The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde:...
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Transcript of The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde:...
The Cycle of Performance
Getting Back on the Path to Excellence Warning Flags/Precursors
The Cycle of Performance
Getting Back on the Path to Excellence Warning Flags/Precursors
Palo Verde: A Case Study
Frederic LakeCorrective Action Program Manager
Palo Verde: A Case Study
Frederic LakeCorrective Action Program Manager
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Potential Stages of Power PlantsPotential Stages of Power Plants
A B C D E
Coming off a Long Period of Strong PerformanceComing off a Long Period of Strong Performance
• Attributes– Mature Culture– Stable Operations– Performance indicators “Green”– Positive recognition by industry (INPO, Peers)
• Attributes– Mature Culture– Stable Operations– Performance indicators “Green”– Positive recognition by industry (INPO, Peers)
Coming off a Long Period of Strong PerformanceComing off a Long Period of Strong Performance
• Behaviors– Overconfidence– Believing your own press– Arrogance– Withdrawal– Managers not reinforcing behaviors to set
high standards– Managers distracted (external changes,
regulatory, major projects)
• Behaviors– Overconfidence– Believing your own press– Arrogance– Withdrawal– Managers not reinforcing behaviors to set
high standards– Managers distracted (external changes,
regulatory, major projects)
Unaware CultureUnaware Culture
• Some members may challenge current behaviors but face denial from other members
• CAP owners may be dealing with poor behaviors
• Strength of the Culture:– Length of time– Stability of membership– Emotional intensity of past experiences
• Some members may challenge current behaviors but face denial from other members
• CAP owners may be dealing with poor behaviors
• Strength of the Culture:– Length of time– Stability of membership– Emotional intensity of past experiences
Palo Verde…..Early 2000’sPalo Verde…..Early 2000’s
• Plant running well• PV recognized as excellent by INPO • The place where people come to
benchmark• Insular Staff
• Plant running well• PV recognized as excellent by INPO • The place where people come to
benchmark• Insular Staff
Mounting Problems…..Mounting Problems…..
• 2004 – 2006:– NRC Substantive Cross-Cutting Issues (SCCI) in
Human Performance and PI&R– Decreasing Equipment Reliability– Increased Forced Loss Rate– Decreasing Regulatory Confidence
• 2007– INPO Evaluation: significant weaknesses in several
areas– NRC ROP Column 4
• 2004 – 2006:– NRC Substantive Cross-Cutting Issues (SCCI) in
Human Performance and PI&R– Decreasing Equipment Reliability– Increased Forced Loss Rate– Decreasing Regulatory Confidence
• 2007– INPO Evaluation: significant weaknesses in several
areas– NRC ROP Column 4
What Problems? What Problems?
• Attributes– Increasing emergent issues/equipment
failures/Forced Outages– Poor CAP Behaviors/Accountability– Efforts to Turn Performance Overly focused
on process/procedure changes
Efforts to Turn Performance Not SuccessfulEfforts to Turn Performance Not Successful• Using old solutions • Cause Analysis fails
to correct underlying problems
• Using old solutions • Cause Analysis fails
to correct underlying problems
The problems that exist today cannot be solved by the same level of thinking that created them.
…Albert Einstein
What Problems? What Problems?
• Behaviors– Event significance not recognized– Signs of performance decline rationalized– Teamwork declines; groups become isolated– Training is minimized – Reluctance to challenge each other
• Behaviors– Event significance not recognized– Signs of performance decline rationalized– Teamwork declines; groups become isolated– Training is minimized – Reluctance to challenge each other
Who me?Who me?
• Attributes– Problems persist– Increasing backlogs – Sub-optimizing– Rapid decline in performance indicators -
station is measuring against themselves– Ineffective Evaluations
Who me?Who me?• Behaviors
– Finger pointing; low accountability– Poor CAP support:
• “loopholes”• Poor closures & resolution• CAP vs. “real work”
– Declining CARB performance• Poor support• High use of alternates• Driving down level of participation
• Behaviors– Finger pointing; low accountability– Poor CAP support:
• “loopholes”• Poor closures & resolution• CAP vs. “real work”
– Declining CARB performance• Poor support• High use of alternates• Driving down level of participation
Interim MeasuresInterim Measures
• Metrics showing magnitude of backlogs
• Outside cause analysis expertise • Team established to determine scope
and magnitude of issues• Comparison of station performance to
the industry (Epiphany)
• Metrics showing magnitude of backlogs
• Outside cause analysis expertise • Team established to determine scope
and magnitude of issues• Comparison of station performance to
the industry (Epiphany)
CommunicationCommunication
• Message:– Unless we change something bad will happen– Objective is sustained performance; not just
getting out of trouble
• Weekly alignment meetings• Executive level CAP message• Safety message• Relentless repetition……….
• Message:– Unless we change something bad will happen– Objective is sustained performance; not just
getting out of trouble
• Weekly alignment meetings• Executive level CAP message• Safety message• Relentless repetition……….
