1Bechtel National Inc.

Mitigating Organizational Weaknesses

Presented September 13, 2006DOE Integrated Safety Management Best Practices Workshop

Mary Heaton, Assistant PM Nuclear Safety & Quality Imperative

Bechtel 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

Industry Event Causes

806 = Individual behavior (32%)due to human performance

Source: INPO, Event Database, March 2000. For all events during 1998 and 1999.

215

26 3988

192

654

9 20

160

82

806

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6

Aoccdrnig to rscheearch at an Elingsh uinervtisy, it

deosn't mttaer in waht oredr the ltteers in a wrod

are, the olny iprmoetnt tihng is taht the frist and lsat

ltteer is at the rghit pclae. The rset can be a toatl

mses and you can sitll raed it wouthit porbelm. Tihs

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the wrod as a wlohe.

7

Fall 2005 Nuclear Safety and Quality CultureBNI, DOE ORP and Office of Enforcement agreed WTP had weaknesses in:

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

8

Nuclear Safety and Quality Imperative

Achieving nuclear safety and quality through procedure compliance

Management Alignment

Gap Analysis

Vision Setting

Compensatory Action

Corrective Action

• Balancing Safety, Quality, Cost, and Schedule

• Communication and Feedback

Oversight & Assessment

Training

• Adequacy of Procedures• Procedure Adherence

ProceduresBehavior

• Training Personnel to Execute Procedures

• Management Oversight & Assessment

• Verification and Approval of Work Activities

• Quality Improvement

We will create, then sustain, an open and trusting environment where each of us:

WTP Nuclear Safety and Quality Imperative

Our overriding priorities are safety and quality

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

NSQI August Metrics

ReduceError and

Issue Significance

Line Identification of Issues(Goal = 65 Percent)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percentage

Trend - Projected

Percentage 71% 58% 54% 69% 59% 73% 66% 58% 57% 50% 69% 59% 79%

Jul-05 Aug Sep Oct Nov Dec Jan-06 Feb Mar Apr May Jun Jul-06 Aug Sep Oct

Contribution by CR Severity Type

0%

10%

20%

30%

40%

50%

60%

70%

80%

Jul-05 Aug Sep Oct Nov Dec Jan-06 Feb Mar Apr May Jun Jul-06

% DR % CAR% Sig. CAR DR TrendCAR Trend Sig. CAR Trend

Deficiency Report – Level 1CAR – Level 2

Sig. CAR – Level 3/4

Line – Functional Orgs.As compared to QA & External

Continue to Shift Error and Issue Identification to the Responsible Individual

NSQI Project Manager

Project Management

Quality Assurance

CommissioningAcquisition Services

ConstructionEngineeringOrganizationStructure

NSQI Cross Functional Activities

Additional NSQI Activities

Procedure Adequacy Process Improvement Project

Training Process Improvement Project

Management Behavior Analysis

Safety and Quality One Hour Briefing Sessions

Nuclear Safety and Quality Behavior Recognition

Human Performance Improvement

Engineering Check Lists

Engineering Quality

Assessment

Construction Utilities Group

Weld Recovery Program

NSQI HGET Training

Systematic Approach to

Training

PIER System

Independent Advisory

Board

Nuclear Safety and Quality Imperative Project

George ClareNSQI Project Manager

Work Breakdown Structure

Matrixed Support Organization

Schedule

Improvement Primary Metric Charts

• Revised organization to centralize support to standardized process and procedures

• Revised project schedule

• Construction Safety Alliance

• Motivational off-site team building and alignment

• Improved long range planning and scheduling

• Monthly all employee meetings

• Safety Rallies

• April 2006 Front line supervisor NSQI/HPI

• Crucial conversations

• Procedural adequacy surveys

• Cross-functional 360° procedure review process

• VPP Steering Committee

• VPP Application Process

Engineering

Construction • Established NSQI expectation at new hire orientation by manager of Construction

• Safety Leadership Development Training

–Communications

–Planning

–Trending/Forecasting

–Motivation

• Cross-functional team develop approach to training (Systematic Approach to Training) (20)

• Identify positions and schedule for job analysis (34)

• Analyze positions, develop and deliver training per SAT

• Establish Training Advisory Board (35)

• Create Training Implementation Matrix per DOE 0rder 5480.20A (36)

• Revise training procedures per systematic approach (37)

• Issue Training Program Plan per schedule (38)

Project- Wide • Develop Centralized Issues Tracking System (PIER) (2)

• Revise Management Assessment Procedure

• Provide training to managers regarding behaviors to achieve a Safety Conscious Work Environment attitude (4)

• Conduct management alignment sessions (5)

• Conduct Management Behavioral Gap Analysis (9)

• Management briefing sessions (6)

• Conduct WTP All Hands Meeting (7)

• Conduct one-hour NSQI stand-down sessions (11)

• Conduct quiz on management expectations (12)

• Revise annual HGET training to include NSQI module (13)

• Establish new hire expectations at new hire orientation by senior project management (14)

• Develop website for anonymous questions (15)

• Implement Human Performance (16)

• Develop communication strategy (17)

• Conduct employee survey (19)

• Identify actions from survey results (33)

• Develop Differing Professional Opinion program

• Recognizing and rewarding desired employee behaviors

• Cross-functional team develop approach to address procedure adequacy (21)

• Baseline procedure format and content to Savannah River Site

• Revise Document Administration procedure to increase clarity (22)

• Identify set of procedures which will undergo review for clarification and revision if necessary (23)

• Revise Phase 1 procedures (24-28)

• Establish database to track requirement flowdown through procedures (31)

• Establish method to hyperlink procedures (32)

• Direct link to procedures from homepage (30)

• Procedure writers attend Human Performance training (29)

• Rapid procedure change process

Oversight & Assessment

Training

• Assign NSQI Project Manager (3)• Develop business case for procedure compliance (8)

ProceduresBehavior

Nuclear Safety and Quality Imperative

• Balancing Safety, Quality, Cost, and Schedule

• Communication and Feedback

• Management Oversight & Assessment

• Verification and Approval of Work Activities

• Quality Improvement

• Adequacy of Procedures

• Procedure Adherence

• Training Personnel to Execute Procedures

• Consolidated engineering organization

– Central technical leadership and design production

– Co-located expertise

– Common equipment groups

– One-stop assessment, feedback, and corrective action

– Consolidated checking and verification functions

– Cross-discipline design support organization for issue tracking, analysis, and improvement actions

– Improved integration of planning tools and resources

• Engineering Quality Analysis tool, monthly updates, action plans

• Revised off-project review procedure

• Process Assurance and E&NS sponsored assessments, including safety envelope and procedural conformance

• Requirements verification process integrated with system description development

• Outside review of key technical risk areas

• Revised project schedule

– Increased durations to support construction and procurement

– Improved sequencing and logic ties of engineering discipline activities

– Improved durations to resolve open technical risk issues

• NSQI communications

– Monthly Engineering Quality presentation on NSQI attributes to all hands

• Engineering leadership off-site sessions regarding NSQI implementation

• Integration of quality goals in management annual performance reviews

• Incorporation of INPO error precursors and HPI principles into CAR follow-up

• Engineering safety envelope stand-down and personal commitment statements

• Augmented Monitoring of New Employees/ Employees with New Assignments

• Discipline-specific coaching

– codes and standards

– design tools

– work process requirements

– feedback from surveillances and corrective actions

– feedback from technical and compliance checklists

• Revised training matrices based on current production deliverables

• Technical completeness checklists in key production areas

• Formal safety envelope training and knowledge check

• PSAR update - training and review

• Additional staff training and utilization in Root Cause Analysis

• Procedure compliance actions

– Compliance checklists/metrics (18)

– Improved procedure change processes

– Procedure compliance statements

– New employee orientation regarding expectations

– WTP document hierarchy clarified and published

• Procedure adequacy actions– Clarification of top-level

requirements in procedures– Review of Engineering Guides for

mandatory requirements – Discipline action on compliance

checklist metrics• Additional specific actions

– Engineering Material Coordinator Guide revised (1)

– Equipment database quality metrics and ongoing screening of tagged components

– Additional E&NS reviews and safety screen signature added to design documents

– Improved implementation feedback for safety envelope and design criteria changes

• Advisory Board• Confirmatory Analysis

Bold and italicized items indicate Compensatory Actions

11

Culture change strategy

Top Down

Bottom Up

Focused Actions Visible, tangible success

Increased credibility

Project-wide culture change

Function-specific issue resolution

12

• Revised organization to centralize support to standardized process and procedures

