WTP Environment 2001 - 2005

1. Mitigating Organizational Weaknesses Presented September 13, 2006DOE Integrated Safety Management Best Practices Workshop Mary Heaton, Assistant PM Nuclear Safety & Quality ImperativeBechtel National, Inc.Hanford Waste Treatment and Immobilization Plant

2. WTP Environment 2001 - 2005 • 2001 challenges – hired/transferred 1800 in approximately 1 yr. from different Bechtel groups, new hires, staff augs • Majority of the technical training was required reading • Few NQA-1 qualified vendors • Corrective action improvements consistently included procedure revisions • Quality, safety and productivity improvements were addressed through six sigma and PBL • Bechtel implemented Performance Based Leadership in the late 90’s • Six Sigma in 2000 • Both to improve productivity, quality of work • Six Sigma Black Belts were included as members or leads of all RCA’s since 2003. • Large reduction in force May 05 and November 05

3. WTP Environment 2001 - 2005 Did latent organizational weaknesses exist?

4. WTP Environment 2001 - 2005 • 2001 challenges – hired/transferred 1800 in approximately 1 yr. from different Bechtel groups, new hires, staff augs • Majority of the technical training was required reading • Few NQA-1 qualified vendors • Corrective action improvements consistently included procedure revisions • Quality, safety and productivity improvements were addressed through six sigma and PBL • Bechtel implemented Performance Based Leadership in the late 90’s • Six Sigma in 2000 • Both to improve productivity, quality of work • Six Sigma Black Belts were included as members or leads of all RCA’s since 2003. • Large reduction in force May 05 and November 05

5. 900 1,676 = Org behavior (68%) 806 800 700 654 600 500 Number of Causes 400 300 215 192 160 200 118 88 82 73 100 39 26 20 9 0 Other/Unknown Work Schedule Work Practices Written Procedure Managerial Methods Training/Qualification Supervisory Methods Change Management Resource Management Verbal Communications Environmental Conditions Human-machine Interface Work Organization/Planning Source: INPO, Event Database, March 2000. For all events during 1998 and 1999. Industry Event Causes due to human performance 806 = Individual behavior (32%)

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7. Procedure compliance Adequacy of procedures Training Balance of cost, schedule, and quality Communication and feedback Quality improvement Questioning attitude Management behaviors Assessment and oversight Balancing safety, quality, cost and schedule Verification of work activities Fall 2005 Nuclear Safety and Quality CultureBNI, DOE ORP and Office of Enforcement agreed WTP had weaknesses in:

8. Management Alignment Gap Analysis Vision Setting Achieving nuclear safety and quality through procedure compliance Nuclear Safety and Quality Imperative Oversight & Assessment Behavior Training Procedures • • Management Oversight & Assessment • Verification and Approval of Work Activities • • Quality Improvement • Balancing Safety, Quality, Cost, and Schedule • Communication and Feedback • Training Personnel to Execute Procedures • • Adequacy of Procedures • Procedure Adherence Compensatory Action Corrective Action

9. WTP Nuclear Safety and Quality Imperative Our overriding priorities are safety and quality We will create, then sustain, an open and trusting environment where each of us: • Takes pride and ownership of safety and quality • Questions what does not seem right – stop and ask • Identifies and shares improvement opportunities • Embraces, and accepts procedure compliance as the foundation of our work TP0602_24

10. Nuclear Safety and Quality Imperative Project George ClareNSQI Project Manager Matrixed Support Organization Schedule Improvement Primary Metric Charts Work Breakdown Structure

11. Culture change strategy Top Down • Project-wide culture change Focused Actions • Visible, tangible success • Increased credibility Bottom Up • Function-specific issue resolution

12. Project-wide compensatory action

13. Centralized issue tracking system: PIER • System implemented to ease identification of issues Issues, Concerns, Questions, Problems, Recommendations Report It Review It Resolve It

14. NSQ culture change activities are pervasive Completed Ongoing Human Performance Training Communication Strategy • Weekly Newsletter• NSQI Website• Posters• Employee Messages Recognition Strategy • Employee Owned• Management Supported All Hands Meeting – March One-Hour Stand-down – April - Culture Cards Expectation Quiz – April Employee Briefings – April... “Ask Jim”/ “Ask Bill” website – March... New Hire Orientation changes – April... HGET Annual Refresher revision – April...

