encourages employee involvement 4. First line supervisors are the primary managers of SOP 5. SOP is one of the managers’ safety management tools 6. Employee Safety Teams review all observation data; use LIMTS to record issues 7. The SOP process is managed and monitored with leading indicators and injury data 8. Communicate performance to everybody, including use of SMS Website 9. DESC continuing review of critical behaviors and status performance as part of monthly meetings 10. SOP Facilitator assists the Directorate in sustaining the process