1Bechtel National Inc.
Mitigating Organizational Weaknesses
Presented September 13, 2006DOE Integrated Safety Management Best Practices Workshop
Mary Heaton, Assistant PM Nuclear Safety & Quality Imperative
Bechtel National, Inc.Hanford Waste Treatment and Immobilization Plant
2
WTP Environment 2001 - 2005 2001 challenges – hired/transferred 1800 in approximately 1 yr. from
different Bechtel groups, new hires, staff augs Majority of the technical training was required reading Few NQA-1 qualified vendors Corrective action improvements consistently included procedure
revisions Quality, safety and productivity improvements were addressed
through six sigma and PBL
– Bechtel implemented Performance Based Leadership in the late 90’s
– Six Sigma in 2000
– Both to improve productivity, quality of work Six Sigma Black Belts were included as members or leads of all
RCA’s since 2003. Large reduction in force May 05 and November 05
3
WTP Environment 2001 - 2005
Did latent organizational weaknesses exist?
4
WTP Environment 2001 - 2005
2001 challenges – hired/transferred 1800 in approximately 1 yr. from different Bechtel groups, new hires, staff augs
Majority of the technical training was required reading Few NQA-1 qualified vendors Corrective action improvements consistently included procedure
revisions Quality, safety and productivity improvements were addressed
through six sigma and PBL
– Bechtel implemented Performance Based Leadership in the late 90’s
– Six Sigma in 2000
– Both to improve productivity, quality of work Six Sigma Black Belts were included as members or leads of all
RCA’s since 2003. Large reduction in force May 05 and November 05
5
Industry Event Causes
806 = Individual behavior (32%)due to human performance
Source: INPO, Event Database, March 2000. For all events during 1998 and 1999.
215
26 3988
192
654
9 20
160
82
806
73118
0
100
200
300
400
500
600
700
800
900
Cha
nge
Man
agem
ent
Env
ironm
enta
l Con
dition
s
Hum
an-m
achin
e In
terfa
ce
Sup
ervis
ory M
etho
ds
Wor
k Org
aniza
tion/
Plannin
g
Writ
ten
Proce
dure
Res
ourc
e M
anag
emen
t
Wor
k Sch
edule
Tra
ining
/Qua
lifica
tion
Ver
bal C
omm
unica
tions
Wor
k Pra
ctice
s
Man
ager
ial M
etho
ds
Other
/Unk
nown
Nu
mb
er
of
Ca
use
s
1,676 = Org behavior (68%)
6
Aoccdrnig to rscheearch at an Elingsh uinervtisy, it
deosn't mttaer in waht oredr the ltteers in a wrod
are, the olny iprmoetnt tihng is taht the frist and lsat
ltteer is at the rghit pclae. The rset can be a toatl
mses and you can sitll raed it wouthit porbelm. Tihs
is bcuseae we do not raed ervey lteter by it slef but
the wrod as a wlohe.
7
Fall 2005 Nuclear Safety and Quality CultureBNI, DOE ORP and Office of Enforcement agreed WTP had weaknesses in:
Procedure compliance Adequacy of procedures Training Balance of cost, schedule, and
quality Communication and feedback
Quality improvement Questioning attitude Management behaviors Assessment and oversight Balancing safety, quality, cost and
schedule Verification of work activities
8
Nuclear Safety and Quality Imperative
Achieving nuclear safety and quality through procedure compliance
Management Alignment
Gap Analysis
Vision Setting
Compensatory Action
Corrective Action
• Balancing Safety, Quality, Cost, and Schedule
• Communication and Feedback
Oversight & Assessment
Training
• Adequacy of Procedures• Procedure Adherence
ProceduresBehavior
• Training Personnel to Execute Procedures
• Management Oversight & Assessment
• Verification and Approval of Work Activities
• Quality Improvement
We will create, then sustain, an open and trusting environment where each of us:
WTP Nuclear Safety and Quality Imperative
Our overriding priorities are safety and quality
Takes pride and ownership of safety and quality
Questions what does not seem right – stop and ask
Identifies and shares improvement opportunities
Embraces, and accepts procedure compliance as the foundation of our work
TP0602_24
10
NSQI August Metrics
ReduceError and
Issue Significance
Line Identification of Issues(Goal = 65 Percent)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Percentage
Trend - Projected
Percentage 71% 58% 54% 69% 59% 73% 66% 58% 57% 50% 69% 59% 79%
Jul-05 Aug Sep Oct Nov Dec Jan-06 Feb Mar Apr May Jun Jul-06 Aug Sep Oct
Contribution by CR Severity Type
0%
10%
20%
30%
40%
50%
60%
70%
80%
Jul-05 Aug Sep Oct Nov Dec Jan-06 Feb Mar Apr May Jun Jul-06
% DR % CAR% Sig. CAR DR TrendCAR Trend Sig. CAR Trend
Deficiency Report – Level 1CAR – Level 2
Sig. CAR – Level 3/4
Line – Functional Orgs.As compared to QA & External
Continue to Shift Error and Issue Identification to the Responsible Individual
NSQI Project Manager
Project Management
Quality Assurance
CommissioningAcquisition Services
ConstructionEngineeringOrganizationStructure
NSQI Cross Functional Activities
Additional NSQI Activities
Procedure Adequacy Process Improvement Project
Training Process Improvement Project
Management Behavior Analysis
Safety and Quality One Hour Briefing Sessions
Nuclear Safety and Quality Behavior Recognition
Human Performance Improvement
Engineering Check Lists
Engineering Quality
Assessment
Construction Utilities Group
Weld Recovery Program
NSQI HGET Training
Systematic Approach to