• Revised project schedule

• Construction Safety Alliance

• Motivational off-site team building and alignment

• Improved long range planning and scheduling

• Monthly all employee meetings

• Safety Rallies

• April 2006 Front line supervisor NSQI/HPI

• Crucial conversations

• Procedural adequacy surveys

• Cross-functional 360° procedure review process

• VPP Steering Committee

• VPP Application Process

Engineering

Construction • Established NSQI expectation at new hire orientation by manager of Construction

• Safety Leadership Development Training

–Communications

–Planning

–Trending/Forecasting

–Motivation

• Cross-functional team develop approach to training (Systematic Approach to Training) (20)

• Identify positions and schedule for job analysis (34)

• Analyze positions, develop and deliver training per SAT

• Establish Training Advisory Board (35)

• Create Training Implementation Matrix per DOE 0rder 5480.20A (36)

• Revise training procedures per systematic approach (37)

• Issue Training Program Plan per schedule (38)

Project- Wide • Develop Centralized Issues Tracking System (PIERs) (2)

• Revise Management Assessment Procedure

• Provide training to managers regarding behaviors to achieve a Safety Conscious Work Environment attitude (4)

• Conduct management alignment sessions (5)

• Management briefing sessions (6)

• Conduct Management Behavioral Gap Analysis (9)

• Conduct WTP All Hands Meeting (7)

• Conduct one-hour NSQI stand-down sessions (11)

• Conduct quiz on management expectations (12)

• Revise annual HGET training to include NSQI module (13)

• Establish new hire expectations at new hire orientation by senior project management (14)

• Develop website for anonymous questions (15)

• Implement Human Performance (16)

• Develop communication strategy (17)

• Conduct employee survey (19)

• Identify actions from survey results (33)

• Develop Differing Professional Opinion program

• Recognizing and rewarding desired employee behaviors

• Cross-functional team develop approach to address procedure adequacy (21)

• Baseline procedure format and content to Savannah River Site

• Revise Document Administration procedure to increase clarity (22)

• Identify set of procedures which will undergo review for clarification and revision if necessary (23)

• Revise Phase 1 procedures (24-28)

• Establish database to track requirement flowdown through procedures (31)

• Establish method to hyperlink procedures (32)

• Direct link to procedures from homepage (30)

• Procedure writers attend Human Performance training (29)

• Rapid procedure change process

Oversight & Assessment

Training

• Assign NSQI Project Manager (3)• Develop business case for procedure compliance (8)

ProceduresBehavior

Nuclear Safety and Quality Imperative

• Balancing Safety, Quality, Cost, and Schedule

• Communication and Feedback

• Management Oversight & Assessment

• Verification and Approval of Work Activities

• Quality Improvement

• Adequacy of Procedures

• Procedure Adherence

• Training Personnel to Execute Procedures

• Consolidated engineering organization

– Central technical leadership and design production

– Co-located expertise

– Common equipment groups

– One-stop assessment, feedback, and corrective action

– Consolidated checking and verification functions

– Cross-discipline design support organization for issue tracking, analysis, and improvement actions

– Improved integration of planning tools and resources

• Engineering Quality Analysis tool, monthly updates, action plans

• Revised off-project review procedure

• Process Assurance and E&NS sponsored assessments, including safety envelope and procedural conformance

• Requirements verification process integrated with system description development

• Outside review of key technical risk areas

• Revised project schedule

– Increased durations to support construction and procurement

– Improved sequencing and logical ties of engineering discipline activities

– Improved durations to resolve open technical risk issues

• NSQI communications

– Monthly Engineering Quality presentation on NSQI attributes to all hands

• Engineering leadership off-site sessions regarding NSQI implementation

• Integration of quality goals in management annual performance reviews

• Incorporation of INPO error precursors and HPI principles into CAR follow-up

• Engineering safety envelope stand-down and personal commitment statements

• Engineering Guide for Augmented Monitoring of New Employees/ Employees with New Assignments

• Discipline-specific coaching

– codes and standards

– design tools

– work process requirements

– feedback from surveillances and corrective actions

– feedback from technical and compliance checklists

• Revised training matrices based on current production deliverables

• Technical completeness checklists in key production areas

• Formal safety envelope training and knowledge check

• PSAR update - training and review

• Additional staff training and utilization in Root Cause Analysis

• Procedure compliance actions

– Compliance checklists/metrics (18)

– Improved procedure change processes

– Procedure compliance statements

– New employee orientation regarding expectations

– WTP document hierarchy clarified and published

• Procedure adequacy actions– Clarification of top-level

requirements in procedures– Review of Engineering Guides for

mandatory requirements – Discipline action on compliance

checklist metrics• Additional specific actions

– Engineering Material Coordinator Guide revised (1)

– Equipment database quality metrics and ongoing screening of tagged components

– Additional E&NS reviews and safety screen signature added to design documents

– Improved implementation feedback for safety envelope and design criteria changes

• Advisory Board• Confirmatory Analysis

Bold and italicized items indicate Compensatory Actions

Project-wide compensatory action

• Cross-functional team develop approach to training (Systematic Approach to Training) (20)

• Identify positions and schedule for job analysis (34)

• Analyze positions, develop and deliver training per SAT

• Establish Training Advisory Board (35)

• Create Training Implementation Matrix per DOE 0rder 5480.20A (36)

• Revise training procedures per systematic approach (37)

• Issue Training Program Plan per schedule (38)

• Develop Centralized Issues Tracking System (PIER) (2)

• Revise Management Assessment Procedure

• Provide training to managers regarding behaviors to achieve a Safety Conscious Work Environment attitude (4)

• Conduct management alignment sessions (5)

• Conduct Management Behavioral Gap Analysis (9)

• Management briefing sessions (6)

• Conduct WTP All Hands Meeting (7)

• Conduct one-hour NSQI stand-down sessions (11)

• Conduct quiz on management expectations (12)

• Revise annual HGET training to include NSQI module (13)

• Establish new hire expectations at new hire orientation by senior project management (14)

• Develop website for anonymous questions (15)

• Implement Human Performance (16)

• Develop communication strategy (17)

• Conduct employee survey (19)

• Identify actions from survey results (33)

• Develop Differing Professional Opinion program

• Recognizing and rewarding desired employee behaviors

• Cross-functional team develop approach to address procedure adequacy (21)

• Baseline procedure format and content to Savannah River Site

• Revise Document Administration procedure to increase clarity (22)

• Identify set of procedures which will undergo review for clarification and revision if necessary (23)

• Revise Phase 1 procedures (24-28)

• Establish database to track requirement flowdown through procedures (31)

• Establish method to hyperlink procedures (32)

• Direct link to procedures from homepage (30)

• Procedure writers attend Human Performance training (29)

• Rapid procedure change process

Oversight & Assessment

Training ProceduresBehavior

• Balancing Safety, Quality, Cost, and Schedule

• Communication and Feedback

• Management Oversight & Assessment

• Verification and Approval of Work Activities

• Quality Improvement

• Adequacy of Procedures

• Procedure Adherence

• Training Personnel to Execute Procedures

13

• Revised organization to centralize support to standardized process and procedures

• Revised project schedule

• Construction Safety Alliance

• Motivational off-site team building and alignment

• Improved long range planning and scheduling

• Monthly all employee meetings

• Safety Rallies

• April 2006 Front line supervisor NSQI/HPI

• Crucial conversations

• Procedural adequacy surveys

• Cross-functional 360° procedure review process

• VPP Steering Committee

• VPP Application Process

Engineering

Construction • Established NSQI expectation at new hire orientation by manager of Construction

• Safety Leadership Development Training

–Communications

–Planning

–Trending/Forecasting

–Motivation

• Cross-functional team develop approach to training (Systematic Approach to Training) (20)

• Identify positions and schedule for job analysis (34)

• Analyze positions, develop and deliver training per SAT

• Establish Training Advisory Board (35)

• Create Training Implementation Matrix per DOE 0rder 5480.20A (36)

• Revise training procedures per systematic approach (37)

• Issue Training Program Plan per schedule (38)

Project- Wide • Develop Centralized Issues Tracking System (PIERs) (2)

• Revise Management Assessment Procedure

• Provide training to managers regarding behaviors to achieve a Safety Conscious Work Environment attitude (4)

• Conduct management alignment sessions (5)

• Management briefing sessions (6)

• Conduct Management Behavioral Gap Analysis (9)

• Conduct WTP All Hands Meeting (7)

• Conduct one-hour NSQI stand-down sessions (11)

• Conduct quiz on management expectations (12)

• Revise annual HGET training to include NSQI module (13)

• Establish new hire expectations at new hire orientation by senior project management (14)

