re-invigorating ism and developing effectiveness measures: experiences from pantex
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Re-Invigorating ISM and Developing Effectiveness Measures: Experiences from Pantex. Larry Supina ISM Program Manager, BWXT Pantex LLC. What is Pantex?. 16,000 Acre WWII Munitions Factory Nuclear Weapons Final Assembly High Explosives Formulation, Synthesis, Fabrication and Machining - PowerPoint PPT PresentationTRANSCRIPT
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*Re-Invigorating ISM and Developing Effectiveness Measures: Experiences from Pantex
Larry Supina ISM Program Manager,BWXT Pantex LLC
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*What is Pantex?16,000 Acre WWII Munitions FactoryNuclear Weapons Final AssemblyHigh Explosives Formulation, Synthesis, Fabrication and Machining3300 EmployeesMost Importantly for Todays Discussion, Pantex is
Bldg. 12-1 as built in 1945
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*What is Pantex? (cont)Hands-on Mechanical ActivitiesVery Linear, Not InteractiveVery Simple, Passive SystemsComplex, Intricate, Arcane RulesPantex is, perhaps, the ultimate in low probability, high consequence event scenariosDan Swaim General Manager, BWXT Pantex
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*Pantex, circa 2002Good OperationsSix-Sigma Processes Improving Quality, CostsIncreasingly Difficult and Complex Regulatory Basis Driving Operational ErrorsExpectations for sustainable, error-free, superior plant performance not being met
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*BWXT Pantex ISM Performance Improvement FocusShift from Manufacturing Bias to Nuclear Operations CultureAdopt High Reliability OrganizationEstablish a Superior Management Team at All LevelsMove from Skills Training to Nuclear Operations Training
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*Tactically, We Needed New Plant Norms
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*Performance Objectives & Key Behaviors cited from INPO 05-003 and INPO Excellence in Human Performance Sept, 199712Performance Objectives:Sustainable, Superior Plant PerformanceSustainable, Event-Free OperationsAvoidance of Unplanned, Long-Duration ShutdownsWell-Managed & Understood Safety, Design, and Operational MarginsSuperior Levels of Plant Worker SafetyHighly Skilled, Knowledgeable and Collaborative Workforce
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*Performance Objectives & Key Behaviors cited from INPO 05-003 and INPO Excellence in Human Performance Sept, 199712Key Individual Behaviors:Communicate to create shared understandingAnticipate error-likely situationsConfirm the integrity of defensesImprove personal capabilities
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*Performance Objectives & Key Behaviors cited from INPO 05-003 and INPO Excellence in Human Performance Sept, 199712Key Leader Behaviors:Facilitate open communicationPromote teamwork to eliminate error-likely situations and strengthen defensesSearch for and eliminate organizational weaknesses that create conditions for errorReinforce desired jobsite behaviorsValue the prevention of errors
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*Performance Objectives & Key Behaviors cited from INPO 05-003 and INPO Excellence in Human Performance Sept, 199712Key Organizational Behaviors:Foster a culture that values prevention of errorsStrengthen the integrity of defenses to prevent or mitigate the consequences of errorPreclude the development of error-likely situationsInstill a learning mindset and encourage continuous improvement
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Pantex ISM Approach
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*Credits & References
Mr. Dan J. Swaim, General Manager BWXT PantexHuman Performance Improvement at Pantex presented at the DOE HPI Confernce 2005Mr. John G. Meyer, Deputy General Manager BWXT PantexCreating a Safety Culture presented at the Pantex Executive Safety Council 2006Mr. Richard S. Hartley Phd. BWXT Pantex Nuclear Safety OversightISM Program Model 2005
Performance Objectives & Key Behaviors cited from INPO 05-003 and INPO Excellence in Human Performance Sept, 1997Managing the Risks of Organizational Accidents by James ReasonSupport of benchmarking activities, LANL, LLNL, SNL Livermore, ORNL,
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Near Miss Data
Chart1
37
16
21
31
6
7
6
15
5
7
20
12
Near Miss Analysis
Data
Type of WorkSupervisionTo PreventCausePlanned ByType of Work
Site# of eventsControlledSkill of the craftIntermittentConstantBetter ProcessBetter ControlsBetter JHABetter SupervisionMgmtPersonal errorPoor Risk AnalysisChanging ConditionsTechnicalWork PlannerWork TeamBothNoneOps/MtceD&DConstructionTrainingTrans
WSRC7167122140421
WVNSCO44412112413
WIPP41331111112114
LANL11111
B37133031111213
Total1991014536234483
ORPS18710171414103272
Total3716203167201237615059820019
9451914
33
Analysis
Type of WorkSupervisionTo PreventCause
# of eventsContolledSkill of the craftIntermittentConstantBetter ProcessBetter ControlsBetter JHABetter SupervisionMgmtPersonal errorPoor Risk AnalysisTechnical
1991014836235482
Type of WorkSupervisionISMS Deficiency AreaType of Work
# of eventsContolledSkill of the craftIntermittentConstantDefine ScopeAnalyze HazardsDevelop ControlsPerform WorkFeedbackOps/MtceD&DConstructionTrainingTrans
18710191210146312331120
98219
211151139
162033951616981611511
Analysis
Near Miss Analysis
Combined
18
17
1
2
10
14
6
3
12
3
3
1
1
ORPS Near Miss Analysis
Sheet1
Type of WorkSupervisionCauseTo PreventType of Work
# of eventsContolledSkill of the craftIntermittentConstantMgmtPersonal errorPoor Risk Analysis/ControlsTechnicalBetter ProcessBetter ControlsBetter JHAOps/MtceD&DConstructionTrainingTrans
37162131676155720121911511
37373339
Sheet1
Near Miss Analysis
Conclusions
ORPS
SiteNear missesHazard analysis a factorPlanner onlyWork team onlyPlanner & work team combinationPlanner & review cmteNone
WSRC9413
LANL211
WIPP4211
B371511
WVNSCO333
Total231120531
ConclusionsActions
Poor JHAs and/or work controls account for majority of near missesReemphasize importance of good JHA and complete control set
Improved Supervision is best measure to prevent incidentsSponsoring Safety Trained Supervisor course, Issuing rotation policy
Change in work scope frequently leads to un-analyzed conditionClarify pre-shift briefing policy to ensure work conditions are as planned.
