ISMS Best Practices Workshop
Just Culture Panel Workshop
Hanford ContractorsDOE Office of River Protection
DOE Richland Operations Office
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ISMS Best Practices Workshop
Just Culture Definition
• Definition: An environment that clearly defines acceptable behavior and recognizes human potential for error in a consistent manner
• Attributes:▪ Recognition of fairness related to the identification
and resolution of human performance problems▪ Distinction between honest mistakes and intentional
shortcuts with respect to discipline▪ Free flow of plant information across all levels of an
organization▪ High level of self-reporting
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ISMS Best Practices Workshop
Just Culture Background
• EPRI study on power plant leading indicators of human performance identified 7 themes▪ Executive commitment▪ Awareness of hazards▪ Preparedness for errors and events▪ Flexibility to meet operational demands▪ Just culture ▪ Learning culture▪ System opacity
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ISMS Best Practices Workshop
Organizational Elements Related to Just Culture
• Organizational Attributes▪ Trust, respect, and fairness▪ Communication that can affect performance highly valued▪ Management communication and reinforcement of desired behaviors
• Process Contributors▪ Processes eliminate human performance weaknesses▪ Procedure deficiencies promptly corrected▪ Root cause analysis identifies organizational process, and individual
contributors to human performance events• Individual Values and Behaviors
▪ Deficiencies and suggested improvements are promptly reported and openly evaluated
▪ Personnel use questioning attitude and don’t proceed in face of uncertainty
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ISMS Best Practices Workshop
Why is Just Culture Important?
• Encourages participation at all levels of an organization in the identification of problems and continuous improvement
• Minimizes the probability of an event with consequences by maximizing organizational awareness of non consequential problems
• Promotes a learning culture and honest investigation of true weaknesses
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ISMS Best Practices Workshop
What Do Contractors Need From DOE Foster a Learning Environment
Avoid judgment, blame, & punishment for non-consequential events if right actions are being taken to address the issue. Introduce the analog of culpability matrix
Recognize errors will occur in implementation of 10 CFR 851. PAAA and 851 enforcement approach inhibits, rather than encourages reporting
Positively reinforce right preventive actionsRecognize and Promote reporting Recognize & Promote HPI Concepts of Identifying Error-
Likely Situations & Strengthening DefensesFocus on Lessons Learned Rather than Number of
Errors. Rationalize approach to recurrenceSPC => Every process has defectsSuccess lies in changing frequency and severity
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ISMS Best Practices Workshop
What Do Workers Need in a Just Culture• Trust - What’s Said Gets Done by Management• Respect for the Individual• Zero tolerance for HIRD • Worker involvement in ISMS• A Belief that Discipline is Fairly Administered• Use of coaching process• Respect for the Labor Contract• Multiple Avenues to Communicate• Worker participation in event investigations• Confidence in broader organizational cause
investigations
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ISMS Best Practices Workshop
What the Field Needs from HQ
• Focus on Setting DOE policy and high level expectations• Identify HQ, Field, and contractor R2A2 and work to
drive consistent performance• Establish consistent corporate metrics that draw from
established sources (e.g. ORPS, CAIRS, ORPS performance analysis) to monitor performance
• Resist the need for instant identification of root causes, consequences, and final actions for events
• Allow Field to address inconsequential events and precursors
• Recognize Field office attempts to foster self-reporting of lower level events without punishing for increased volume of minor events
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ISMS Best Practices Workshop
What HQ can do to fosterJust Culture
• Continue to support and sponsor HPI across the complex
• Identify and Celebrate success
• Incorporate HPI into the Corporate Performance Metrics (e.g. Discovery Clock)
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ISMS Best Practices Workshop
What is RL Doing?
• Developed a joint HPI Strategic Plan• Training Key RL staff on HPI Principles (36 for 8 hr
and 7 for 4-day course through 7/7/06)• Striving to celebrate performance (e.g. HEC R
response, SWSD safety day, others…)• Consideration of HPI aspects in contract actions• Direct communication of RL perspective on key
performance areas (HEC, elec, near miss)• RL acceptance of non-traditional corrective actions
to strengthen barriers/defenses to address latent organizational weaknesses
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ISMS Best Practices Workshop
What is ORP Doing?
• Developing a safety conscious work environment for all personnel (Feds and Contractors)
• HPI Training for Fed Staff (all in ORP will be trainied in 8 hr and about 40% in 4 day)
• Encouraging Contractor implementation of HPI principles• Promoting VPP to our Contractors• Encouraging personnel (Fed & Contractor personnel) to
report at below event levels so lessons can be learned without the cost of an event
• Using HPI tools to investigate events
ISMS Best Practices Workshop
Just Culture Panel Workshop – Hanford Experience
CH2M HILL Hanford Group, Inc.