• Develop website for anonymous questions (15)

• Implement Human Performance (16)

• Develop communication strategy (17)

• Conduct employee survey (19)

• Identify actions from survey results (33)

• Develop Differing Professional Opinion program

• Recognizing and rewarding desired employee behaviors

• Cross-functional team develop approach to address procedure adequacy (21)

• Baseline procedure format and content to Savannah River Site

• Revise Document Administration procedure to increase clarity (22)

• Identify set of procedures which will undergo review for clarification and revision if necessary (23)

• Revise Phase 1 procedures (24-28)

• Establish database to track requirement flowdown through procedures (31)

• Establish method to hyperlink procedures (32)

• Direct link to procedures from homepage (30)

• Procedure writers attend Human Performance training (29)

• Rapid procedure change process

Oversight & Assessment

Training

• Assign NSQI Project Manager (3)• Develop business case for procedure compliance (8)

ProceduresBehavior

Nuclear Safety and Quality Imperative

• Balancing Safety, Quality, Cost, and Schedule

• Communication and Feedback

• Management Oversight & Assessment

• Verification and Approval of Work Activities

• Quality Improvement

• Adequacy of Procedures

• Procedure Adherence

• Training Personnel to Execute Procedures

• Consolidated engineering organization

– Central technical leadership and design production

– Co-located expertise

– Common equipment groups

– One-stop assessment, feedback, and corrective action

– Consolidated checking and verification functions

– Cross-discipline design support organization for issue tracking, analysis, and improvement actions

– Improved integration of planning tools and resources

• Engineering Quality Analysis tool, monthly updates, action plans

• Revised off-project review procedure

• Process Assurance and E&NS sponsored assessments, including safety envelope and procedural conformance

• Requirements verification process integrated with system description development

• Outside review of key technical risk areas

• Revised project schedule

– Increased durations to support construction and procurement

– Improved sequencing and logical ties of engineering discipline activities

– Improved durations to resolve open technical risk issues

• NSQI communications

– Monthly Engineering Quality presentation on NSQI attributes to all hands

• Engineering leadership off-site sessions regarding NSQI implementation

• Integration of quality goals in management annual performance reviews

• Incorporation of INPO error precursors and HPI principles into CAR follow-up

• Engineering safety envelope stand-down and personal commitment statements

• Engineering Guide for Augmented Monitoring of New Employees/ Employees with New Assignments

• Discipline-specific coaching

– codes and standards

– design tools

– work process requirements

– feedback from surveillances and corrective actions

– feedback from technical and compliance checklists

• Revised training matrices based on current production deliverables

• Technical completeness checklists in key production areas

• Formal safety envelope training and knowledge check

• PSAR update - training and review

• Additional staff training and utilization in Root Cause Analysis

• Procedure compliance actions

– Compliance checklists/metrics (18)

– Improved procedure change processes

– Procedure compliance statements

– New employee orientation regarding expectations

– WTP document hierarchy clarified and published

• Procedure adequacy actions– Clarification of top-level

requirements in procedures– Review of Engineering Guides for

mandatory requirements – Discipline action on compliance

checklist metrics• Additional specific actions

– Engineering Material Coordinator Guide revised (1)

– Equipment database quality metrics and ongoing screening of tagged components

– Additional E&NS reviews and safety screen signature added to design documents

– Improved implementation feedback for safety envelope and design criteria changes

• Advisory Board• Confirmatory Analysis

Bold and italicized items indicate Compensatory Actions

Centralized issue tracking system: PIER

System implemented to ease identification of issues

Issues, Concerns, Questions, Problems,

Recommendations

Report It

Resolve It

Review It

14

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...

NSQ culture change activities are pervasive

Completed Ongoing• Revised organization to centralize

support to standardized process and procedures

• Revised project schedule

• Construction Safety Alliance

• Motivational off-site team building and alignment

• Improved long range planning and scheduling

• Monthly all employee meetings

• Safety Rallies

• April 2006 Front line supervisor NSQI/HPI

• Crucial conversations

• Procedural adequacy surveys

• Cross-functional 360° procedure review process

• VPP Steering Committee

• VPP Application Process

Engineering

Construction • Established NSQI expectation at new hire orientation by manager of Construction

• Safety Leadership Development Training

–Communications

–Planning

–Trending/Forecasting

–Motivation

• Cross-functional team develop approach to training (Systematic Approach to Training) (20)

• Identify positions and schedule for job analysis (34)

• Analyze positions, develop and deliver training per SAT

• Establish Training Advisory Board (35)

• Create Training Implementation Matrix per DOE 0rder 5480.20A (36)

• Revise training procedures per systematic approach (37)

• Issue Training Program Plan per schedule (38)

Project- Wide • Develop Centralized Issues Tracking System (PIERs) (2)

• Revise Management Assessment Procedure

• Provide training to managers regarding behaviors to achieve a Safety Conscious Work Environment attitude (4)

• Conduct management alignment sessions (5)

• Management briefing sessions (6)

• Conduct Management Behavioral Gap Analysis (9)

• Conduct WTP All Hands Meeting (7)

• Conduct one-hour NSQI stand-down sessions (11)

• Conduct quiz on management expectations (12)

• Revise annual HGET training to include NSQI module (13)

• Establish new hire expectations at new hire orientation by senior project management (14)

• Develop website for anonymous questions (15)

• Implement Human Performance (16)

• Develop communication strategy (17)

• Conduct employee survey (19)

• Identify actions from survey results (33)

• Develop Differing Professional Opinion program

• Recognizing and rewarding desired employee behaviors

• Cross-functional team develop approach to address procedure adequacy (21)

• Baseline procedure format and content to Savannah River Site

• Revise Document Administration procedure to increase clarity (22)

• Identify set of procedures which will undergo review for clarification and revision if necessary (23)

• Revise Phase 1 procedures (24-28)

• Establish database to track requirement flowdown through procedures (31)

• Establish method to hyperlink procedures (32)

• Direct link to procedures from homepage (30)

• Procedure writers attend Human Performance training (29)

• Rapid procedure change process

Oversight & Assessment

Training

• Assign NSQI Project Manager (3)• Develop business case for procedure compliance (8)

ProceduresBehavior

Nuclear Safety and Quality Imperative

• Balancing Safety, Quality, Cost, and Schedule

• Communication and Feedback

• Management Oversight & Assessment

• Verification and Approval of Work Activities

• Quality Improvement

• Adequacy of Procedures

• Procedure Adherence

• Training Personnel to Execute Procedures

• Consolidated engineering organization

– Central technical leadership and design production

– Co-located expertise

– Common equipment groups

– One-stop assessment, feedback, and corrective action

– Consolidated checking and verification functions

– Cross-discipline design support organization for issue tracking, analysis, and improvement actions

– Improved integration of planning tools and resources

• Engineering Quality Analysis tool, monthly updates, action plans

• Revised off-project review procedure

• Process Assurance and E&NS sponsored assessments, including safety envelope and procedural conformance

• Requirements verification process integrated with system description development

• Outside review of key technical risk areas

• Revised project schedule

– Increased durations to support construction and procurement

– Improved sequencing and logical ties of engineering discipline activities

– Improved durations to resolve open technical risk issues

• NSQI communications

– Monthly Engineering Quality presentation on NSQI attributes to all hands

• Engineering leadership off-site sessions regarding NSQI implementation

• Integration of quality goals in management annual performance reviews

• Incorporation of INPO error precursors and HPI principles into CAR follow-up

• Engineering safety envelope stand-down and personal commitment statements

• Engineering Guide for Augmented Monitoring of New Employees/ Employees with New Assignments

• Discipline-specific coaching

– codes and standards

– design tools

– work process requirements

– feedback from surveillances and corrective actions

– feedback from technical and compliance checklists

• Revised training matrices based on current production deliverables

• Technical completeness checklists in key production areas

• Formal safety envelope training and knowledge check

• PSAR update - training and review

• Additional staff training and utilization in Root Cause Analysis

• Procedure compliance actions

– Compliance checklists/metrics (18)

– Improved procedure change processes

– Procedure compliance statements

– New employee orientation regarding expectations

– WTP document hierarchy clarified and published

• Procedure adequacy actions– Clarification of top-level

requirements in procedures– Review of Engineering Guides for

mandatory requirements – Discipline action on compliance

checklist metrics• Additional specific actions

– Engineering Material Coordinator Guide revised (1)

– Equipment database quality metrics and ongoing screening of tagged components

– Additional E&NS reviews and safety screen signature added to design documents

– Improved implementation feedback for safety envelope and design criteria changes