Training
PIER System
Independent Advisory
Board
Nuclear Safety and Quality Imperative Project
George ClareNSQI Project Manager
Work Breakdown Structure
Matrixed Support Organization
Schedule
Improvement Primary Metric Charts
• Revised organization to centralize support to standardized process and procedures
• Revised project schedule
• Construction Safety Alliance
• Motivational off-site team building and alignment
• Improved long range planning and scheduling
• Monthly all employee meetings
• Safety Rallies
• April 2006 Front line supervisor NSQI/HPI
• Crucial conversations
• Procedural adequacy surveys
• Cross-functional 360° procedure review process
• VPP Steering Committee
• VPP Application Process
Engineering
Construction • Established NSQI expectation at new hire orientation by manager of Construction
• Safety Leadership Development Training
–Communications
–Planning
–Trending/Forecasting
–Motivation
• Cross-functional team develop approach to training (Systematic Approach to Training) (20)
• Identify positions and schedule for job analysis (34)
• Analyze positions, develop and deliver training per SAT
• Establish Training Advisory Board (35)
• Create Training Implementation Matrix per DOE 0rder 5480.20A (36)
• Revise training procedures per systematic approach (37)
• Issue Training Program Plan per schedule (38)
Project- Wide • Develop Centralized Issues Tracking System (PIER) (2)
• Revise Management Assessment Procedure
• Provide training to managers regarding behaviors to achieve a Safety Conscious Work Environment attitude (4)
• Conduct management alignment sessions (5)
• Conduct Management Behavioral Gap Analysis (9)
• Management briefing sessions (6)
• Conduct WTP All Hands Meeting (7)
• Conduct one-hour NSQI stand-down sessions (11)
• Conduct quiz on management expectations (12)
• Revise annual HGET training to include NSQI module (13)
• Establish new hire expectations at new hire orientation by senior project management (14)
• Develop website for anonymous questions (15)
• Implement Human Performance (16)
• Develop communication strategy (17)
• Conduct employee survey (19)
• Identify actions from survey results (33)
• Develop Differing Professional Opinion program
• Recognizing and rewarding desired employee behaviors
• Cross-functional team develop approach to address procedure adequacy (21)
• Baseline procedure format and content to Savannah River Site
• Revise Document Administration procedure to increase clarity (22)
• Identify set of procedures which will undergo review for clarification and revision if necessary (23)
• Revise Phase 1 procedures (24-28)
• Establish database to track requirement flowdown through procedures (31)
• Establish method to hyperlink procedures (32)
• Direct link to procedures from homepage (30)
• Procedure writers attend Human Performance training (29)
• Rapid procedure change process
Oversight & Assessment
Training
• Assign NSQI Project Manager (3)• Develop business case for procedure compliance (8)
ProceduresBehavior
Nuclear Safety and Quality Imperative
• Balancing Safety, Quality, Cost, and Schedule
• Communication and Feedback
• Management Oversight & Assessment
• Verification and Approval of Work Activities
• Quality Improvement
• Adequacy of Procedures
• Procedure Adherence
• Training Personnel to Execute Procedures
• Consolidated engineering organization
– Central technical leadership and design production
– Co-located expertise
– Common equipment groups
– One-stop assessment, feedback, and corrective action
– Consolidated checking and verification functions
– Cross-discipline design support organization for issue tracking, analysis, and improvement actions
– Improved integration of planning tools and resources
• Engineering Quality Analysis tool, monthly updates, action plans
• Revised off-project review procedure
• Process Assurance and E&NS sponsored assessments, including safety envelope and procedural conformance
• Requirements verification process integrated with system description development
• Outside review of key technical risk areas
• Revised project schedule
– Increased durations to support construction and procurement
– Improved sequencing and logic ties of engineering discipline activities
– Improved durations to resolve open technical risk issues
• NSQI communications
– Monthly Engineering Quality presentation on NSQI attributes to all hands
• Engineering leadership off-site sessions regarding NSQI implementation
• Integration of quality goals in management annual performance reviews
• Incorporation of INPO error precursors and HPI principles into CAR follow-up
• Engineering safety envelope stand-down and personal commitment statements
• Augmented Monitoring of New Employees/ Employees with New Assignments
• Discipline-specific coaching
– codes and standards
– design tools
– work process requirements
– feedback from surveillances and corrective actions
– feedback from technical and compliance checklists
• Revised training matrices based on current production deliverables
• Technical completeness checklists in key production areas
• Formal safety envelope training and knowledge check
• PSAR update - training and review