Stop Work authority needs to be emphasizedIssued Timeout policy to all projects
SupervisionISMS Deficiency AreaType of Work
# of eventsIntermittentConstantDefine ScopeAnalyze HazardsDevelop ControlsPerform WorkFeedbackOps/MtceD&DConstructionTrainingTrans
181712101463123311
Cause
MgmtPersonal errorPoor Risk AnalysisChanging ConditionsTechnical
3273
11
11
1
1
111
1
1
11
11
1
1
11
44413319
ORPS Near Miss Analysis
Data
Type of WorkSupervisionTo PreventCausePlanned ByType of Work
Site# of eventsControlledSkill of the craftIntermittentConstantBetter ProcessBetter ControlsBetter JHABetter SupervisionMgmtPersonal errorPoor Risk AnalysisChanging ConditionsTechnicalWork PlannerWork TeamBothNoneOps/MtceD&DConstructionTrainingTrans
WSRC7167122140421
WVNSCO44412112413
WIPP41331111112114
LANL11111
B37133031111213
Total1991014536234483
ORPS18710171414103272
Total3716203167201237615059820019
9451914
33
Analysis
Type of WorkSupervisionTo PreventCause
# of eventsContolledSkill of the craftIntermittentConstantBetter ProcessBetter ControlsBetter JHABetter SupervisionMgmtPersonal errorPoor Risk AnalysisTechnical
1991014836235482
Type of WorkSupervisionISMS Deficiency AreaType of Work
# of eventsContolledSkill of the craftIntermittentConstantDefine ScopeAnalyze HazardsDevelop ControlsPerform WorkFeedbackOps/MtceD&DConstructionTrainingTrans
18710191210146312331120
98219
211151139
162033951616981611511
Analysis
Near Miss Analysis
Combined
18
17
1
2
10
14
6
3
12
3
3
1
1
ORPS Near Miss Analysis
Sheet1
Type of WorkSupervisionCauseTo PreventType of Work
# of eventsContolledSkill of the craftIntermittentConstantMgmtPersonal errorPoor Risk Analysis/ControlsTechnicalBetter ProcessBetter ControlsBetter JHAOps/MtceD&DConstructionTrainingTrans
37162131676155720121911511
37373339
Sheet1
Near Miss Analysis
Conclusions
ORPS
SiteNear missesHazard analysis a factorPlanner onlyWork team onlyPlanner & work team combinationPlanner & review cmteNone
WSRC9413
LANL211
WIPP4211
B371511
WVNSCO333
Total231120531
ConclusionsActions
Poor JHAs and/or work controls account for majority of near missesReemphasize importance of good JHA and complete control set
Improved Supervision is best measure to prevent incidentsSponsoring Safety Trained Supervisor course, Issuing rotation policy
Change in work scope frequently leads to un-analyzed conditionClarify pre-shift briefing policy to ensure work conditions are as planned.
Stop Work authority needs to be emphasizedIssued Timeout policy to all projects
SupervisionISMS Deficiency AreaType of Work
# of eventsIntermittentConstantDefine ScopeAnalyze HazardsDevelop ControlsPerform WorkFeedbackOps/MtceD&DConstructionTrainingTrans
181712101463123311
Cause
MgmtPersonal errorPoor Risk AnalysisChanging ConditionsTechnical
3273
11
11
1
1
111
1
1
11
11
1
1
11
44413319
ORPS Near Miss Analysis
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*Management Development A Three Year Drive!Instilling Competency and AccountabilityCross-cutting All LevelsBuilding Mutual Commitment, Agreed Upon Methods of BusinessImproved Selection (and Off-Ramp!) Processes No End in Sight
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*How Different Organizational Cultures Handle Safety InformationSource: Managing the Risks of Organizational Accidents by James Reason
Pathological CultureBureaucratic CultureGenerative CultureDont want to knowMessengers are shotResponsibility is shirkedFailure is punished or concealedNew ideas are actively discouragedMay not find outMessengers are listened to if they arriveResponsibility is compartmentalizedFailure leads to local repairsNew ideas often present problemsActively seek itMessengers are trained and rewardedResponsibility is sharedFailures lead to far-reaching reformsNew ideas are welcomed
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Relative Progression Toward HRO
Total Effort
Improvement
Initial GapAnalysis
ISM Implemented
HRO
ISM FullyFunctioning
Learning OrganizationStriving TowardHRO
We meet DOE/NNSA customers expectations
We exceed DOE/NNSA customers expectations & pass muster w/ external HROs
Strong Nuclear Weapon Safety Culture
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*Getting the Lesson LearnableActually Learning the LessonContinued Efforts in Progress
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ISMS
Define the ScopeAnalyze the HazardsImplement controlsPerform the work safelyProvide feedback
Part of all baseline planning effortsRemove high hazards firstIncreases safety of workers, the public and the environment.
ISMS is our safety program