• Advisory Board• Confirmatory Analysis

Bold and italicized items indicate Compensatory Actions

Human Performance Training

Communication Strategy• Weekly Newsletter• NSQI Website• Posters• Employee Messages

Recognition Strategy• Employee Owned• Management

Supported

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

• Revised organization to centralize support to standardized process and procedures

• Revised project schedule

• Construction Safety Alliance

• Motivational off-site team building and alignment

• Improved long range planning and scheduling

• Monthly all employee meetings

• Safety Rallies

• April 2006 Front line supervisor NSQI/HPI

• Crucial conversations

• Procedural adequacy surveys

• Cross-functional 360° procedure review process

• VPP Steering Committee

• VPP Application Process

Engineering

Construction • Established NSQI expectation at new hire orientation by manager of Construction

• Safety Leadership Development Training

–Communications

–Planning

–Trending/Forecasting

–Motivation

• Cross-functional team develop approach to training (Systematic Approach to Training) (20)

• Identify positions and schedule for job analysis (34)

• Analyze positions, develop and deliver training per SAT

• Establish Training Advisory Board (35)

• Create Training Implementation Matrix per DOE 0rder 5480.20A (36)

• Revise training procedures per systematic approach (37)

• Issue Training Program Plan per schedule (38)

Project- Wide • Develop Centralized Issues Tracking System (PIERs) (2)

• Revise Management Assessment Procedure

• Provide training to managers regarding behaviors to achieve a Safety Conscious Work Environment attitude (4)

• Conduct management alignment sessions (5)

• Management briefing sessions (6)

• Conduct Management Behavioral Gap Analysis (9)

• Conduct WTP All Hands Meeting (7)

• Conduct one-hour NSQI stand-down sessions (11)

• Conduct quiz on management expectations (12)

• Revise annual HGET training to include NSQI module (13)

• Establish new hire expectations at new hire orientation by senior project management (14)

• Develop website for anonymous questions (15)

• Implement Human Performance (16)

• Develop communication strategy (17)

• Conduct employee survey (19)

• Identify actions from survey results (33)

• Develop Differing Professional Opinion program

• Recognizing and rewarding desired employee behaviors

• Cross-functional team develop approach to address procedure adequacy (21)

• Baseline procedure format and content to Savannah River Site

• Revise Document Administration procedure to increase clarity (22)

• Identify set of procedures which will undergo review for clarification and revision if necessary (23)

• Revise Phase 1 procedures (24-28)

• Establish database to track requirement flowdown through procedures (31)

• Establish method to hyperlink procedures (32)

• Direct link to procedures from homepage (30)

• Procedure writers attend Human Performance training (29)

• Rapid procedure change process

Oversight & Assessment

Training

• Assign NSQI Project Manager (3)• Develop business case for procedure compliance (8)

ProceduresBehavior

Nuclear Safety and Quality Imperative

• Balancing Safety, Quality, Cost, and Schedule

• Communication and Feedback

• Management Oversight & Assessment

• Verification and Approval of Work Activities

• Quality Improvement

• Adequacy of Procedures

• Procedure Adherence

• Training Personnel to Execute Procedures

• Consolidated engineering organization

– Central technical leadership and design production

– Co-located expertise

– Common equipment groups

– One-stop assessment, feedback, and corrective action

– Consolidated checking and verification functions

– Cross-discipline design support organization for issue tracking, analysis, and improvement actions

– Improved integration of planning tools and resources

• Engineering Quality Analysis tool, monthly updates, action plans

• Revised off-project review procedure

• Process Assurance and E&NS sponsored assessments, including safety envelope and procedural conformance

• Requirements verification process integrated with system description development

• Outside review of key technical risk areas

• Revised project schedule

– Increased durations to support construction and procurement

– Improved sequencing and logical ties of engineering discipline activities

– Improved durations to resolve open technical risk issues

• NSQI communications

– Monthly Engineering Quality presentation on NSQI attributes to all hands

• Engineering leadership off-site sessions regarding NSQI implementation

• Integration of quality goals in management annual performance reviews

• Incorporation of INPO error precursors and HPI principles into CAR follow-up

• Engineering safety envelope stand-down and personal commitment statements

• Engineering Guide for Augmented Monitoring of New Employees/ Employees with New Assignments

• Discipline-specific coaching

– codes and standards

– design tools

– work process requirements

– feedback from surveillances and corrective actions

– feedback from technical and compliance checklists

• Revised training matrices based on current production deliverables

• Technical completeness checklists in key production areas

• Formal safety envelope training and knowledge check

• PSAR update - training and review

• Additional staff training and utilization in Root Cause Analysis

• Procedure compliance actions

– Compliance checklists/metrics (18)

– Improved procedure change processes

– Procedure compliance statements

– New employee orientation regarding expectations

– WTP document hierarchy clarified and published

• Procedure adequacy actions– Clarification of top-level

requirements in procedures– Review of Engineering Guides for

mandatory requirements – Discipline action on compliance

checklist metrics• Additional specific actions

– Engineering Material Coordinator Guide revised (1)

– Equipment database quality metrics and ongoing screening of tagged components

– Additional E&NS reviews and safety screen signature added to design documents

– Improved implementation feedback for safety envelope and design criteria changes

• Advisory Board• Confirmatory Analysis

Bold and italicized items indicate Compensatory Actions

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

• Revised organization to centralize support to standardized process and procedures

• Revised project schedule

• Construction Safety Alliance

• Motivational off-site team building and alignment

• Improved long range planning and scheduling

• Monthly all employee meetings

• Safety Rallies

• April 2006 Front line supervisor NSQI/HPI

• Crucial conversations

• Procedural adequacy surveys

• Cross-functional 360° procedure review process

• VPP Steering Committee

• VPP Application Process

Engineering

Construction • Established NSQI expectation at new hire orientation by manager of Construction

• Safety Leadership Development Training

–Communications

–Planning

–Trending/Forecasting

–Motivation

• Cross-functional team develop approach to training (Systematic Approach to Training) (20)

• Identify positions and schedule for job analysis (34)

• Analyze positions, develop and deliver training per SAT

• Establish Training Advisory Board (35)

• Create Training Implementation Matrix per DOE 0rder 5480.20A (36)

• Revise training procedures per systematic approach (37)

• Issue Training Program Plan per schedule (38)

Project- Wide • Develop Centralized Issues Tracking System (PIERs) (2)

• Revise Management Assessment Procedure

• Provide training to managers regarding behaviors to achieve a Safety Conscious Work Environment attitude (4)

• Conduct management alignment sessions (5)

• Management briefing sessions (6)

• Conduct Management Behavioral Gap Analysis (9)

• Conduct WTP All Hands Meeting (7)

• Conduct one-hour NSQI stand-down sessions (11)

• Conduct quiz on management expectations (12)

• Revise annual HGET training to include NSQI module (13)

• Establish new hire expectations at new hire orientation by senior project management (14)

• Develop website for anonymous questions (15)

• Implement Human Performance (16)

• Develop communication strategy (17)

• Conduct employee survey (19)

• Identify actions from survey results (33)

• Develop Differing Professional Opinion program

• Recognizing and rewarding desired employee behaviors

• Cross-functional team develop approach to address procedure adequacy (21)

• Baseline procedure format and content to Savannah River Site

• Revise Document Administration procedure to increase clarity (22)

• Identify set of procedures which will undergo review for clarification and revision if necessary (23)

• Revise Phase 1 procedures (24-28)

• Establish database to track requirement flowdown through procedures (31)

• Establish method to hyperlink procedures (32)

• Direct link to procedures from homepage (30)

• Procedure writers attend Human Performance training (29)

• Rapid procedure change process

Oversight & Assessment

Training

• Assign NSQI Project Manager (3)• Develop business case for procedure compliance (8)

ProceduresBehavior

Nuclear Safety and Quality Imperative

• Balancing Safety, Quality, Cost, and Schedule

• Communication and Feedback

• Management Oversight & Assessment

• Verification and Approval of Work Activities

• Quality Improvement

• Adequacy of Procedures

• Procedure Adherence

• Training Personnel to Execute Procedures

• Consolidated engineering organization

– Central technical leadership and design production

– Co-located expertise

– Common equipment groups

– One-stop assessment, feedback, and corrective action

– Consolidated checking and verification functions

– Cross-discipline design support organization for issue tracking, analysis, and improvement actions

– Improved integration of planning tools and resources

• Engineering Quality Analysis tool, monthly updates, action plans

• Revised off-project review procedure

• Process Assurance and E&NS sponsored assessments, including safety envelope and procedural conformance

• Requirements verification process integrated with system description development