• Additional staff training and utilization in Root Cause Analysis
• Procedure compliance actions
– Compliance checklists/metrics (18)
– Improved procedure change processes
– Procedure compliance statements
– New employee orientation regarding expectations
– WTP document hierarchy clarified and published
• Procedure adequacy actions– Clarification of top-level
requirements in procedures– Review of Engineering Guides for
mandatory requirements – Discipline action on compliance
checklist metrics• Additional specific actions
– Engineering Material Coordinator Guide revised (1)
– Equipment database quality metrics and ongoing screening of tagged components
– Additional E&NS reviews and safety screen signature added to design documents
– Improved implementation feedback for safety envelope and design criteria changes
• Advisory Board• Confirmatory Analysis
Bold and italicized items indicate Compensatory Actions
11
Culture change strategy
Top Down
Bottom Up
Focused Actions Visible, tangible success
Increased credibility
Project-wide culture change
Function-specific issue resolution
12
• Revised organization to centralize support to standardized process and procedures
• Revised project schedule
• Construction Safety Alliance
• Motivational off-site team building and alignment
• Improved long range planning and scheduling
• Monthly all employee meetings
• Safety Rallies
• April 2006 Front line supervisor NSQI/HPI
• Crucial conversations
• Procedural adequacy surveys
• Cross-functional 360° procedure review process
• VPP Steering Committee
• VPP Application Process
Engineering
Construction • Established NSQI expectation at new hire orientation by manager of Construction
• Safety Leadership Development Training
–Communications
–Planning
–Trending/Forecasting
–Motivation
• Cross-functional team develop approach to training (Systematic Approach to Training) (20)
• Identify positions and schedule for job analysis (34)
• Analyze positions, develop and deliver training per SAT
• Establish Training Advisory Board (35)
• Create Training Implementation Matrix per DOE 0rder 5480.20A (36)
• Revise training procedures per systematic approach (37)
• Issue Training Program Plan per schedule (38)
Project- Wide • Develop Centralized Issues Tracking System (PIERs) (2)
• Revise Management Assessment Procedure
• Provide training to managers regarding behaviors to achieve a Safety Conscious Work Environment attitude (4)
• Conduct management alignment sessions (5)
• Management briefing sessions (6)
• Conduct Management Behavioral Gap Analysis (9)
• Conduct WTP All Hands Meeting (7)
• Conduct one-hour NSQI stand-down sessions (11)
• Conduct quiz on management expectations (12)
• Revise annual HGET training to include NSQI module (13)
• Establish new hire expectations at new hire orientation by senior project management (14)
• Develop website for anonymous questions (15)
• Implement Human Performance (16)
• Develop communication strategy (17)
• Conduct employee survey (19)
• Identify actions from survey results (33)
• Develop Differing Professional Opinion program
• Recognizing and rewarding desired employee behaviors
• Cross-functional team develop approach to address procedure adequacy (21)
• Baseline procedure format and content to Savannah River Site
• Revise Document Administration procedure to increase clarity (22)
• Identify set of procedures which will undergo review for clarification and revision if necessary (23)
• Revise Phase 1 procedures (24-28)
• Establish database to track requirement flowdown through procedures (31)
• Establish method to hyperlink procedures (32)
• Direct link to procedures from homepage (30)
• Procedure writers attend Human Performance training (29)
• Rapid procedure change process
Oversight & Assessment
Training
• Assign NSQI Project Manager (3)• Develop business case for procedure compliance (8)
ProceduresBehavior
Nuclear Safety and Quality Imperative
• Balancing Safety, Quality, Cost, and Schedule
• Communication and Feedback
• Management Oversight & Assessment
• Verification and Approval of Work Activities
• Quality Improvement
• Adequacy of Procedures
• Procedure Adherence
• Training Personnel to Execute Procedures
• Consolidated engineering organization
– Central technical leadership and design production
– Co-located expertise
– Common equipment groups
– One-stop assessment, feedback, and corrective action
– Consolidated checking and verification functions
– Cross-discipline design support organization for issue tracking, analysis, and improvement actions
– Improved integration of planning tools and resources
• Engineering Quality Analysis tool, monthly updates, action plans
• Revised off-project review procedure
• Process Assurance and E&NS sponsored assessments, including safety envelope and procedural conformance
• Requirements verification process integrated with system description development
• Outside review of key technical risk areas
• Revised project schedule
– Increased durations to support construction and procurement
– Improved sequencing and logical ties of engineering discipline activities
– Improved durations to resolve open technical risk issues
• NSQI communications
– Monthly Engineering Quality presentation on NSQI attributes to all hands