15. Desired management behaviors • Balance safety and quality and cost and schedule • Maintain consistent conservatism in decisions • Be receptive to constructive criticism, willing to acknowledge mistakes, and open and transparent • Willingness to actively listen, be influenced, provide feedback, interact with employees • Give measured, reflective, facts-based responses • Provide consistent, meaningful, positive reinforcement • Apply fair and consistent discipline

16. Human Performance • Senior Management sponsorship – Larry Simmons • Integrating HP into our current processes through employee education • Self assessments • CAR causal identification • Event critiques • Root Cause Analysis • Employee Concerns and Employee Relations investigations • Trained 69 people to date; 49 trained in the 4 day HPI course; 600+ trained at July Safety Rally (manuals & non-manuals); 2 trained at INPO • Moving toward self-sufficient training • Using EPC examples

17. Procedures PIP – Process Phases: • Identify • Requirements • Process Mapping • Measure • Fishbone • XY Matrix • Data Collection • Analyze • Analyzed Data Collected • Review other sites procedures

18. Procedures PIP – Process X’s (largest contributors): • Human Factors • Length • Complexity • Should vs. Shall • Structure • Inconsistencies

19. Procedure improvements • Identified potential improvement opportunities • Compared procedures with Savannah River Site • Improvement action items: • Revision of Document Administration Procedure • Standard structure • Clearer definitions • Include attributes of an adequate procedure • Better flowdown and change management • Evaluation/revision of AB/QAM affecting procedures • Three-phased approach; Phase I nearing completion

20. Training PIP Phases: • Identify & Measure • Requirements • Existing Process Mapping • Analyze • Identify Process (XY Matrix) • Design • Detailed Process Mapping • Verify • Plans and Schedules

21. Training PIP – Process Potential Solutions: • Continue existing training program • Systematic Approach to Training on Positions that meet criteria (Graded Approach) • Systematic Approach to Training on all Positions • Supervisor verifies competency

22. Training improvements • Prior Approach • Manage/Supervisor accountability • On-target; procedure-focused • Narrow; limited classroom • Basis not well documented • No measure of effectiveness • Interim Actions • Discipline-specific enhancements to address identified shortcomings • Overall objective • Documented basis • Broad perspective • Effective media

23. Engineering Actions

24. Procedure compliance checklists • Purpose: Leading indicator to identify error precursor conditions • Implemented by document checker as part of normal, pre-approval, document review • Used for calculations, drawings, specifications, material requisitions, and supplier deviation disposition requisitions • Initial results: • High originator compliance by attribute (0.25% checker “holds” for correction by originator) • About 8% of design documents had at least one compliance “hold” for correction that was identified during checking • Metrics pinpoint actionable areas of improvement opportunity

25. Procedure compliance checklists (examples)

26. Procedure compliance checklists • Actions based on metrics: • Continue using checklists for all calculations, drawings, specifications, material requisitions, and supplier deviation disposition requests • Discipline-specific actions based on metrics: • Originator feedback for non-recurring checker “holds” • Staff coaching for recurring checker “holds” • Procedure clarification

27. Potential At Risk Practices • Performing a task with two or more procedures • Following procedures cookbook style • Removing several danger tags quickly without annotating removal of the tags on the clearance sheet • Performing critical checks without peer review or concurrent verification • Having several review and approval steps • Attempting to lift too much weight to avoid multiple trips • Signing off several steps of a work plan or procedure before performing the steps

28. Construction Actions Changing our culture

29. Changing our behavior • Safety leadership development training • Communications • Planning • Leading indicators and metrics • Motivation • Revising site work rules and discipline policy with the Safety Alliance • Implementing HPI • Application process for VPP Star Status • Specific goals in key managers’ annual reviews and performance measurement plans

30. Events Occur . . . • More often due to error-prone tasks and error-prone work environments than from error-prone individuals. • Error prone tasks and work environments are usually created by latent organizational weaknesses.

31. Continue to shift issue identification to originator Continue to shift issue identification to originator How do we measure culture? Reduce significance Quality Assurance Identification (audit/ assessment) Functional Identification (self assessment) Responsible Individual Other External Agency Findings DOE Finding