• Outside review of key technical risk areas

• Revised project schedule

– Increased durations to support construction and procurement

– Improved sequencing and logical ties of engineering discipline activities

– Improved durations to resolve open technical risk issues

• NSQI communications

– Monthly Engineering Quality presentation on NSQI attributes to all hands

• Engineering leadership off-site sessions regarding NSQI implementation

• Integration of quality goals in management annual performance reviews

• Incorporation of INPO error precursors and HPI principles into CAR follow-up

• Engineering safety envelope stand-down and personal commitment statements

• Engineering Guide for Augmented Monitoring of New Employees/ Employees with New Assignments

• Discipline-specific coaching

– codes and standards

– design tools

– work process requirements

– feedback from surveillances and corrective actions

– feedback from technical and compliance checklists

• Revised training matrices based on current production deliverables

• Technical completeness checklists in key production areas

• Formal safety envelope training and knowledge check

• PSAR update - training and review

• Additional staff training and utilization in Root Cause Analysis

• Procedure compliance actions

– Compliance checklists/metrics (18)

– Improved procedure change processes

– Procedure compliance statements

– New employee orientation regarding expectations

– WTP document hierarchy clarified and published

• Procedure adequacy actions– Clarification of top-level

requirements in procedures– Review of Engineering Guides for

mandatory requirements – Discipline action on compliance

checklist metrics• Additional specific actions

– Engineering Material Coordinator Guide revised (1)

– Equipment database quality metrics and ongoing screening of tagged components

– Additional E&NS reviews and safety screen signature added to design documents

– Improved implementation feedback for safety envelope and design criteria changes

• Advisory Board• Confirmatory Analysis

Bold and italicized items indicate Compensatory Actions

17

Effect

Large Scope

Easier to get 1 through

Not Enough Info

Inconsistent

Structure

Details Lost

Complexity

Amount of Reviewers

New Nuke Job

Amount of Requirements

Findings ProceduresNot Value Added

#/Titles

Tools

Reqs - Where are they

Flow chart -

Out of date info

Examples not updated

Flow Process not updated

Change Process

Appendicies

ShouldsConsistent use of forms/inst.

Duplicate Overlap Procedures

Conflict instructions & forms & Reqs

Mgt Override

Mgt Direction

User Expectations

Loop Holes

Alternatives

Wordiness

Compensating for Training

too much detail

Based on Competence

Based on Training

Guide vs. Procedure

Procedures Vs. Alternatives

Who Decides

Criteria

Detail

Understanding Definitions

Mandatory vs. Not

Procedure Creep (full circle)

Failure to understand impacts

Incidents

Lessons Learned

Requirements

Findings

Political Expectations

Human Factors

Finding Details

Frustration / Find

Procedural Adequacy

Verbatim Compliance

Should vs shall

Too detailed

Guide vs procedure

More opps for failure

No Project Standards

Sloppiness

Failure to Clearly ID reqs in proc.

Forcing Process / Flow

Shall vs. Should

Perceived Definitions

Inconsistent Definitions

Improper usage of shall vs should

Use of passive vs active voice

increases wordinessincreased # interpretations

Where's the balance?

misuse of application

CARs (Time/Rep/$)

violated shall

inproper use of shall

violation

Inconsistent Consequences

Definitions (reqs in)

management expectations

irrelevant reqs.

inconsistent instructions vs forms

division of resp.

detail philosophy vs procedure

judgement vs procedure checklists

EvolutionFormat

Form Driven

1 pg form vs 20pgs instruct.

Interpretations / Reqs

clarifications

clarifications

interpretations

Who writes the procedures

trained

competent

questioning attitudeSME

Tech Writer

Limited Procedure Resources (overhead)

Binning / less duplication

Less procedures to look at

Review & Approval

Mult. Functs InvolvedGet all views

Guide vs. Procedure

Defensive MedicineCorp Approval

Lack of TeamworkIterations / Socpe

LogisticsEarly approver invovlement

Rules MixingUniqueness

Allow Flexability

Training

Assignment of Procedures

Linking Procedures

Job specific

Visibility

Incidents drive addtions

'Clarification'

percieved Reqs

why vs. what and how

Reqs change

Missed change flowdowns

can update seperately

Different ownerships

Comms between Depts

Complexity

Revision Process

Linkage

CAR Fix

Easy to fix procedure vs. behavior

Idea posturing

Background

Easy to provePriority Perception in Procedure

People learn differently

Experiences / Bias

Assumptions of common knowledge

Logical flow

Workload

appropriate length

KISS Structure / Language

Poor Structure

Precedence

Absent in directions

Human Factors

Schedule

Change process limited

Changing Strategy

Tech Comptency of Writer

Can't write

Apathy

Scope of review / Interface

ID of flowdowns

Human Factors

Scope

Purpose

Cycle Times

Approval / Concure processs

Proc. Creep

Structure

Level of Detail

Alternative not utilized

Human Factors

Verbiage Choice

Characteristic Selection MatrixResults

0%

2%

4%

6%

8%

10%

12%

14%

16%

Sh

all v

s. S

ho

uld

Hu

man

Fac

tors

Str

uct

ure

/No

Pro

ject

Std

s.

Inco

nsi

sten

cy/S

lop

py

Pro

c. C

on

ten

t

Ch

ang

e P

roce

ss

CA

R F

ix

Pro

ced

ure

vs.

Alts

Lev

el o

f Det

ail

(Co

mp

lexi

ty)

Co

nfli

ctin

gF

orm

s/In

st.

Du

plic

ate/

Ove

rlap

Cle

arly

ref

eren

cin

gR

eqs

Input Characteristic

Ch

arac

teri

stic

Imp

ort

ance

(%)

Procedure Creation

Ext

ern

al F

unct

ional R

evi

ew

Inte

rnal F

unct

ional R

evi

ew

Pro

cedure

Gro

up

Pro

cedure

Auth

or

Yes

No

Yes

No

Yes

Yes

No

Yes

Yes

No

Yes

No

Yes

No

Yes

No

No

Yes

No

No

Yes

Yes

No

Yes

No

Yes

No

No

Yes

Yes

No No

No

Yes

All commentsincorporated?

ResolutionAccepted?

ResolutionAccepted?

Forwardcomments to

author forresolution*

Commentsfrom review?

Reviewer Criteria-Defined by procedure(MGT-007)-Affected Functions

-SME-Corporate Review(Chief’s Review)

-Minimum Reviewers-EN&S-QA-Config Mgt-Safety Assurance

Initiate commentresolution with

reviewer

Commentsfrom review?

Incorporateeditorial changesCreate DHR and

review requestemail. Send

review request torequired reviewers

File no commentsemail

Functionalconcurrence

required?

Resolve and/orincorporate all

reviewercomments into

procedure

Send concurrencerequest email toDHR reviewers

Editorialchanges?

Send final versionof procedure to PG

Start concurrenceprocess

ID Reviewers

Concurrence?

Forwardcomments to

author forresolution

Start reviewprocess

CollectRequirements Informal/Internal

Reviews

Decide who writesprocedure

Write ProcedureDraft

Who-EstablishedProcedure Groups-SME-User-Mgmt-Corp

Decide-Time-Budget-Est. Group-Competence/Qualified-Multiple-Risk-Ghost Writer

Collect reqs.-Content-Flowdowns-BNI policy/procedure-Codes/standards-QAM-ABMGMT. Reqs.-LicensingDocs/Permits-Other OutsideGroups-Internal Funct.Groups-Other WTPProcedures

Procedure Drafting-Templates-Style Guide-ExistingProcedure-Forms-Flow charts_______________

GuideProcedure/

Guide/DesktopInstruction

Decision Criteria-Implementing?ProcedureGuides/Instructions-Shall-Procedure/Corp. Proc/SWPP-Directed to by QA/ Mngr.-Quality/Safety-Time Constraints-Who is going to review it?

Procedure

ID Need

DesktopInstruction

CreateConstruction

review checklist*

QA Manager Signand return

procedure to PG

Send approvedprocedure to PDC

for issuance.

Incorporateeditorial changes

PG Submits forMOC approval

Route for QAchecklist

signatures. (PerGPP-QA-207).

Incorporateeditorial changes

FM Approves?

Print final versionfor signature

Maintain non-record copy of

approvedprocedure

Editorialchanges?

QA Mgt App. Criteria-Rev. 0-QAM

QA Concurs?

Editorialchanges?

Start approvalprocess

Additionalconstructionreviewers?

Complete checklistand sign*

procedure asapplicable. Returnprocedure to PG

Editorialchanges?

FM Signs andreturns to PG

QAManagersignaturerequired?