• Engineering leadership off-site sessions regarding NSQI implementation
• Integration of quality goals in management annual performance reviews
• Incorporation of INPO error precursors and HPI principles into CAR follow-up
• Engineering safety envelope stand-down and personal commitment statements
• Engineering Guide for Augmented Monitoring of New Employees/ Employees with New Assignments
• Discipline-specific coaching
– codes and standards
– design tools
– work process requirements
– feedback from surveillances and corrective actions
– feedback from technical and compliance checklists
• Revised training matrices based on current production deliverables
• Technical completeness checklists in key production areas
• Formal safety envelope training and knowledge check
• PSAR update - training and review
• Additional staff training and utilization in Root Cause Analysis
• Procedure compliance actions
– Compliance checklists/metrics (18)
– Improved procedure change processes
– Procedure compliance statements
– New employee orientation regarding expectations
– WTP document hierarchy clarified and published
• Procedure adequacy actions– Clarification of top-level
requirements in procedures– Review of Engineering Guides for
mandatory requirements – Discipline action on compliance
checklist metrics• Additional specific actions
– Engineering Material Coordinator Guide revised (1)
– Equipment database quality metrics and ongoing screening of tagged components
– Additional E&NS reviews and safety screen signature added to design documents
– Improved implementation feedback for safety envelope and design criteria changes
• Advisory Board• Confirmatory Analysis
Bold and italicized items indicate Compensatory Actions
Project-wide compensatory action
• Cross-functional team develop approach to training (Systematic Approach to Training) (20)
• Identify positions and schedule for job analysis (34)
• Analyze positions, develop and deliver training per SAT
• Establish Training Advisory Board (35)
• Create Training Implementation Matrix per DOE 0rder 5480.20A (36)
• Revise training procedures per systematic approach (37)
• Issue Training Program Plan per schedule (38)
• Develop Centralized Issues Tracking System (PIER) (2)
• Revise Management Assessment Procedure
• Provide training to managers regarding behaviors to achieve a Safety Conscious Work Environment attitude (4)
• Conduct management alignment sessions (5)
• Conduct Management Behavioral Gap Analysis (9)
• Management briefing sessions (6)
• Conduct WTP All Hands Meeting (7)
• Conduct one-hour NSQI stand-down sessions (11)
• Conduct quiz on management expectations (12)
• Revise annual HGET training to include NSQI module (13)
• Establish new hire expectations at new hire orientation by senior project management (14)
• Develop website for anonymous questions (15)
• Implement Human Performance (16)
• Develop communication strategy (17)
• Conduct employee survey (19)
• Identify actions from survey results (33)
• Develop Differing Professional Opinion program
• Recognizing and rewarding desired employee behaviors
• Cross-functional team develop approach to address procedure adequacy (21)
• Baseline procedure format and content to Savannah River Site
• Revise Document Administration procedure to increase clarity (22)
• Identify set of procedures which will undergo review for clarification and revision if necessary (23)
• Revise Phase 1 procedures (24-28)
• Establish database to track requirement flowdown through procedures (31)
• Establish method to hyperlink procedures (32)
• Direct link to procedures from homepage (30)
• Procedure writers attend Human Performance training (29)
• Rapid procedure change process
Oversight & Assessment
Training ProceduresBehavior
• Balancing Safety, Quality, Cost, and Schedule
• Communication and Feedback
• Management Oversight & Assessment
• Verification and Approval of Work Activities
• Quality Improvement
• Adequacy of Procedures
• Procedure Adherence
• Training Personnel to Execute Procedures
13
• Revised organization to centralize support to standardized process and procedures
• Revised project schedule
• Construction Safety Alliance
• Motivational off-site team building and alignment
• Improved long range planning and scheduling
• Monthly all employee meetings
• Safety Rallies
• April 2006 Front line supervisor NSQI/HPI
• Crucial conversations
• Procedural adequacy surveys
• Cross-functional 360° procedure review process
• VPP Steering Committee
• VPP Application Process
Engineering
Construction • Established NSQI expectation at new hire orientation by manager of Construction
• Safety Leadership Development Training
–Communications
–Planning
–Trending/Forecasting
–Motivation
• Cross-functional team develop approach to training (Systematic Approach to Training) (20)
• Identify positions and schedule for job analysis (34)
• Analyze positions, develop and deliver training per SAT
• Establish Training Advisory Board (35)
• Create Training Implementation Matrix per DOE 0rder 5480.20A (36)
• Revise training procedures per systematic approach (37)
• Issue Training Program Plan per schedule (38)
