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Managed by UT-Battellefor the Department of Energy
Human Performance Improvement (HPI) Implementation at ORNL - “A Grass
Roots Approach.”
Sam McKenzieSNS Site Operations
Manager
August 19, 2009
2 Managed by UT-Battellefor the Department of Energy Presentation_name
Human Performance Initiative at ORNL
· ORNL began human performance initiative in November 2005 after 6 staff from each major directorate attended a Human Performance course by DOE (Shane Bush).
· These “advocates” began preparing a Fundamentals Class with Training Department
· Parallel Process began to introduce the DuPont Safety Observation for Supervisors Program (STOP)
· Facilities and Operations Directorate (Bargaining Unit) decide to implement the STOP for supervisors as mandatory.
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HPI @ ORNL con’t
· A modified STOP for Supervisors “Program” and HPI Fundamentals Training were presented to Leadership Team as options for Lab wide adherence.
· Mandatory Management Observation Training (modified STOP) held for all Division Directors and Group Leaders with expectation of 2 surveillances per month.
· HPI grass roots effort rolled out by offering optional 8 hour class to lab employees (mandatory for Investigators and Critique Facilitators).
· Optional aspect rendered limited success with lab employees
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HPI @ SNS
· 2007 SNS acknowledges HPI as high priority· Research Accelerator Division (RAD) requires all
Group Leaders, Lead Engineers and Physicists to attend mandatory 8 hours Fundamentals Class
· Identified need for next level employees to be exposed to HPI Principles (4 hours)
· Above levels of training were expanded to other SNS Divisions
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ORNL Focus Group
· Mission to identify opportunities to incorporate HPI principles into operation and maintenance of the complex/site, to fully implement and integrate HPI into our space management, work processes, operations and work execution, and to develop tools to aid in our management of errors.
· Several opportunities were identified to include:
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Radiological Events
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Postings
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Postings con’t
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Next Steps @ SNS
· Re-Tool Training to allow more daily use applications “Paper vs Physical Plant”
· Develop Error Management Tool “Tripod Delta” based on James Reason’s scheme
· Conduct campaigns on processes within our Major Operating entities looking Latent Weaknesses.
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Next Steps @ORNL
· Continue HPI evaluations as issues arise· Enhance the Steering Committee’s charter to
assume more Safety role· Drill HPI principles down to greater cross
section of employees· Continue HPI Spotlight with High Level
Messages· Get the Culpability Flow Chart incorporated
into Event Analysis Subject Area (SBMS)
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Yes
No Yes
Yes
No
YesNoNo
Yes No
Culpability Evaluation Flowchart
Intentional Act (not an error)
Intentional Act Intentional Act (not an error)(not an error)
Were expectations reasonable, available,
workable, intelligible, and correct?
Were expectations reasonable, available,
workable, intelligible, and correct?
Deficiencies intraining, selection,
assignment, or experience?
Deficiencies intraining, selection,
assignment, or experience?
Blameless error
Blameless Blameless errorerror
Correctivetraining or
otherintervention
may be warranted
CorrectiveCorrectivetraining ortraining or
otherotherinterventionintervention
may be may be warrantedwarranted
Possiblenegligent
error
PossiblePossiblenegligentnegligent
errorerror
System induced
error
System System inducedinduced
errorerror
Possiblerecklessviolation
PossiblePossiblerecklessrecklessviolationviolation
Organization induced violation
Organization Organization induced induced violationviolation
Discipline requiredAccountability PR&DProcess Issue
YesNoYes
Yes
Diminishingculpability
NoWere actions as intended?
Were actions as intended?
Knowingly violate expectations?
Knowingly violate expectations?
Passsubstitution
test?
Passsubstitution
test?
History ofhuman
performance problems?
History ofhuman
performance problems?
Attachment A
Were consequences as intended?
Were consequences as intended?
Evaluate OrganizationalProcesses & Management /
Supervisory Methods
Evaluate OrganizationalProcesses & Management /
Supervisory Methods
No Selfreported?
Selfreported?
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Signs and Postings