Concur?

Incorporateeditorial changes

QA ManagerConcurs?

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 ProcedureStandard structureClearer definitionsInclude attributes of an adequate procedure

– Better flowdown and change management

– Evaluation/revision of AB/QAM affecting proceduresThree-phased approach; Phase I nearing completion

• Revised organization to centralize support to standardized process and procedures

• Revised project schedule

• Construction Safety Alliance

• Motivational off-site team building and alignment

• Improved long range planning and scheduling

• Monthly all employee meetings

• Safety Rallies

• April 2006 Front line supervisor NSQI/HPI

• Crucial conversations

• Procedural adequacy surveys

• Cross-functional 360° procedure review process

• VPP Steering Committee

• VPP Application Process

Engineering

Construction • Established NSQI expectation at new hire orientation by manager of Construction

• Safety Leadership Development Training

–Communications

–Planning

–Trending/Forecasting

–Motivation

• Cross-functional team develop approach to training (Systematic Approach to Training) (20)

• Identify positions and schedule for job analysis (34)

• Analyze positions, develop and deliver training per SAT

• Establish Training Advisory Board (35)

• Create Training Implementation Matrix per DOE 0rder 5480.20A (36)

• Revise training procedures per systematic approach (37)

• Issue Training Program Plan per schedule (38)

Project- Wide • Develop Centralized Issues Tracking System (PIERs) (2)

• Revise Management Assessment Procedure

• Provide training to managers regarding behaviors to achieve a Safety Conscious Work Environment attitude (4)

• Conduct management alignment sessions (5)

• Management briefing sessions (6)

• Conduct Management Behavioral Gap Analysis (9)

• Conduct WTP All Hands Meeting (7)

• Conduct one-hour NSQI stand-down sessions (11)

• Conduct quiz on management expectations (12)

• Revise annual HGET training to include NSQI module (13)

• Establish new hire expectations at new hire orientation by senior project management (14)

• Develop website for anonymous questions (15)

• Implement Human Performance (16)

• Develop communication strategy (17)

• Conduct employee survey (19)

• Identify actions from survey results (33)

• Develop Differing Professional Opinion program

• Recognizing and rewarding desired employee behaviors

• Cross-functional team develop approach to address procedure adequacy (21)

• Baseline procedure format and content to Savannah River Site

• Revise Document Administration procedure to increase clarity (22)

• Identify set of procedures which will undergo review for clarification and revision if necessary (23)

• Revise Phase 1 procedures (24-28)

• Establish database to track requirement flowdown through procedures (31)

• Establish method to hyperlink procedures (32)

• Direct link to procedures from homepage (30)

• Procedure writers attend Human Performance training (29)

• Rapid procedure change process

Oversight & Assessment

Training

• Assign NSQI Project Manager (3)• Develop business case for procedure compliance (8)

ProceduresBehavior

Nuclear Safety and Quality Imperative

• Balancing Safety, Quality, Cost, and Schedule

• Communication and Feedback

• Management Oversight & Assessment

• Verification and Approval of Work Activities

• Quality Improvement

• Adequacy of Procedures

• Procedure Adherence

• Training Personnel to Execute Procedures

• Consolidated engineering organization

– Central technical leadership and design production

– Co-located expertise

– Common equipment groups

– One-stop assessment, feedback, and corrective action

– Consolidated checking and verification functions

– Cross-discipline design support organization for issue tracking, analysis, and improvement actions

– Improved integration of planning tools and resources

• Engineering Quality Analysis tool, monthly updates, action plans

• Revised off-project review procedure

• Process Assurance and E&NS sponsored assessments, including safety envelope and procedural conformance

• Requirements verification process integrated with system description development

• Outside review of key technical risk areas

• Revised project schedule

– Increased durations to support construction and procurement

– Improved sequencing and logical ties of engineering discipline activities

– Improved durations to resolve open technical risk issues

• NSQI communications

– Monthly Engineering Quality presentation on NSQI attributes to all hands

• Engineering leadership off-site sessions regarding NSQI implementation

• Integration of quality goals in management annual performance reviews

• Incorporation of INPO error precursors and HPI principles into CAR follow-up

• Engineering safety envelope stand-down and personal commitment statements

• Engineering Guide for Augmented Monitoring of New Employees/ Employees with New Assignments

• Discipline-specific coaching

– codes and standards

– design tools

– work process requirements

– feedback from surveillances and corrective actions

– feedback from technical and compliance checklists

• Revised training matrices based on current production deliverables

• Technical completeness checklists in key production areas

• Formal safety envelope training and knowledge check

• PSAR update - training and review

• Additional staff training and utilization in Root Cause Analysis

• Procedure compliance actions

– Compliance checklists/metrics (18)

– Improved procedure change processes

– Procedure compliance statements

– New employee orientation regarding expectations

– WTP document hierarchy clarified and published

• Procedure adequacy actions– Clarification of top-level

requirements in procedures– Review of Engineering Guides for

mandatory requirements – Discipline action on compliance

checklist metrics• Additional specific actions

– Engineering Material Coordinator Guide revised (1)

– Equipment database quality metrics and ongoing screening of tagged components

– Additional E&NS reviews and safety screen signature added to design documents

– Improved implementation feedback for safety envelope and design criteria changes

• Advisory Board• Confirmatory Analysis

Bold and italicized items indicate Compensatory Actions

20

Characteristic Selection MatrixResults

0%

5%

10%

15%

20%

25%

30%

35%

Ful

l SA

T

Exi

stin

g +

Som

eS

AT

Exi

stin

g +

Dem

onst

rate

com

pete

ncy

and

supe

rvis

or v

erify

by

sign

atur

e in

divi

dual

is q

ualif

ied.

Exi

stin

g Tr

aini

ngP

rogr

am

Input CharacteristicC

ha

rac

teri

sti

c Im

po

rta

nc

e (

%)

WTP Training

DesignPosition Analysis DevelopAnalyze EvaluateImplement

Fun

ctio

nal

Org

aniz

atio

nT

rain

ing

w/ F

unct

iona

l SM

E

STARTContact Trainingfor Job Analysis

New positionidentified?

Schedule JobAnalysis with

FunctionalOrganization

EvaluateFunctional Areas /

Positions usingcriteria to

determine if SATrequired

Meet SATCriteria?

Identify and listduties of a job

Yes

Meet GradedSAT Criteria?

Perform GradedSAT

Yes

No FurtherAssessment

No

Determine trainingrequirements forposition based on

experience &knowledge of

manager

Characterize tasksby difficulty,

importance, andfrequency

Determineappropriate

training(classroom, CBT,

reading)

Identify theknowledge andskills of future

students

Documentdetermination and

justification

Determine whatstudent will learnin class & how

learning willtransfer to job

(LearningObjectives)

Evaluate trainingeffectiveness on

the job

Material is taughtto students

Evaluateeffectiveness of

the program

End

Develop anexamination plan

to test competency

Determine whatwill be taught and

instructionalmethods

Studentcompetency is

assessed

Identifyimprovements for

the course

Determine howcompetency will be

demonstrated

Approve CourseDesign

Turn trainingdesign into training

material

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

• Revised organization to centralize support to standardized process and procedures

• Revised project schedule

• Construction Safety Alliance

• Motivational off-site team building and alignment

• Improved long range planning and scheduling

• Monthly all employee meetings

• Safety Rallies

• April 2006 Front line supervisor NSQI/HPI

• Crucial conversations

• Procedural adequacy surveys

• Cross-functional 360° procedure review process

• VPP Steering Committee

• VPP Application Process

Engineering

Construction • Established NSQI expectation at new hire orientation by manager of Construction

• Safety Leadership Development Training

–Communications

–Planning

–Trending/Forecasting

–Motivation

• Cross-functional team develop approach to training (Systematic Approach to Training) (20)

• Identify positions and schedule for job analysis (34)

• Analyze positions, develop and deliver training per SAT

• Establish Training Advisory Board (35)

• Create Training Implementation Matrix per DOE 0rder 5480.20A (36)

• Revise training procedures per systematic approach (37)

• Issue Training Program Plan per schedule (38)

Project- Wide • Develop Centralized Issues Tracking System (PIERs) (2)

• Revise Management Assessment Procedure

• Provide training to managers regarding behaviors to achieve a Safety Conscious Work Environment attitude (4)

• Conduct management alignment sessions (5)

• Management briefing sessions (6)

• Conduct Management Behavioral Gap Analysis (9)

• Conduct WTP All Hands Meeting (7)

• Conduct one-hour NSQI stand-down sessions (11)

• Conduct quiz on management expectations (12)