Project- Wide • Develop Centralized Issues Tracking System (PIERs) (2)
• Revise Management Assessment Procedure
• Provide training to managers regarding behaviors to achieve a Safety Conscious Work Environment attitude (4)
• Conduct management alignment sessions (5)
• Management briefing sessions (6)
• Conduct Management Behavioral Gap Analysis (9)
• Conduct WTP All Hands Meeting (7)
• Conduct one-hour NSQI stand-down sessions (11)
• Conduct quiz on management expectations (12)
• Revise annual HGET training to include NSQI module (13)
• Establish new hire expectations at new hire orientation by senior project management (14)
• Develop website for anonymous questions (15)
• Implement Human Performance (16)
• Develop communication strategy (17)
• Conduct employee survey (19)
• Identify actions from survey results (33)
• Develop Differing Professional Opinion program
• Recognizing and rewarding desired employee behaviors
• Cross-functional team develop approach to address procedure adequacy (21)
• Baseline procedure format and content to Savannah River Site
• Revise Document Administration procedure to increase clarity (22)
• Identify set of procedures which will undergo review for clarification and revision if necessary (23)
• Revise Phase 1 procedures (24-28)
• Establish database to track requirement flowdown through procedures (31)
• Establish method to hyperlink procedures (32)
• Direct link to procedures from homepage (30)
• Procedure writers attend Human Performance training (29)
• Rapid procedure change process
Oversight & Assessment
Training
• Assign NSQI Project Manager (3)• Develop business case for procedure compliance (8)
ProceduresBehavior
Nuclear Safety and Quality Imperative
• Balancing Safety, Quality, Cost, and Schedule
• Communication and Feedback
• Management Oversight & Assessment
• Verification and Approval of Work Activities
• Quality Improvement
• Adequacy of Procedures
• Procedure Adherence
• Training Personnel to Execute Procedures
• Consolidated engineering organization
– Central technical leadership and design production
– Co-located expertise
– Common equipment groups
– One-stop assessment, feedback, and corrective action
– Consolidated checking and verification functions
– Cross-discipline design support organization for issue tracking, analysis, and improvement actions
– Improved integration of planning tools and resources
• Engineering Quality Analysis tool, monthly updates, action plans
• Revised off-project review procedure
• Process Assurance and E&NS sponsored assessments, including safety envelope and procedural conformance
• Requirements verification process integrated with system description development
• Outside review of key technical risk areas
• Revised project schedule
– Increased durations to support construction and procurement
– Improved sequencing and logical ties of engineering discipline activities
– Improved durations to resolve open technical risk issues
• NSQI communications
– Monthly Engineering Quality presentation on NSQI attributes to all hands
• Engineering leadership off-site sessions regarding NSQI implementation
• Integration of quality goals in management annual performance reviews
• Incorporation of INPO error precursors and HPI principles into CAR follow-up
• Engineering safety envelope stand-down and personal commitment statements
• Engineering Guide for Augmented Monitoring of New Employees/ Employees with New Assignments
• Discipline-specific coaching
– codes and standards
– design tools
– work process requirements
– feedback from surveillances and corrective actions
– feedback from technical and compliance checklists
• Revised training matrices based on current production deliverables
• Technical completeness checklists in key production areas
• Formal safety envelope training and knowledge check
• PSAR update - training and review
• Additional staff training and utilization in Root Cause Analysis
• Procedure compliance actions
– Compliance checklists/metrics (18)
– Improved procedure change processes
– Procedure compliance statements
– New employee orientation regarding expectations
– WTP document hierarchy clarified and published
• Procedure adequacy actions– Clarification of top-level
requirements in procedures– Review of Engineering Guides for
mandatory requirements – Discipline action on compliance
checklist metrics• Additional specific actions
– Engineering Material Coordinator Guide revised (1)
– Equipment database quality metrics and ongoing screening of tagged components
– Additional E&NS reviews and safety screen signature added to design documents
– Improved implementation feedback for safety envelope and design criteria changes
• Advisory Board• Confirmatory Analysis
Bold and italicized items indicate Compensatory Actions
Centralized issue tracking system: PIER
System implemented to ease identification of issues
Issues, Concerns, Questions, Problems,
Recommendations
Report It
Resolve It
Review It
14
All Hands Meeting – March
One-Hour Stand-down – April- Culture Cards
Expectation Quiz – April
Employee Briefings – April...
“Ask Jim”/ “Ask Bill” website – March...
New Hire Orientation changes – April...
HGET Annual Refresher revision – April...
