performance improvement in a nuclear laboratory setting

Performance Improvement ina Nuclear Laboratory SettingPerformance Improvement ina Nuclear Laboratory Setting

Kathy Smith

Director, PINO

AECL, Chalk River Labs

2011 September

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Agenda

• What/who is AECL?? PINO?• The model• Corrective Action Program• Human Performance Program• Where are we going next?• Questions

AECL - OFFICIAL USE ONLY / À USAGE EXCLUSIF - EACL

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Atomic Energy of Canada Limited

• Established in 1952 to lead the Canadian nuclear industry.

• Over 4,900 employees located across many sites.

• CANDU recognized as one of the top 10 major engineering achievements of the past century in Canada.

• Currently undergoing a significant restructuring with a re-focus to a Science and Technology organization (Canada’s National Nuclear Lab).


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Key Chalk River Activities

1. Reactor Development

2. CRL Nuclear Operations

3. Research & Development

4. Isotope Production

5. Waste Management & Decommissioning


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Performance Improvement and Nuclear Oversight (PINO)

• Established as an organization in mid 2006• Key to continuous improvement • Built on the framework of the Operating Experience

Program• Provides insights to senior management on areas of

performance vulnerabilities• Supports the operating license requirements• Reports to the Senior VP through the GM for Programs

and Nuclear Oversight.


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PINO Organization

Dedicated team of auditors conduct performance based audits based on risk. Team provides oversight to the

team of advocates and supports the use of Error Precursor Tools (Event Free Tools – EFTs) across the labs.

Staff responsible for:• Corrective Action Program• Trending• Benchmarking• Sharing of OPEX/OE• Change Management


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Continuous Improvement Model N

um

ber

of

Even

ts Rules & procedures

Quality Management

Error Prevention - Human Performance

Quality Control

Quality Assurance

1960’s 1980’s 1990’s

Human Factors


8AECL - OFFICIAL USE ONLY / À USAGE EXCLUSIF - EACL

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The Corrective Action Program


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“ImpAct” is the name chosen for the problem identification and corrective action program in NL and comes from the words Improvement and Action.

ImpAct is a blameless program to capture information and take appropriate action to improve

performance and prevent occurrence/ recurrence of significant events.

ImpAct


• Correction Action Plan (CAP) program• Problems are identified and standardized• Individuals are assigned to correct problems• Trends are identified• Supports a strong reporting culture• Lessons learned are shared• Management oversight and engagement

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Why ImpAct?

ImpAct


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Problem Identification

Initial Review & Approval (FLM)

Remedial/ Compensatory

Actions

Management Review(MST and MRM)

Cause AnalysisCorrective

Actions

Verification & Effectiveness Review

(MRM/IRB)

“Problems” include events, non-conformances, issues, and

needs for improvement.

They can also be identified in assessments, audits and program

reviews.

ImpAct Process


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Improvement in Reporting Culture

0100020003000400050006000700080009000

10000

2006 2007 2008 2009 2010

# of

Eve

nt R

epor

ts

Year

Total # Event Reports (ENF + ImpAct) per year by SL

SL1

SL2

SL3

SL4

0%10%20%30%40%50%60%70%80%90%

2006 2007 2008 2009 2010

# o

f E

ven

t R

epo

rts

Year

Percent Event Reports (ENF + ImpAct) per year by SL

SL1

SL2

SL3

SL4


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Reporting Culture by SL of events

0

50

100

150

200

2006 2007 2008 2009 2010

To

tal

# o

f S

L1+

SL

2

Year

Reporting Culture - SL1 + SL2 Events

0

2000

4000

6000

8000

10000

12000

2006 2007 2008 2009 2010

To

tal

# o

f S

L3+

SL

4

Year

Reporting Culture - SL3 + SL 4 Events


ImpAct Process Health Report

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D&W

M

Eng

F&B

S

ISR

P/ P

NL

MP

F

NR

U

NFO

NFF

F

NO

Nuc

Pro

gsO

p Su

p

P&N

O

R&D

SLS

SM

SU

Wk

Mgt

Ove

rall

Last

Mon

th

Number of Days to First Management Oversight (Avg)

11 0 10 10 1 8 1 6 3 1 0 0 3 0 5 0 10 6 9

Number of Days to Process ImpAct (Avg)

59 12 22 223 140 313 345 207 432 115 101 80 62 293 148 108 220 196 199

ACA Timeliness (Avg Days) 99 136 361 110 148 99

Timely Completion of SL1 and SL2 Corrective Actions (% On Time)

0 0 66 100 75 0 62 36

Timely Completion of SL3 and SL4 Corrective Actions (% On Time)

45 75 100 100 100 14 0 66 5 73 0 87 82 66 14 100 30 27

Corrective action quality (% Graded Score)

100 88 88 0 83 63 100 50 100 0 100 69 33 100 25 74 89

ACA quality (% Graded Score) 80 94 95 96 86 100 90

Number of ImpActs Raised (Count)

127 63 52 25 36 78 20 15 5 176 60 42 100 13 89 3 10 914 785

Trend and OPEX ImpActs Raised (Count)

13 3 8 2 1 14 6 3 1 10 0 1 7 1 3 0 0 73 42

June Overall Percentage 62% 82% 89% 48% 83% 56% 67% 73% 45% 77% 47% 73% 89% 67% 67% 55% 35% 63%

May Overall Percentage 89% 82% 73% 46% 87% 50% 70% 48% 32% 70% 77% 69% 69% 47% 53% 70% 90% 53%