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ISMS Best Practices Workshop
Our ISMS strategy is based on an open work Our ISMS strategy is based on an open work environment where everyone feels free to raise environment where everyone feels free to raise
issues without fear of HIRDissues without fear of HIRD
ISMS at CH2M HILL
Event Prevention
Employee involvement
Problem identification and
resolution
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ISMS Best Practices Workshop
CH2M Prime
Contractor
1999 2000 2001 2002 2003 2004 2005 2006
Tank Farm Acceleration
StrategyProblem
Evaluation Report System ESTARS
Integrated Mission
Acceleration Plan (IMAP)
Vapor Issues
Organi-zational
Readiness
Safe Work Environment
(SWE) Culture
Assessment
Released Sub-
Contracted Staff
Augmentation
Mandatory Respirator Usage in
FarmsISMS/
CONOPS Improvement
Training
ISMS Expectations
4/15/05
Vapor Resolution
WFO VPP Star Status
Human Performance Improvement
Training
Management Changes
Integration of SWE, ISMS &
HPI
Follow-up SWE Survey
GAP
CH2M HILL Improvement Cycle
Accident Injury Rate
PIP Addressing OA Vapor
Issues
A-Prefix Farms –
Mask Cessation
244-CR Vault Event
7/22/04
CAP Completed for 244-CR
Event
Project Delivery System
Mission Alignment Process (MAP)
SWE Mentoring
Involuntary Reduction of
Force
ISMS PIP
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ISMS Best Practices Workshop
CH2M HILL ECP Requests
2002 2003 2004 2005 2006
Number ECPRequests
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ISMS Best Practices Workshop
Frequency of PER Initiations
0
100
200
300
400
500
600
700
800M
ay
-01
Ma
y-0
2
Ma
y-0
3
Ma
y-0
4
Ma
y-0
5
Ma
y-0
6
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ISMS Best Practices Workshop
5 Year DART and Recordable Injury Rates
DART RatesFive Year Summary
3.64
2.82
0.11
1.83
1.02
0.0
1.0
2.0
3.0
4.0
5.0
Cas
es/2
00,0
00 H
rs
Recordable RatesFive Year Summary
3.08
5.39
3.78
1.54
3.14
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
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ISMS Best Practices Workshop
Conduct of Operations Index Frequency
0
10
20
30
40
50
60
70
80
90
100
A) Skin and clothing Contaminations 8 8 2 2 0
B) Procedure Not Folllowed 11 2 0 0 0
C) Procedure Problem 15 3 8 3 2
D) Training Issues 3 2 1 1 0
E) Management Issues 40 19 12 7 5
F) Lockout/Tagout 5 1 1 0 1
G) Work Control Issues 9 11 7 2 1
FY2002 FY2003 FY2004 FY2005 FY2006 (Year to date)
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ISMS Best Practices Workshop
CH2M HILL Actions Taken to Implement Just Culture
• Alternative avenues expanded – more union safety representatives; Hanford concerns council
• All employee surveys conducted• Improved IROF process communication and fairness• Cause analysis process changed to identify
organizational contributors to human performance events
• Single, web based problem identification process • Trust, respect, and fairness expectations issued• HPI Training conducted• Discipline process revised to improve fair treatment
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ISMS Best Practices Workshop
2004 Employee Survey Process Improvement Issues
• Accountability Issues▪ Improve consistency in holding everyone
accountable for their behavior▪ Improve fairness and consistency of
disciplinary process▪ Improve timeliness of disciplinary process
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ISMS Best Practices Workshop
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ISMS Best Practices Workshop
Comparison of Disciplinary Actions by Employee Group
2003 2004 2005
Non Exempt 1 (3%) 0 2 (5%)
Exempt 8 (27%) 6 (29%) 20 (45%)
Bargaining Unit 21 (70%) 15 (71%) 22 (50%)
Total 30 21 44
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ISMS Best Practices Workshop
Response Time From Event to Review
Discplinary Action Response Time
3629
19
0
10
20
30
40
2003 2004 2005
DaysDays
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ISMS Best Practices Workshop
99% of respondents say they will take action if potentially unsafe conditions, work practices, or products are seen
99 100
2005 HILL All Employee Survey
Question 10: Do you take action if you see potentially unsafe
conditions, work practices, or products?
98
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ISMS Best Practices Workshop
ISM Best Practice WorkshopAurora, CO
Sept 12-13, 2006
Safety Excellence-Creating a Just Culture
Fluor Hanford Inc.
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ISMS Best Practices WorkshopSafety Excellence-Just Culture
How’s Fluor Hanford Promoting a Just Culture
• Path to a Just Culture began in August 1996▪ Fluor’s Zero Accident Program
• Provided a Firm belief that Injuries are not the cost of progress.