NSQ culture change activities are pervasive
Completed Ongoing• Revised organization to centralize
support to standardized process and procedures
• Revised project schedule
• Construction Safety Alliance
• Motivational off-site team building and alignment
• Improved long range planning and scheduling
• Monthly all employee meetings
• Safety Rallies
• April 2006 Front line supervisor NSQI/HPI
• Crucial conversations
• Procedural adequacy surveys
• Cross-functional 360° procedure review process
• VPP Steering Committee
• VPP Application Process
Engineering
Construction • Established NSQI expectation at new hire orientation by manager of Construction
• Safety Leadership Development Training
–Communications
–Planning
–Trending/Forecasting
–Motivation
• Cross-functional team develop approach to training (Systematic Approach to Training) (20)
• Identify positions and schedule for job analysis (34)
• Analyze positions, develop and deliver training per SAT
• Establish Training Advisory Board (35)
• Create Training Implementation Matrix per DOE 0rder 5480.20A (36)
• Revise training procedures per systematic approach (37)
• Issue Training Program Plan per schedule (38)
Project- Wide • Develop Centralized Issues Tracking System (PIERs) (2)
• Revise Management Assessment Procedure
• Provide training to managers regarding behaviors to achieve a Safety Conscious Work Environment attitude (4)
• Conduct management alignment sessions (5)
• Management briefing sessions (6)
• Conduct Management Behavioral Gap Analysis (9)
• Conduct WTP All Hands Meeting (7)
• Conduct one-hour NSQI stand-down sessions (11)
• Conduct quiz on management expectations (12)
• Revise annual HGET training to include NSQI module (13)
• Establish new hire expectations at new hire orientation by senior project management (14)
• Develop website for anonymous questions (15)
• Implement Human Performance (16)
• Develop communication strategy (17)
• Conduct employee survey (19)
• Identify actions from survey results (33)
• Develop Differing Professional Opinion program
• Recognizing and rewarding desired employee behaviors
• Cross-functional team develop approach to address procedure adequacy (21)
• Baseline procedure format and content to Savannah River Site
• Revise Document Administration procedure to increase clarity (22)
• Identify set of procedures which will undergo review for clarification and revision if necessary (23)
• Revise Phase 1 procedures (24-28)
• Establish database to track requirement flowdown through procedures (31)
• Establish method to hyperlink procedures (32)
• Direct link to procedures from homepage (30)
• Procedure writers attend Human Performance training (29)
• Rapid procedure change process
Oversight & Assessment
Training
• Assign NSQI Project Manager (3)• Develop business case for procedure compliance (8)
ProceduresBehavior
Nuclear Safety and Quality Imperative
• Balancing Safety, Quality, Cost, and Schedule
• Communication and Feedback
• Management Oversight & Assessment
• Verification and Approval of Work Activities
• Quality Improvement
• Adequacy of Procedures
• Procedure Adherence
• Training Personnel to Execute Procedures
• Consolidated engineering organization
– Central technical leadership and design production
– Co-located expertise
– Common equipment groups
– One-stop assessment, feedback, and corrective action
– Consolidated checking and verification functions
– Cross-discipline design support organization for issue tracking, analysis, and improvement actions
– Improved integration of planning tools and resources
• Engineering Quality Analysis tool, monthly updates, action plans
• Revised off-project review procedure
• Process Assurance and E&NS sponsored assessments, including safety envelope and procedural conformance
• Requirements verification process integrated with system description development
• Outside review of key technical risk areas
• Revised project schedule
– Increased durations to support construction and procurement
– Improved sequencing and logical ties of engineering discipline activities
– Improved durations to resolve open technical risk issues
• NSQI communications
– Monthly Engineering Quality presentation on NSQI attributes to all hands
• Engineering leadership off-site sessions regarding NSQI implementation
• Integration of quality goals in management annual performance reviews
• Incorporation of INPO error precursors and HPI principles into CAR follow-up
• Engineering safety envelope stand-down and personal commitment statements
• Engineering Guide for Augmented Monitoring of New Employees/ Employees with New Assignments
• Discipline-specific coaching
– codes and standards
– design tools
– work process requirements
– feedback from surveillances and corrective actions
– feedback from technical and compliance checklists
• Revised training matrices based on current production deliverables
• Technical completeness checklists in key production areas
• Formal safety envelope training and knowledge check
• PSAR update - training and review
• Additional staff training and utilization in Root Cause Analysis
• Procedure compliance actions
– Compliance checklists/metrics (18)
– Improved procedure change processes
– Procedure compliance statements
– New employee orientation regarding expectations
– WTP document hierarchy clarified and published
• Procedure adequacy actions– Clarification of top-level
requirements in procedures– Review of Engineering Guides for
mandatory requirements – Discipline action on compliance
checklist metrics• Additional specific actions
– Engineering Material Coordinator Guide revised (1)
– Equipment database quality metrics and ongoing screening of tagged components