• Revise annual HGET training to include NSQI module (13)

• Establish new hire expectations at new hire orientation by senior project management (14)

• Develop website for anonymous questions (15)

• Implement Human Performance (16)

• Develop communication strategy (17)

• Conduct employee survey (19)

• Identify actions from survey results (33)

• Develop Differing Professional Opinion program

• Recognizing and rewarding desired employee behaviors

• Cross-functional team develop approach to address procedure adequacy (21)

• Baseline procedure format and content to Savannah River Site

• Revise Document Administration procedure to increase clarity (22)

• Identify set of procedures which will undergo review for clarification and revision if necessary (23)

• Revise Phase 1 procedures (24-28)

• Establish database to track requirement flowdown through procedures (31)

• Establish method to hyperlink procedures (32)

• Direct link to procedures from homepage (30)

• Procedure writers attend Human Performance training (29)

• Rapid procedure change process

Oversight & Assessment

Training

• Assign NSQI Project Manager (3)• Develop business case for procedure compliance (8)

ProceduresBehavior

Nuclear Safety and Quality Imperative

• Balancing Safety, Quality, Cost, and Schedule

• Communication and Feedback

• Management Oversight & Assessment

• Verification and Approval of Work Activities

• Quality Improvement

• Adequacy of Procedures

• Procedure Adherence

• Training Personnel to Execute Procedures

• Consolidated engineering organization

– Central technical leadership and design production

– Co-located expertise

– Common equipment groups

– One-stop assessment, feedback, and corrective action

– Consolidated checking and verification functions

– Cross-discipline design support organization for issue tracking, analysis, and improvement actions

– Improved integration of planning tools and resources

• Engineering Quality Analysis tool, monthly updates, action plans

• Revised off-project review procedure

• Process Assurance and E&NS sponsored assessments, including safety envelope and procedural conformance

• Requirements verification process integrated with system description development

• Outside review of key technical risk areas

• Revised project schedule

– Increased durations to support construction and procurement

– Improved sequencing and logical ties of engineering discipline activities

– Improved durations to resolve open technical risk issues

• NSQI communications

– Monthly Engineering Quality presentation on NSQI attributes to all hands

• Engineering leadership off-site sessions regarding NSQI implementation

• Integration of quality goals in management annual performance reviews

• Incorporation of INPO error precursors and HPI principles into CAR follow-up

• Engineering safety envelope stand-down and personal commitment statements

• Engineering Guide for Augmented Monitoring of New Employees/ Employees with New Assignments

• Discipline-specific coaching

– codes and standards

– design tools

– work process requirements

– feedback from surveillances and corrective actions

– feedback from technical and compliance checklists

• Revised training matrices based on current production deliverables

• Technical completeness checklists in key production areas

• Formal safety envelope training and knowledge check

• PSAR update - training and review

• Additional staff training and utilization in Root Cause Analysis

• Procedure compliance actions

– Compliance checklists/metrics (18)

– Improved procedure change processes

– Procedure compliance statements

– New employee orientation regarding expectations

– WTP document hierarchy clarified and published

• Procedure adequacy actions– Clarification of top-level

requirements in procedures– Review of Engineering Guides for

mandatory requirements – Discipline action on compliance

checklist metrics• Additional specific actions

– Engineering Material Coordinator Guide revised (1)

– Equipment database quality metrics and ongoing screening of tagged components

– Additional E&NS reviews and safety screen signature added to design documents

– Improved implementation feedback for safety envelope and design criteria changes

• Advisory Board• Confirmatory Analysis

Bold and italicized items indicate Compensatory Actions

23

Oversight & Assessment

Training ProceduresBehavior

• Balancing Safety, Quality, Cost, and Schedule

• Communication and Feedback

• Management Oversight & Assessment

• Verification and Approval of Work Activities

• Quality Improvement

• Adequacy of Procedures

• Procedure Adherence

• Training Personnel to Execute Procedures

• Consolidated engineering organization

– Central technical leadership and design production

– Co-located expertise

– Common equipment groups

– One-stop assessment, feedback, and corrective action

– Consolidated checking and verification functions

– Cross-discipline design support organization for issue tracking, analysis, and improvement actions

– Improved integration of planning tools and resources

• Engineering Quality Analysis tool, monthly updates, action plans

• Revised off-project review procedure

• Process Assurance and E&NS sponsored assessments, including safety envelope and procedural conformance

• Requirements verification process integrated with system description development

• Outside review of key technical risk areas

• Revised project schedule

– Increased durations to support construction and procurement

– Improved sequencing and logic ties of engineering discipline activities

– Improved durations to resolve open technical risk issues

• NSQI communications

– Monthly Engineering Quality presentation on NSQI attributes to all hands

• Engineering leadership off-site sessions regarding NSQI implementation

• Integration of quality goals in management annual performance reviews

• Incorporation of INPO error precursors and HPI principles into CAR follow-up

• Engineering safety envelope stand-down and personal commitment statements

• Augmented Monitoring of New Employees/ Employees with New Assignments

• Discipline-specific coaching

– codes and standards

– design tools

– work process requirements

– feedback from surveillances and corrective actions

– feedback from technical and compliance checklists

• Revised training matrices based on current production deliverables

• Technical completeness checklists in key production areas

• Formal safety envelope training and knowledge check

• PSAR update - training and review

• Additional staff training and utilization in Root Cause Analysis

• Procedure compliance actions

– Compliance checklists/metrics (18)

– Improved procedure change processes

– Procedure compliance statements

– New employee orientation regarding expectations

– WTP document hierarchy clarified and published

• Procedure adequacy actions– Clarification of top-level

requirements in procedures– Review of Engineering Guides for

mandatory requirements – Discipline action on compliance

checklist metrics• Additional specific actions

– Engineering Material Coordinator Guide revised (1)

– Equipment database quality metrics and ongoing screening of tagged components

– Additional E&NS reviews and safety screen signature added to design documents

– Improved implementation feedback for safety envelope and design criteria changes

• Revised organization to centralize support to standardized process and procedures

• Revised project schedule

• Construction Safety Alliance

• Motivational off-site team building and alignment

• Improved long range planning and scheduling

• Monthly all employee meetings

• Safety Rallies

• April 2006 Front line supervisor NSQI/HPI

• Crucial conversations

• Procedural adequacy surveys

• Cross-functional 360° procedure review process

• VPP Steering Committee

• VPP Application Process

Engineering

Construction • Established NSQI expectation at new hire orientation by manager of Construction

• Safety Leadership Development Training

–Communications

–Planning

–Trending/Forecasting

–Motivation

• Cross-functional team develop approach to training (Systematic Approach to Training) (20)

• Identify positions and schedule for job analysis (34)

• Analyze positions, develop and deliver training per SAT

• Establish Training Advisory Board (35)

• Create Training Implementation Matrix per DOE 0rder 5480.20A (36)

• Revise training procedures per systematic approach (37)

• Issue Training Program Plan per schedule (38)

Project- Wide • Develop Centralized Issues Tracking System (PIERs) (2)

• Revise Management Assessment Procedure

• Provide training to managers regarding behaviors to achieve a Safety Conscious Work Environment attitude (4)

• Conduct management alignment sessions (5)

• Management briefing sessions (6)

• Conduct Management Behavioral Gap Analysis (9)

• Conduct WTP All Hands Meeting (7)

• Conduct one-hour NSQI stand-down sessions (11)

• Conduct quiz on management expectations (12)

• Revise annual HGET training to include NSQI module (13)

• Establish new hire expectations at new hire orientation by senior project management (14)

• Develop website for anonymous questions (15)

• Implement Human Performance (16)

• Develop communication strategy (17)

• Conduct employee survey (19)

• Identify actions from survey results (33)

• Develop Differing Professional Opinion program

• Recognizing and rewarding desired employee behaviors

• Cross-functional team develop approach to address procedure adequacy (21)

• Baseline procedure format and content to Savannah River Site

• Revise Document Administration procedure to increase clarity (22)

• Identify set of procedures which will undergo review for clarification and revision if necessary (23)

• Revise Phase 1 procedures (24-28)

• Establish database to track requirement flowdown through procedures (31)

• Establish method to hyperlink procedures (32)

• Direct link to procedures from homepage (30)

• Procedure writers attend Human Performance training (29)

• Rapid procedure change process

Oversight & Assessment

Training

• Assign NSQI Project Manager (3)• Develop business case for procedure compliance (8)

