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!