Hazardous Energy Work Control

1. Hazardous Energy Work Control

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. 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. 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. 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. 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. 2005 2006 2007 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Two Mechanical Incidents - ORPS Electrical Incident - ORPS ORPS Closure Submitted DOE Letter RCA to be Re-evaluated Seven Electrical Incidents - ORPS Two Electrical Incidents - ORPS ORPS Closure Rejected LOTO Incident not in ORPS Management Suspension of Work Establish CUG Interim Work Control Six Sigma Designed Metrics • Incident Investigations • Need for RCA • LOTO Improvements • Work Control Oversight Actions Complete CAR Issued 10 Actions • Work Control Center for Life Critical Processes • Lockout / Tagout • Configuration Management • Excavation Permits • Hot Work Permits • Hazardous Work Permits Effective Assessment DOE Annual LOTO Surveillance Mgt. Assessment of Electrical Work Processes Self Assessments Perform RCA Twenty Recommendations Corporate ES&H Assessment Safety Standown Hazardous Energy Corporate ES&H Assessment HPI Assessment of ORPS Reports HPI Training Electrical Safety Assessment Safety Rally Safety Rally BNI Request HPI Assessment Site Wide PSP Update for Electrical • Working Outside Controls • Work Place Culture • DOE/Contractor Relationship DOE Safety Reminder Letter from James Rispoli Reduced Fee for Chilled Workforce DOE Electrical Safety Month Nuclear Safety Culture Rally DOE ORP Electrical Safety Assessment Reduced Fee for Nuclear Safety Culture Key DOE $10,000 Electrical Safety Challenge DOE Electrical PPE Letter from Roy Schepens US DOE Actions & & BNI Actions DOE Initiate DNFSB Commitment 23 • Work Package Quality • Hazard Analysis • Planning and Scheduling • Management Expectations Work Control Assessment SAW2

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. 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. 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. 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. 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. Typical Hazardous Energy Package

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

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

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

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

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 FEEDBACK

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

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

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 PLANNING & CONTROL

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

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 PLANNING & CONTROL

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

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

26. Section 11 Hazardous Work Permit Hazardous Work Permit procedure integrated in package Forms driven by Hazardous Work Permit procedure PLANNING, CONTROL & AUTHORIZATION

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

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

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 FEEDBACK

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

31. Electricians in Proper PPE for Zero Energy Check

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 PLANNING TOOL – Removing/Reducing Barriers for Timely Production

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 PLANNING & CONTROL

34. Construction Power Distribution Rack

35. Standardized Orange and Black ID Labels

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. PLANNING

37. LCD Partial Screen Shot

38. LCD Partial Screen Shot

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 QUALIFIED PERSONNEL

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 DEFENSE IN DEPTH

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. 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. Hazardous Energy Incident Metrics Nov 2001 to Oct 2005 Oct 2005 to July 2006 Type of Report 3 (< 1 per year) 6 (8 per year) Corrective Action Report ORPS Reports CAIRS Safety Reports 15* 9 ** 0 0 * 14 events with hazard exposure, 1 with no hazard exposure ** 3 events with hazard exposure, 6 with no hazard exposure

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 A Trusting Culture is Emerging

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 Developing a Strong Conduct of Operations