ImpAct Process Health Report Last 15 Months

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Month APR MAY JUN JUL AUG SEPT OCT NOV DEC JAN FEB MAR APR MAY JUNNumber of Days to First Management Oversight (Avg) 36 18 15 63 51 23 9 10 23 9 7 5 8 9 6Number of Days to Process ImpAct (Avg) 230 208 206 234 215 213 192 191 208 209 207 211 211 198 196ACA Timeliness (Avg Days) 170 227 175 267 174 112 99 116 148 102 97 114 84 99 148Timely Completion of SL1 and SL2 Corrective Actions (% On Time) 27 13 79 54 50 63 55 78 80 88 85 75 45 36 62Timely Completion of SL3 and SL4 Corrective Actions (% On Time) 24 48 45 26 28 27 28 29 44 45 28 30 26 27 30Corrective action quality (% Graded Score) 45 58 71 68 63 72 52 86 77 82 75 79 71 89 74ACA quality (% Graded Score) 75 79 93 82 88 86 82 93 86 90Number of ImpActs Raised (Count) 835 814 931 771 717 820 979 987 787 750 782 786 761 785 914Trend and OPEX ImpActs Raised (Count) 55 45 71 50 78 76 115 73 54 60 74 41 46 42 73

APR MAY JUN JUL AUG SEPT OCT NOV DEC JAN FEB MAR APR MAY JUN

IPHR TOTAL PERCENTAGE SCORE (%) 41% 45% 56% 43% 43% 46% 55% 61% 55% 63% 63% 64% 54% 53% 63%

2010/11 FY 2011/2012 FY

41% 45%56%

43% 43% 46%55%

61%55%

63% 63% 64%54% 53%

63%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

APR MAY JUN JUL AUG SEPT OCT NOV DEC JAN FEB MAR APR MAY JUN


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The Human Performance Program


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Human Performance: Guiding Principles

• Organizational values influence individual behaviors

• Performance is based on reinforcement and self-motivation

• Recognition that people are fallible, and even the best make mistakes.

• Error-likely situations are predictable and preventable, but only if we recognize them.

• Events can be avoided by understanding past events (OPEX) and applying lessons learned.


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Top 10 Error Traps…

1. Stress2. High work load3. Time pressure4. Poor communications5. Vague/poor work guidance 6. Overconfidence7. Infrequent or first time task 8. Distractions9. First working day following time

off > 4 days10. The end of a shift or work cycle

All Feel the Same

Put us in or keep us in Knowledge Based


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Program Advocates: Development Strategy


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• Act as informal leaders within their organizations, they use the language and model the desired behaviours.

• Support managers and supervisors in implementing Human Performance by providing a ready resource when those leaders are uncertain or have questions of interpretation (Advocates are the first link in the “help chain”).

• Established points of contact within the line organizations, they act as a resource for the Human Performance program, by:• providing feedback to Human Performance branch about

successes and challenges,• representing their lines to assist in development (ensuring

Human Performance program initiatives align with the needs of the line) and provide review and comment when Human Performance program elements are being revised, and

• acting as peer contacts for advocates in other lines, to allow sharing of ideas and experience.

Human Performance Advocates: Roles


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Key Program Metric: Event Free Day Reset


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Think Human Performance.

EFDR:

Event Free Day Reset.

YTD:

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Q4TD: 7Q3 Target: 5

Fy 10-11 Target: <20

EFDRs – Communication Format


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Event Free Tools vs. EFDRs in FY 10/11 – Q4


19NRX Exhaust Fan Unplanned Shutdown

20Bag Left on Smoke Detector

21Incorrect Gasket Results in Contamination Event

22CPTC Circuit Trip Instruments Out of Calibration

23 Fuel Rod Removed From the NRU Reactor Prior to Establishing a Safety Bank

24Employee Tripped and Suffered Severe Injury in NRU

25Employee Falls Into Hot Cell Isolation Room

Q4(7)

YTD (25)

Self-checking 1 2

Verification 1 11

Conservative Decision-Making 1 9

Pre-Job Brief &Post-Job Review 1 4

Communication 0 4

Procedure Use & Adherence 3 10

Safe Practices 3 9

EFDR:



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110.00

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25.00

30.00

35.00

Rolling Average of Past 6 Events

Rolling Average of Past 20 Events

NL HU Performance - Days Between EFDRs


EFDR:


(7.2)

(15.3)


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Mini Safety Culture Surveys

AECL’s Nuclear Laboratories have committed to perform ongoing quarterly Safety Culture “mini-surveys”. Each of these will take a snapshot of our progress. The sample size will be approximately 20% of the Nuclear Laboratories staff for each survey, with the sample drawn from across the organization.

The first of these surveys was conducted between May 17th and June 2nd.

The second is scheduled to run October 4th -20th .

The survey is administered by an independent outside contractor and delivered electronically through a unique hyperlink provided by email to each employee in the sample.

The survey consists of 73 questions, and takes approximately 20-30 minutes to complete. The framework for the survey is based upon the eight principles described by WANO (World Association of Nuclear Operators), and is being used across the entire US commercial nuclear fleet.


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Our next steps


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Where do we go from here??

• Continue with roll out training on Human Performance Fundamentals• Enhance the tool that supports the Corrective

Action Database• Strengthen the Field Observations program

(Leaders in the Field, Paired Observations)• Develop and implement robust trending tools to

support early identification of vulnerability• Implement a Benchmarking program that

captures lessons learned and actions from interactions with our peers• Continue with mini Safety Culture Surveys


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Questions??


performance improvement in a nuclear laboratory setting

Documents

questions2aecl official

impactaecl official

usage exclusif eacl10impact

senior management

appropriate action

canadian nuclear industry

performance based audits

words improvement