▪ Presidents’ & Employee Zero Accident Councils• Provided voice in program & ownership of work area
▪ HAMTC Safety Rep. Program• Provided the Communication, Built Trust, Win-Win• STOP Work Responsibility
▪ Pursuit of VPP• The avenue to worker involvement in work planning & execution.
▪ ISMS• Standardized the process & program• Provided a consistent process for projects & workers
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ISMS Best Practices Workshop
Safety Excellence-Just Culture Furthering the Fluor Hanford Culture
• Continuing to Build on Union Safety Reps. , EZACs & VPP• Initiating Human Performance Improvement
▪ Over 700 trained in HPI Fundamentals▪ 40 HPI Practitioners Trained to Implement at Project Level▪ Learning that Errors will happen, and building defenses to mitigate
consequences.• Investigating Incidents using HPI techniques
▪ Looking deeper into the organization for errors & conditions▪ Greater chance of fixing more than just the immediate event
• Integrating Culpability Matrix into decisions on discipline ▪ Understanding better why good people make mistakes▪ Removing the latitude of poor performers to hide in the organization
• Focusing on Early Conflict Resolution• Supervisor Leadership Training on Mediation• Trained Intervention Mentors• Outside Consultants As Necessary
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ISMS Best Practices WorkshopCulpability Evaluation Flowchart
Were actions as intended?
Knowingly violate expectation?
Pass substitution test?
(see note)
History of human performance problems?
Were expectations reasonable, available, workable, intelligible,
and correct?
Were the consequences
intended?
Deficiencies in training and selection or inexperience?
Self-Reported
Organization induced violation
System induced
error
Blameless error
Intentional act (not an
error)
Corrective training or
other intervention
may be warranted
Possible reckless violation
Possible negligent
error
No
Yes Yes
Yes Yes Yes Yes
No
No No Yes
Note: Would other employees have made the same error?
Evaluate organizational processes and management/supervisory methods
No No
No
No Yes
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ISMS Best Practices Workshop
Safety Excellence – Just CultureFluor Hanford Results
• Metrics Tell the Story▪ VPP Culture Survey Chart▪ Employee Safety Concern Chart▪ Total Injury Rate Chart▪ Number of Safety Related Grievances Chart
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ISMS Best Practices Workshop
Contacts
George Jackson, Executive Vice PresidentFluor Hanford(509) 372-1050 [email protected]
Tony Umek, Vice President Safety & Health (509)373-5983 [email protected]
Dave Jackson, Deputy Vice President Safety & Health (509)376-0082 [email protected]
John Jeskey, HAMTC Safety Rep DirectorFluor Hanford(509) 396-1009 [email protected]
P.O. Box 1000 H8-67, Richland, WA 99352
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ISMS Best Practices Workshop
River CorridorClosure Project
Safety • People • Results
U.S. Department of EnergyRichland Operations Office
HPI Just CultureWorkshop Panel On Hanford Experience
Phillip KeuhlenDirector, Safety, Health & Quality
September 12, 2006
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ISMS Best Practices Workshop
Achieving “Just Culture” During Transition To A New Contract
• Special situation:▪ Contract in public domain, often in public discussion,
before transition▪ New management = new means & methods▪ Uncertainty about future in work force▪ Rumors about intentions precede you
• WCH approached as part of establishing strong industrial and nuclear safety culture
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ISMS Best Practices Workshop
INPO Principles for a Strong Nuclear Safety Culture as a Blueprint
• Everyone is personally responsible for nuclear safety• Leaders demonstrate commitment to safety• Trust permeates the organization• Decision making reflects safety first• Nuclear technology is recognized as special and unique• A questioning attitude is cultivated• Organization learning is embraced• Nuclear safety undergoes constant examination
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ISMS Best Practices Workshop
How WCH Approached Development of a Just Culture (1)
• Embraced ISMS as the integrating umbrella• Instituted robust communication process
▪ Conveyed “Zero is the only goal” for employee injuries▪ Actively promoted “Time Out for Safety”▪ Management highly visible and approachable at work sites
• Trained FLS as the critical interface with the craft▪ How do we convey by our actions that people are our most
valuable resource?▪ Tools and exercises in FLS Leadership Workshop
• Incentivized safety performance for all employees
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ISMS Best Practices Workshop
How WCH Approached Development of a Just Culture (2)
• Instituted Local Safety Improvement Teams (LSIT)▪ Employee led (often by union stewards), management supported▪ Prompt action & feedback are key elements
• Strengthened HAMTC Safety Representative Program▪ Weekly drive builds mutual trust & confidence
• Built supporting processes▪ HPI event investigation▪ Culpability matrix considered in constructive discipline
• Cultivated employee leadership for pursuit of VPP
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ISMS Best Practices Workshop
WCH Metrics Indicate Just Culture is “Taking”
• Employee Concerns
• Grievances
• Safety Performance
ISMS Best Practices Workshop
Questions and Answers