Stop the BleedingStop the Bleeding
• Direct and targeted actions to break the culture patterns and stop the declining performance:– Problem definition & triage– Causal analysis to determine underlying
drivers and actions– Training using outside expertise in the
essential functions of CAP, including causal analysis and CARB
– Refining metrics and reinforcing accountability for CAP
• Direct and targeted actions to break the culture patterns and stop the declining performance:– Problem definition & triage– Causal analysis to determine underlying
drivers and actions– Training using outside expertise in the
essential functions of CAP, including causal analysis and CARB
– Refining metrics and reinforcing accountability for CAP
Safety NetsSafety Nets
• Increased oversight• Closure Review Boards for actions
important to the recovery• 100% CAP Closure Reviews• Increased management control of
CAP administrative functions
• Increased oversight• Closure Review Boards for actions
important to the recovery• 100% CAP Closure Reviews• Increased management control of
CAP administrative functions
BehaviorsBehaviors
• Directive Management from Executive Leadership and CAP Program Owner
• Focus on Specific CAP Behaviors:– Identification of Issues– Causal Analysis Quality– Quality Completion of Corrective Actions
• Training to close skills and knowledge gaps and to improve performance
• Directive Management from Executive Leadership and CAP Program Owner
• Focus on Specific CAP Behaviors:– Identification of Issues– Causal Analysis Quality– Quality Completion of Corrective Actions
• Training to close skills and knowledge gaps and to improve performance
Evaluate GapsEvaluate Gaps
• Team devoted to analyses of performance
• Results grouped into Fundamental Overall Problem Areas:– Causal analysis performed for each area– Outside expertise – Actions formed the basis for the Site
Integrated Improvement Plan (SIIP), and the NRC Confirmatory Action Letter (CAL)
• Team devoted to analyses of performance
• Results grouped into Fundamental Overall Problem Areas:– Causal analysis performed for each area– Outside expertise – Actions formed the basis for the Site
Integrated Improvement Plan (SIIP), and the NRC Confirmatory Action Letter (CAL)
1. Organizational Effectiveness2. Operational Focus3. Emergency Preparedness 4. Engineering Programs 5. Design Control / Configuration Management6. Engineering Technical Rigor7. Equipment Reliability 8. Industrial Safety 9. Problem Identification & Resolution10. Procedures / Work Instructions11. Managing Plant Work Loads12. Training & Qualification13. EDG K-1 Relay (White Finding)14. RAS Event (Yellow Finding)
1. Organizational Effectiveness2. Operational Focus3. Emergency Preparedness 4. Engineering Programs 5. Design Control / Configuration Management6. Engineering Technical Rigor7. Equipment Reliability 8. Industrial Safety 9. Problem Identification & Resolution10. Procedures / Work Instructions11. Managing Plant Work Loads12. Training & Qualification13. EDG K-1 Relay (White Finding)14. RAS Event (Yellow Finding)
Cause Analysis Cause Analysis
Palo Verde Leadership ModelPalo Verde Leadership Model
We SAFELY and efficiently generate electricity
for the long term
Turning the Tide Turning the Tide
• Attributes– High volume of identification, causal analysis, and
reliance on compensatory measures– Station begins to recognize that problem identification
and resolution is a behavior; not simply a process– Metrics drive performance– Consistent message to the organization on staying
the course
Turning the Tide Turning the Tide
• Behaviors– Leaders start to align around:
• Need to improve• Improvement goals• Operational focus
– Leaders working down a level and exhibit a directive leadership style
– WeBe – some workers take a “wait and see” attitude (we’ll be here when you’re gone)
• Behaviors– Leaders start to align around:
• Need to improve• Improvement goals• Operational focus
– Leaders working down a level and exhibit a directive leadership style
– WeBe – some workers take a “wait and see” attitude (we’ll be here when you’re gone)
Closing the GapsClosing the Gaps
• Attributes– Overall plant performance improving– Fewer major equipment issues– Performance indicators continue to show
improvement– High CAP backlog of conditions and actions,
many of which may be no longer necessary
Closing the GapsClosing the Gaps
• Behaviors– Using experience, self-assessment, and
benchmarking to improve major processes – Leaders focus on improving accountability
which allows for compensatory measures to be replaced by long-term processes
– Improved coordination between departments– Some pockets of resistance; however, the
gap between high performers and low performers is widening and becoming more evident
• Behaviors– Using experience, self-assessment, and
benchmarking to improve major processes – Leaders focus on improving accountability
which allows for compensatory measures to be replaced by long-term processes
– Improved coordination between departments– Some pockets of resistance; however, the
gap between high performers and low performers is widening and becoming more evident
The Plateau………..The Plateau………..
• Symptoms:– If you think this is bad…you should have seen
it before• Actions:
– Focus on 3-5 year plans not just the immediate improvement plans
– Communication and awareness– Overtly looking for signs of the plateau &
continuous challenging
• Symptoms:– If you think this is bad…you should have seen
it before• Actions:
– Focus on 3-5 year plans not just the immediate improvement plans
– Communication and awareness– Overtly looking for signs of the plateau &
continuous challenging
Demonstrating Performance Improvement Demonstrating Performance Improvement
• Attributes– Plant operating reliably– Problems identified early and low level
trending, analysis, and other performance improvement tools are used
– Improved metrics that compare to industry– Involvement with the industry
Demonstrating Performance Improvement Demonstrating Performance Improvement
• Behaviors– Highly accountable organization– Supervisors consistently reinforce
expectations– Equipment failures are considered
organizational failures– We find and fix our problems
• Behaviors– Highly accountable organization– Supervisors consistently reinforce
expectations– Equipment failures are considered
organizational failures– We find and fix our problems
A B C D E
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Potential Stages of Power PlantsPotential Stages of Power Plants
Common Warning Flags & FactorsCommon Warning Flags & Factors
• Overconfidence• Isolationism• Production Priorities
– Safety is assumed and not explicitly emphasized
– Significance of issues underplayed• Operations and Engineering:
– Poor application of fundamentals– Erosion of design margins
• Poor Change Management• Defensive Leaders• Poor Self-Critical Behaviors
• Overconfidence• Isolationism• Production Priorities
– Safety is assumed and not explicitly emphasized
– Significance of issues underplayed• Operations and Engineering:
– Poor application of fundamentals– Erosion of design margins
• Poor Change Management• Defensive Leaders• Poor Self-Critical Behaviors
Life is 10% what happens to you and
90% how you CHOOSE
to react to it!
Life is 10% what happens to you and
90% how you CHOOSE
to react to it!