This presentation was produced under contract number DE-AC04-00AL66620 with

This presentation was produced under contract number DE-AC04-00AL66620 with

Differing ProfessionalOpinion ProgramTHE SAFETY VALVE IN THE FEEDBACK PROCESS

What is a DPO?

• “A Differing Professional Opinion is a– Conscientious expression of a professional judgment

that • Differs from the prevailing staff view, • Disagrees with a management decision or policy

position, or • Takes issue with a proposed or an established practice

– Involving technical, legal, or policy issues that, – In the professional judgment of the submitter, – Adversely affect the environment, and/or the safety

and health of the public and/or persons engaged in work at the Plant.”

WI 02.04.01.17.04

“People do not always argue because they misunderstand one another; they argue because they

hold different goals”

William H. Whyte Jr.

What is NOT a DPO?

• Issues that are administrative in nature (e.g., procedures for review and comment or Price-Anderson enforcement procedures)

• Personnel issues (e.g., performance elements, evaluations and ratings or work assignments by management)

What is NOT a DPO?

• Issues that relate to contracts not relating to technical ES&H issues (e.g., fees or contract negotiations)

• Issues related to collective bargaining

What is NOT a DPO?

• Issues that are addressed through the grievance process or personnel appeal procedures

• Issues that relate to wrongdoing (Differing Professional Opinion Manager (DPOM) refers these to Internal Audit)

What is NOT a DPO?

• Issues submitted anonymously or for which confidentiality is requested

• Issues that have been considered and already addressed under this process unless significant, new information is available.

What examples of potential, ongoing or historical

DPO’s can you think of?

Why a DPO Program?

• Genesis within DOE– DNFSB 2004-1 Implementation Plan

• Commitment to implement a DPO program within DOE

– Action Items 4.a-b: Columbia & D-B Lessons Learned Report

• Commitment for DOE contractors to implement a DPO process and adopt in contracts

– Action Item 4.c: Columbia & D-B Lessons Learned Report

Columbia & Davis-Besse

Pantex Studied the DOE Columbia/D-B Report in 2006

Absence of DPO Process Prominent in DOE Report

Pantex DPO Program

• Timeline– “On radar” as DNFSB 2004-1 Concern – Issue #4 from Anonymous Letter Response

Action Plan (PER 2007-0059)– Impact evaluation of DOE M 442.1-1 & added

to contract in FEB 07– DPO Implementation team formed late FEB– Process Development late FEB to early APR– Bulletin, WI & PX Form published 13 APRIL.

Key DPO Building Blocks

Bulletin # 967

• Applies to employees & BWXT subcontractors

• Seeks to establish an environment that supports the raising of issues.

• Requires impartial, competent evaluation

• Recognizes positive outcomes when appropriate.

Bulletin # 967

• NO RETALIATION!!

None of

this!!

DPO WI 02.04.01.17.04

• Sets clear conditions for acceptance of formal DPO

• Requires submitter to attempt resolution through management chain, when possible.

• Allows for both accelerated and extended reviews.

DPO Preconditions

“… no time limits for completion of thesediscussions, no tracking requirements,and no requirements to keep writtenrecords….”

“… no time limits for completion of thesediscussions, no tracking requirements,and no requirements to keep writtenrecords….”

PX-5476

• Used to evaluate acceptability of a DPO

• Submitter provides as much detail as possible

• Submitter recommends reviewers for DPO

• Can be used for classified DPOs.

DPO Process Overview

NO

YES

NO YES

NO

Employee or Subontractor

Technical IssueRE: ES&H

Reject and/or resubmit

Problemsw/ staffing Issue thru Mgmt chain

?

AttemptTo Resolve issue

Through MgmtChain ?

Submitter’s IssueAccepted intoDPO Process

DPOM Verifies Sufficient

Information from Submitter

DPOM AppointsFinal Decision

Manager (FDM) w/in 10 days

DPOM Recommends Ad Hoc Review Panel

to FDM w/in 10 days

FDM Assigns Panel Members to

Review DPO

Ad Hoc Panel (AHP) Members

Review DPO

AHP Issues Recommendation

w/in 30 days to FDM

FDM transmits recommendations to DPO Submitter

*

SubmitterAccepts

Findings?

FDM coordinates any actions w/ line

managers

Final Decision documented and/or implemented.

FDM recognizes Submitter’s efforts

as appropriate

YES

*Alternate processes available.

DPO’s & the Safety Conscious

Work Environment (SCWE)

A Strong Combination

DPO &SCWE

• A SCWE safety-conscious-work-environment describes a workplace in which all employees – Contribute to a priority focus on safety by

speaking up about safety concerns– Because they feel comfortable and valued

doing so.