– Additional E&NS reviews and safety screen signature added to design documents
– Improved implementation feedback for safety envelope and design criteria changes
• Advisory Board• Confirmatory Analysis
Bold and italicized items indicate Compensatory Actions
Human Performance Training
Communication Strategy• Weekly Newsletter• NSQI Website• Posters• Employee Messages
Recognition Strategy• Employee Owned• Management
Supported
15
Desired management behaviors
Balance safety and quality and cost and schedule Maintain consistent conservatism in decisions Be receptive to constructive criticism, willing to acknowledge mistakes,
and open and transparent Willingness to actively listen, be influenced, provide feedback, interact
with employees Give measured, reflective, facts-based responses Provide consistent, meaningful, positive reinforcement Apply fair and consistent discipline
• Revised organization to centralize support to standardized process and procedures
• Revised project schedule
• Construction Safety Alliance
• Motivational off-site team building and alignment
• Improved long range planning and scheduling
• Monthly all employee meetings
• Safety Rallies
• April 2006 Front line supervisor NSQI/HPI
• Crucial conversations
• Procedural adequacy surveys
• Cross-functional 360° procedure review process
• VPP Steering Committee
• VPP Application Process
Engineering
Construction • Established NSQI expectation at new hire orientation by manager of Construction
• Safety Leadership Development Training
–Communications
–Planning
–Trending/Forecasting
–Motivation
• Cross-functional team develop approach to training (Systematic Approach to Training) (20)
• Identify positions and schedule for job analysis (34)
• Analyze positions, develop and deliver training per SAT
• Establish Training Advisory Board (35)
• Create Training Implementation Matrix per DOE 0rder 5480.20A (36)
• Revise training procedures per systematic approach (37)
• Issue Training Program Plan per schedule (38)
Project- Wide • Develop Centralized Issues Tracking System (PIERs) (2)
• Revise Management Assessment Procedure
• Provide training to managers regarding behaviors to achieve a Safety Conscious Work Environment attitude (4)
• Conduct management alignment sessions (5)
• Management briefing sessions (6)
• Conduct Management Behavioral Gap Analysis (9)
• Conduct WTP All Hands Meeting (7)
• Conduct one-hour NSQI stand-down sessions (11)
• Conduct quiz on management expectations (12)
• Revise annual HGET training to include NSQI module (13)
• Establish new hire expectations at new hire orientation by senior project management (14)
• Develop website for anonymous questions (15)
• Implement Human Performance (16)
• Develop communication strategy (17)
• Conduct employee survey (19)
• Identify actions from survey results (33)
• Develop Differing Professional Opinion program
• Recognizing and rewarding desired employee behaviors
• Cross-functional team develop approach to address procedure adequacy (21)
• Baseline procedure format and content to Savannah River Site
• Revise Document Administration procedure to increase clarity (22)
• Identify set of procedures which will undergo review for clarification and revision if necessary (23)
• Revise Phase 1 procedures (24-28)
• Establish database to track requirement flowdown through procedures (31)
• Establish method to hyperlink procedures (32)
• Direct link to procedures from homepage (30)
• Procedure writers attend Human Performance training (29)
• Rapid procedure change process
Oversight & Assessment
Training
• Assign NSQI Project Manager (3)• Develop business case for procedure compliance (8)
ProceduresBehavior
Nuclear Safety and Quality Imperative
• Balancing Safety, Quality, Cost, and Schedule
• Communication and Feedback
• Management Oversight & Assessment
• Verification and Approval of Work Activities
• Quality Improvement
• Adequacy of Procedures
• Procedure Adherence
• Training Personnel to Execute Procedures
• Consolidated engineering organization
– Central technical leadership and design production
– Co-located expertise
– Common equipment groups
– One-stop assessment, feedback, and corrective action
– Consolidated checking and verification functions
– Cross-discipline design support organization for issue tracking, analysis, and improvement actions
– Improved integration of planning tools and resources
• Engineering Quality Analysis tool, monthly updates, action plans
• Revised off-project review procedure
• Process Assurance and E&NS sponsored assessments, including safety envelope and procedural conformance
• Requirements verification process integrated with system description development
• Outside review of key technical risk areas
• Revised project schedule
– Increased durations to support construction and procurement
– Improved sequencing and logical ties of engineering discipline activities
– Improved durations to resolve open technical risk issues
• NSQI communications
– Monthly Engineering Quality presentation on NSQI attributes to all hands
• Engineering leadership off-site sessions regarding NSQI implementation
• Integration of quality goals in management annual performance reviews
• Incorporation of INPO error precursors and HPI principles into CAR follow-up
• Engineering safety envelope stand-down and personal commitment statements
• Engineering Guide for Augmented Monitoring of New Employees/ Employees with New Assignments
• Discipline-specific coaching
– codes and standards
– design tools
– work process requirements
– feedback from surveillances and corrective actions
– feedback from technical and compliance checklists
• Revised training matrices based on current production deliverables