ProceduresBehavior

Nuclear Safety and Quality Imperative

• Balancing Safety, Quality, Cost, and Schedule

• Communication and Feedback

• Management Oversight & Assessment

• Verification and Approval of Work Activities

• Quality Improvement

• Adequacy of Procedures

• Procedure Adherence

• Training Personnel to Execute Procedures

• Consolidated engineering organization

– Central technical leadership and design production

– Co-located expertise

– Common equipment groups

– One-stop assessment, feedback, and corrective action

– Consolidated checking and verification functions

– Cross-discipline design support organization for issue tracking, analysis, and improvement actions

– Improved integration of planning tools and resources

• Engineering Quality Analysis tool, monthly updates, action plans

• Revised off-project review procedure

• Process Assurance and E&NS sponsored assessments, including safety envelope and procedural conformance

• Requirements verification process integrated with system description development

• Outside review of key technical risk areas

• Revised project schedule

– Increased durations to support construction and procurement

– Improved sequencing and logical ties of engineering discipline activities

– Improved durations to resolve open technical risk issues

• NSQI communications

– Monthly Engineering Quality presentation on NSQI attributes to all hands

• Engineering leadership off-site sessions regarding NSQI implementation

• Integration of quality goals in management annual performance reviews

• Incorporation of INPO error precursors and HPI principles into CAR follow-up

• Engineering safety envelope stand-down and personal commitment statements

• Engineering Guide for Augmented Monitoring of New Employees/ Employees with New Assignments

• Discipline-specific coaching

– codes and standards

– design tools

– work process requirements

– feedback from surveillances and corrective actions

– feedback from technical and compliance checklists

• Revised training matrices based on current production deliverables

• Technical completeness checklists in key production areas

• Formal safety envelope training and knowledge check

• PSAR update - training and review

• Additional staff training and utilization in Root Cause Analysis

• Procedure compliance actions

– Compliance checklists/metrics (18)

– Improved procedure change processes

– Procedure compliance statements

– New employee orientation regarding expectations

– WTP document hierarchy clarified and published

• Procedure adequacy actions– Clarification of top-level

requirements in procedures– Review of Engineering Guides for

mandatory requirements – Discipline action on compliance

checklist metrics• Additional specific actions

– Engineering Material Coordinator Guide revised (1)

– Equipment database quality metrics and ongoing screening of tagged components

– Additional E&NS reviews and safety screen signature added to design documents

– Improved implementation feedback for safety envelope and design criteria changes

• Advisory Board• Confirmatory Analysis

Bold and italicized items indicate Compensatory Actions

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

• Revised organization to centralize support to standardized process and procedures

• Revised project schedule

• Construction Safety Alliance

• Motivational off-site team building and alignment

• Improved long range planning and scheduling

• Monthly all employee meetings

• Safety Rallies

• April 2006 Front line supervisor NSQI/HPI

• Crucial conversations

• Procedural adequacy surveys

• Cross-functional 360° procedure review process

• VPP Steering Committee

• VPP Application Process

• Established NSQI expectation at new hire orientation by manager of Construction

• Safety Leadership Development Training

–Communications

–Planning

–Trending/Forecasting

–Motivation

Oversight & Assessment

Training ProceduresBehavior

Nuclear Safety and Quality Imperative

• Balancing Safety, Quality, Cost, and Schedule

• Communication and Feedback

• Management Oversight & Assessment

• Verification and Approval of Work Activities

• Quality Improvement

• Adequacy of Procedures

• Procedure Adherence

• Training Personnel to Execute Procedures

• Revised organization to centralize support to standardized process and procedures

• Revised project schedule

• Construction Safety Alliance

• Motivational off-site team building and alignment

• Improved long range planning and scheduling

• Monthly all employee meetings

• Safety Rallies

• April 2006 Front line supervisor NSQI/HPI

• Crucial conversations

• Procedural adequacy surveys

• Cross-functional 360° procedure review process

• VPP Steering Committee

• VPP Application Process

Engineering

Construction • Established NSQI expectation at new hire orientation by manager of Construction

• Safety Leadership Development Training

–Communications

–Planning

–Trending/Forecasting

–Motivation

• Cross-functional team develop approach to training (Systematic Approach to Training) (20)

• Identify positions and schedule for job analysis (34)

• Analyze positions, develop and deliver training per SAT

• Establish Training Advisory Board (35)

• Create Training Implementation Matrix per DOE 0rder 5480.20A (36)

• Revise training procedures per systematic approach (37)

• Issue Training Program Plan per schedule (38)

Project- Wide • Develop Centralized Issues Tracking System (PIERs) (2)

• Revise Management Assessment Procedure

• Provide training to managers regarding behaviors to achieve a Safety Conscious Work Environment attitude (4)

• Conduct management alignment sessions (5)

• Management briefing sessions (6)

• Conduct Management Behavioral Gap Analysis (9)

• Conduct WTP All Hands Meeting (7)

• Conduct one-hour NSQI stand-down sessions (11)

• Conduct quiz on management expectations (12)

• Revise annual HGET training to include NSQI module (13)

• Establish new hire expectations at new hire orientation by senior project management (14)

• Develop website for anonymous questions (15)

• Implement Human Performance (16)

• Develop communication strategy (17)

• Conduct employee survey (19)

• Identify actions from survey results (33)

• Develop Differing Professional Opinion program

• Recognizing and rewarding desired employee behaviors

• Cross-functional team develop approach to address procedure adequacy (21)

• Baseline procedure format and content to Savannah River Site

• Revise Document Administration procedure to increase clarity (22)

• Identify set of procedures which will undergo review for clarification and revision if necessary (23)

• Revise Phase 1 procedures (24-28)

• Establish database to track requirement flowdown through procedures (31)

• Establish method to hyperlink procedures (32)

• Direct link to procedures from homepage (30)

• Procedure writers attend Human Performance training (29)

• Rapid procedure change process

Oversight & Assessment

Training

• Assign NSQI Project Manager (3)• Develop business case for procedure compliance (8)

ProceduresBehavior

Nuclear Safety and Quality Imperative

• Balancing Safety, Quality, Cost, and Schedule

• Communication and Feedback

• Management Oversight & Assessment

• Verification and Approval of Work Activities

• Quality Improvement

• Adequacy of Procedures

• Procedure Adherence

• Training Personnel to Execute Procedures

• Consolidated engineering organization

– Central technical leadership and design production

– Co-located expertise

– Common equipment groups

– One-stop assessment, feedback, and corrective action

– Consolidated checking and verification functions

– Cross-discipline design support organization for issue tracking, analysis, and improvement actions

– Improved integration of planning tools and resources

• Engineering Quality Analysis tool, monthly updates, action plans

• Revised off-project review procedure

• Process Assurance and E&NS sponsored assessments, including safety envelope and procedural conformance

• Requirements verification process integrated with system description development

• Outside review of key technical risk areas

• Revised project schedule

– Increased durations to support construction and procurement

– Improved sequencing and logical ties of engineering discipline activities

– Improved durations to resolve open technical risk issues

• NSQI communications

– Monthly Engineering Quality presentation on NSQI attributes to all hands

• Engineering leadership off-site sessions regarding NSQI implementation

• Integration of quality goals in management annual performance reviews

• Incorporation of INPO error precursors and HPI principles into CAR follow-up

• Engineering safety envelope stand-down and personal commitment statements

• Engineering Guide for Augmented Monitoring of New Employees/ Employees with New Assignments

• Discipline-specific coaching

– codes and standards

– design tools

– work process requirements

– feedback from surveillances and corrective actions

– feedback from technical and compliance checklists

• Revised training matrices based on current production deliverables

• Technical completeness checklists in key production areas

• Formal safety envelope training and knowledge check

• PSAR update - training and review

• Additional staff training and utilization in Root Cause Analysis

• Procedure compliance actions

– Compliance checklists/metrics (18)

– Improved procedure change processes

– Procedure compliance statements

– New employee orientation regarding expectations

– WTP document hierarchy clarified and published

• Procedure adequacy actions– Clarification of top-level

requirements in procedures– Review of Engineering Guides for

mandatory requirements – Discipline action on compliance

checklist metrics• Additional specific actions

– Engineering Material Coordinator Guide revised (1)

– Equipment database quality metrics and ongoing screening of tagged components

– Additional E&NS reviews and safety screen signature added to design documents

– Improved implementation feedback for safety envelope and design criteria changes

• Advisory Board• Confirmatory Analysis

Bold and italicized items indicate Compensatory Actions

Construction ActionsChanging 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

How do we measure culture?

Continue to shift issue identification to originatorContinue to shift issue identification to originator

Reduce significance

ResponsibleIndividual

Functional Identification

(self assessment)

Quality Assurance

Identification(audit/

assessment)

DOE FindingOther External

Agency Findings