• At its core, SCWE is about the free flow of information relating to safety

• Leaders: How SCWE are You? Do you:– Encourage Issues?– Listen? (for both scope and perception)– Act on Issues?– Give Feedback?– Walk the Talk?– Promote the Programs?– Know Your Command Climate?

A SCWE Reduces Formal DPOs

Team Members …

• Are you– Passionate & unguarded in your discussion of issues?– Deeply concerned about the prospect of letting down your

peers?– Slow to seek credit for your own contributions, but quick to

point out those of others?

• Do you– Call out one another’s deficiencies or unproductive

behaviors?– Quickly & genuinely apologize to one another when you

say or do something damaging to the team?– Challenge one another about your plans and approaches?

How Do We Voice Our Concerns?

When Do We Speak Up?

Why Team Dysfunction Occurs

When Team Dysfunction Occurs …

• The DPO Program is the “safety valve” when our information “free flow” fails ortrust falters.

The “Pinball” Approach to a Safety Culture

Bankruptcy

Catastrophe

UnrockedBoat

Better defenses converted to

increased production

Protection

Production

Seeking Differences Within a Strong Safety Culture

Pantex DPO Experience

• Only 1 formal DPO thus far…– Involved an environmental remediation issue– Good bit of “management consternation” at

outset until process was understood– Resulted in Company NOT siding with

Submitter, ALTHOUGH … – Improvements to overall program were

requested by Ad Hoc Review Panel.– Submitter accepted results.

Wait a Minute!

What have we learned so far?

Lessons Learned: Submitter

• DPO Program Manager needs to work with Submitter to make sure issue can be understood by independent Final Decision Manager.

• Make sure Submitter agrees with stated issue prior to beginning evaluation.

Ad Hoc Review Panel

Lessons Learned: Ad Hoc Review Panel

• Appropriate technical credentials essential! • Be Flexible in time lines

– Make sure that Ad Hoc Review Panel fully understands issue and has framed it properly before evaluation period begins.

• Work with Submitter & Majority-Opinion Holders (Manager, Technical Authority, etc.) to gather pertinent information and analyze issue.

Final Decision Manager

The Need for a Solid Reputation & Independence

RecognizeCourage & Positive Contributions …

• Informal DPO’s are being actively worked and vetted in each organization.

• We all benefit from the act of putting our arguments in writing.– Important technical decisions should not be based solely on

verbal discussions or PowerPoint presentations.• “There is no excuse for a manager not understanding the

technical details of his or her business.”– Demand debate. Confront difficult issues.

• “We should do things so well that no one can criticize us.”– This often requires strong technical, written arguments, both

for and against a proposed solution.

President & General Manager’s Expectations

The Need for the Differing View

• "One must create the ability in his staff to generate clear, forceful arguments for opposing viewpoints as well as for their own. Open discussions and disagreement must be encouraged, so that all sides of an issue will be fully explored. Further, important issues should be presented in writing. Nothing so sharpens the thought process as writing down one's arguments. Weaknesses overlooked in oral discussions become painfully obvious in the written page."

Admiral H.G. Rickover

QUESTIONS?

Supplemental Slides

DPOs: Gone Missing

Seldom Discussed: K-Reactor

Well-Studied: Columbia & Challenger

A Case for the DPO Program

A Review of theDecision to Restart

K-Reactor(SRS)

K-Reactor Background• Constructed in 1953• Expected to run for 5 years at 250 MWth

• Operated from 1954 to 1988 at 2500 MWth

• 1988: K, L, & P Reactors Shutdown due to operator errors and design problems with emergency core cooling systems.

• … around the same time… Hanford N-Reactor permanently shut down, Rocky Flats shut down, Fernald shut down.

Commercial Reactor vs. K-ReactorBasic Design

No Secondary Coolant LoopNo Secondary Coolant Loop

Secondary Coolant LoopSecondary Coolant Loop

Primary Coolant LoopPrimary Coolant Loop

Environment

Primary Coolant LoopPrimary Coolant Loop

Environment

K-Reactor

Savannah River Site L-Reactor

P-Reactor

R-Reactor

Swamp

Reviewer’s Troubling Findings

• Inadequate tritium liquid effluent monitoring

• Effluent samples monitored only once every 72-hours.

• Review team had significant concerns in accepting substandard sampling protocols

105-K Area

Reactor

CoolingTower

Outbrief Didn’t Go Well

• DOE Pre-Start finding on liquid effluent tritium monitoring

• Significant pushback on reviewer from the contractor– Contractor position: Existing and planned

improvements “were acceptable”

• DOE-SR Customer felt same pressure to proceed on schedule

• Quite a dilemma.

