ISMS Best Practices Workshop

Initial Steps to Integrate HPI into ISMSContinuous Improvement

CH2M HILL Hanford Group, Inc.September 12-13, 2006

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ISMS Best Practices Workshop

Background

• Senior management received DOE sponsored HPI fundamentals training – Dec 05

• Hanford contractors selected to participate in EM HPI pilot – Jan 06

• Joint DOE/CH2M HILL implementation plan established based on INPO recommended approach – Jan 06

• Senior management commitment to implement HPI – Jan 06

• Senior management decision to include HPI as ISMS continuous improvement initiative – Mar 06

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ISMS Best Practices Workshop

HPI Implementation Plan

• Senior management commitment established

• HPI steering committee formed• Gap analysis performed between INPO

HPI attributes and existing event prevention activities

• ISMS improvement plan revised to include HPI

• Implemented the improvement plan

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ISMS Best Practices Workshop

• Charter created• Composed of operations and support program

personnel, including bargaining unit• Chaired by senior operations leadership• Includes organizational and process HPI

champions • Approved GAP analysis and implementation plan• Provided program oversight for the training needs

analysis• Tracks progress of implementation plan and makes

course corrections as needed• Identifies and reviews communication needs

HPI Steering Committee

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ISMS Best Practices Workshop

HPI Steering Committee Strategy

From:

Emphasizing administration in our processes

Robust defense against second guessing

Robust reaction to events

To:

Robust hazard identification and mitigation

Processes built for the user

Robust prevention of events

Shift the organizational focus

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ISMS Best Practices Workshop

Provides current state of the organization and forms basis for improvement plan

• Multi-disciplined team selected • GAP Analysis focused on event prevention• Assessment criteria obtained from 3 INPO sources

• The Human Performance Improvement Initiative Site Gap Analysis Tool

• Performance Objectives and Criteria, (INPO 05-003, May 2005) Human Performance Criteria OR.3

• Job-Site Conditions Self-Assessment Questionnaire• Criteria based on commercial nuclear operational excellence• Criteria were modified for DOE activities• Assessment plan discussed with INPO representatives

GAP Analysis

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ISMS Best Practices Workshop

GAP Analysis MethodologyUse INPO HPI Process as Benchmark

Adapt Process for TFC Use

Conduct Qualitative Evaluation of 7 Functional Areas (INPO Gap Analysis

Tool)

Conduct PER Review with Focus

on People, Communications, and Management

Conduct Interviews of Causal Analysis

Personnel for Selected Events

Conduct Procedure Review Using HPI

Checklist

Conduct Interviews Using INPO HPI

Assessment Criteria

Analyze Results

Identify Strengths

Identify On-going Initiatives Where HPI Tools Can Be

Easily Adapted

Identify Opportunities for

Improvement

Establish and Implement HPI Strategies - Communication Strategy

- Education Strategy- Organization/Process Strategy

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ISMS Best Practices Workshop

GAP Analysis Opportunities• Use of the critical task concept • Proactive planning defending against error likely

situations• Tailoring controls to the critical task• Ensuring controls are not buried in extraneous

information• Training for field/support personnel and

management• Ensuring workers attention is properly focused

▪ Recognition of error likely situations and error precursors▪ Defenses to minimize errors

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ISMS Best Practices Workshop

Event Prevention Integration into ISMS Implementation Examples

• Procedures development• Human resource processes• Work Planning • Walkdowns • Design engineering considerations• Pre-Job briefings• Post-Job briefings• Lessons learned• Management / self assessments• Event analysis / investigation

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ISMS Best Practices Workshop

Example of HPI Integration into ISMS Implementation: Critical Task

• Not all aspects of a job are equally important▪ Some actions/tasks are irrecoverable; once the action is

taken, the reverse action cannot recover.

• Some steps have more chances for error • Need to consider as part of hazards analysis

▪ Is changing the state of the facility, system, component, or the well-being of the individual dependent on the individual worker?

▪ Is the outcome of the error intolerable from a personnel safety or facility perspective?

• Helps focus attention on potential consequences so appropriate defenses can be put in place

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ISMS Best Practices Workshop

• Purpose and approach▪ Consistent with SAT approach to training▪ GAP Analysis recommendations included ▪ Guidance provided by HPI Steering committee

• Objectives▪ Identify intended students (planners, procedure writers,

managers, event investigators, etc)▪ Identify training emphasis and objectives▪ Identify timeframe & duration

• Multidiscipline Analysis Team▪ Represented employees▪ Support Programs▪ First Line Supervisors▪ Line Management

Training Needs Analysis

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ISMS Best Practices Workshop

Identify and Train 3 Audiences

• Subject Matter Experts▪ Focus on line organizations (work planning & operations)▪ Include support program staff as needed

• Personnel that can facilitate implementation▪ Line managers, first line supervisors▪ Support program staff

• General field workers on basic event prevention tools

Training Needs Analysis Results

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ISMS Best Practices Workshop

▪ Define Scope of Work• Application to facility specific processes

▪ Hazards Identification and Controls• Critical task emphasis• Shift from static to dynamic hazards analysis• Procedure development and use• HPI procedure checklist

▪ Perform Work• Critical task• Error precursors• Error likely situations • Tools to prevent errors

▪ Feedback & Improvement • Self-assessment process using INPO warning flags (based on Davis-

Besse organizational behaviors)• INPO jobsite self-assessment

ISMS Integration Using HPI

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ISMS Best Practices Workshop

• Trained▪ 43 SMEs▪ Approximately 80 Managers (ongoing)▪ Approximately 400 Employees (ongoing)

• Work Planning▪ Simplified process ▪ Critical task focus improved hazards identification and control ▪ Improved usability▪ Clearly identify hazards (dynamic hazards analysis)

• Plans and Procedures▪ Event prevention focus simplified process (e.g., Waste Programs

eliminated over 25 plans, procedures, etc)▪ Improved usability▪ Compliance is more easily demonstrated

Early Successes

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ISMS Best Practices Workshop

Lessons Learned

• Senior management vision and commitment is essential• Adapting NRC/INPO safety culture principles (SWE) helped

HPI implementation• Benchmarking was necessary and critical for effective

change • HPI improvement initiatives must be integrated with ISMS• VPP initiative helped HPI implementation• Gap analysis was a good tool to focus initial improvement

plan• Involvement of union safety representatives in event

investigations helped support free flow of information• Involvement of bargaining unit personnel in procedure

development has strengthened procedure usability and compliance