A Fateful Decision

OR?

The Decision

• Accepted change of pre-start to post-start finding to meet schedule.

• Contractor’s planned improvements – and Secretary’s looming disappointment – used to justify change in finding significance.

13 December 1991

Restart Authorized

14 December 1991

Reactor Testing Begins

22 December 1991

Reactor leak begins in one of 9000 steam generator tubes

24 December 1991(48 hours later)

Reactor Leak Detected150 gallons of tritiated water released

6000 Curies of tritium headed to Savannah RiverReactor Shutdown

Christmas Eve 1991

… “Consultant” gets a call at home from a friend working holiday shift at

K-Reactor …

“Anger Lingers After Leak at Atomic Site”

“‘It's the overall picture that bothers me,’ said State Representative Harriet Keyserling of Beaufort. ‘Two years ago they had a similar spill, and an internal report said they had to start monitoring it in a different way. Two years later, they have never done it. Now when everyone is screaming, they say, ‘We're going to do it tomorrow.’”

New York Times, 13 JAN 1992

“3 Lawmakers Press to Keep Weapons Reactor Shut”

“Democratic and Republican members of the South Carolina Congressional delegation urged Energy Secretary James D. Watkins today to keep an old reactor at the Savannah River nuclear weapons plant shut down until new safety measures are taken and the Energy Department prepares a study justifying a need to start it. …

“…The letter, which is the most explicit statement of doubt about the Savannah River plant's safety that has ever been issued by South Carolina lawmakers, comes a month after an accident that spilled 150 gallons of radioactive water into the Savannah River. The spill caused radiation levels in the river to exceed Federal safety limits, prompting a public water system downstream that serves 50,000 people around Beaufort, S.C., to shut its intake valve.”

New York Times, 17 JAN 1992

“Savannah River Reactor to Stay Shut1,200 Layoffs Set”

“A battered old nuclear reactor at the Energy Department's Savannah River, S.C., weapons plant that is the nation's only source of a radioactive gas used in nuclear warheads will not be restarted, Energy Secretary Hazel R. O'Leary has announced…

“… At least 1,200 workers at the plant near Aiken, S.C., will be laid off, O'Leary said.”

The Washington Post, 31 MAR 1993

1996

K-Reactor placed in cold shutdown

9 Years Pass

K-Reactor Take-Aways1. From a radiological

standpoint, the release was minimal- 6000 Ci < 0.08 mrem to MEOI

2. Annual tritium liquid effluent releases were 7,000 Ci higher on average…. Air effluent releases: 1.9 E05 Ci average*

3. No residual environmental damage

But….4. This “non-event” proved to be

the tipping point….5. Time pressures & Facilitative

assumptions propagated technically indefensible practices

6. Differing professional opinions were not solicited or welcomed

7. Trust given to DOE by South Carolina, Georgia and Congress was significantly harmed

8. “I told you so” mentality allowed Congress to withhold K-reactor funding & kill the project.

9. $3B Wasted.

10.Nation’s only source of tritium for weapons program lost for over 18 years.

*DOE/EH-0644

Revisiting NASA

Challenger Disaster: 28 JAN 1986

… & 7 Years Later

Columbia Disaster: 1 FEB 2003

Has NASA Learned?

7 MonthsPost-Columbia

7 MonthsPost-Columbia

Or not … 17 Months Pre-Columbia!

NASA Was “Talking the Talk”

NASA Wasn’t “Walking the Talk”

• NASA Technical Standard prohibited launch IF foam shedding occurs– 112 Launches pre-Columbia showed evidence

of foam shedding• No actions taken

– By Columbia (STS-107)… foam strikes during takeoff were “routine” and not evaluated after 82% of missions back to STS-1

• CAIB: “The machine was talking to us, but nobody was listening.”

On Launch Day, 16 JAN 03

• 3,233 Criticality 1/1R critical item list hazards that had been waived.– Criticality 1/1R component failures result in

loss of the orbiter and crew.

• CAIB: “The unexpected became the expected, which became the accepted.”

That’s nice, but … Where’s the DPO connection?

Application to DPO’s

• Organizational accidents are not necessarily “self-revealing” at the time a fateful management decision is made.

• Managers must look for the “weak signals” of concern their employees may be providing.

• Raising safety issues – big and small – must be encouraged and welcomed.

“Sometimes when I consider what tremendous consequences come from little things … I am tempted to think there are no little things.”

Bruce Barton