• Technical completeness checklists in key production areas
• Formal safety envelope training and knowledge check
• PSAR update - training and review
• Additional staff training and utilization in Root Cause Analysis
• Procedure compliance actions
– Compliance checklists/metrics (18)
– Improved procedure change processes
– Procedure compliance statements
– New employee orientation regarding expectations
– WTP document hierarchy clarified and published
• Procedure adequacy actions– Clarification of top-level
requirements in procedures– Review of Engineering Guides for
mandatory requirements – Discipline action on compliance
checklist metrics• Additional specific actions
– Engineering Material Coordinator Guide revised (1)
– Equipment database quality metrics and ongoing screening of tagged components
– Additional E&NS reviews and safety screen signature added to design documents
– Improved implementation feedback for safety envelope and design criteria changes
• Advisory Board• Confirmatory Analysis
Bold and italicized items indicate Compensatory Actions
16
Human Performance
Senior Management sponsorship – Larry Simmons Integrating HP into our current processes through employee
education
– Self assessments
– CAR causal identification
– Event critiques
– Root Cause Analysis
– Employee Concerns and Employee Relations investigations Trained 69 people to date; 49 trained in the 4 day HPI course;
600+ trained at July Safety Rally (manuals & non-manuals); 2 trained at INPO
Moving toward self-sufficient training
– Using EPC examples
• Revised organization to centralize support to standardized process and procedures
• Revised project schedule
• Construction Safety Alliance
• Motivational off-site team building and alignment
• Improved long range planning and scheduling
• Monthly all employee meetings
• Safety Rallies
• April 2006 Front line supervisor NSQI/HPI
• Crucial conversations
• Procedural adequacy surveys
• Cross-functional 360° procedure review process
• VPP Steering Committee
• VPP Application Process
Engineering
Construction • Established NSQI expectation at new hire orientation by manager of Construction
• Safety Leadership Development Training
–Communications
–Planning
–Trending/Forecasting
–Motivation
• Cross-functional team develop approach to training (Systematic Approach to Training) (20)
• Identify positions and schedule for job analysis (34)
• Analyze positions, develop and deliver training per SAT
• Establish Training Advisory Board (35)
• Create Training Implementation Matrix per DOE 0rder 5480.20A (36)
• Revise training procedures per systematic approach (37)
• Issue Training Program Plan per schedule (38)
Project- Wide • Develop Centralized Issues Tracking System (PIERs) (2)
• Revise Management Assessment Procedure
• Provide training to managers regarding behaviors to achieve a Safety Conscious Work Environment attitude (4)
• Conduct management alignment sessions (5)
• Management briefing sessions (6)
• Conduct Management Behavioral Gap Analysis (9)
• Conduct WTP All Hands Meeting (7)
• Conduct one-hour NSQI stand-down sessions (11)
• Conduct quiz on management expectations (12)
• Revise annual HGET training to include NSQI module (13)
• Establish new hire expectations at new hire orientation by senior project management (14)
• Develop website for anonymous questions (15)
• Implement Human Performance (16)
• Develop communication strategy (17)
• Conduct employee survey (19)
• Identify actions from survey results (33)
• Develop Differing Professional Opinion program
• Recognizing and rewarding desired employee behaviors
• Cross-functional team develop approach to address procedure adequacy (21)
• Baseline procedure format and content to Savannah River Site
• Revise Document Administration procedure to increase clarity (22)
• Identify set of procedures which will undergo review for clarification and revision if necessary (23)
• Revise Phase 1 procedures (24-28)
• Establish database to track requirement flowdown through procedures (31)
• Establish method to hyperlink procedures (32)
• Direct link to procedures from homepage (30)
• Procedure writers attend Human Performance training (29)
• Rapid procedure change process
Oversight & Assessment
Training
• Assign NSQI Project Manager (3)• Develop business case for procedure compliance (8)
ProceduresBehavior
Nuclear Safety and Quality Imperative
• Balancing Safety, Quality, Cost, and Schedule
• Communication and Feedback
• Management Oversight & Assessment
• Verification and Approval of Work Activities
• Quality Improvement
• Adequacy of Procedures
• Procedure Adherence
• Training Personnel to Execute Procedures
• Consolidated engineering organization
– Central technical leadership and design production
– Co-located expertise
– Common equipment groups
– One-stop assessment, feedback, and corrective action
– Consolidated checking and verification functions
– Cross-discipline design support organization for issue tracking, analysis, and improvement actions
– Improved integration of planning tools and resources
• Engineering Quality Analysis tool, monthly updates, action plans
• Revised off-project review procedure
• Process Assurance and E&NS sponsored assessments, including safety envelope and procedural conformance
• Requirements verification process integrated with system description development
• Outside review of key technical risk areas
• Revised project schedule
– Increased durations to support construction and procurement
– Improved sequencing and logical ties of engineering discipline activities
– Improved durations to resolve open technical risk issues
• NSQI communications
– Monthly Engineering Quality presentation on NSQI attributes to all hands
• Engineering leadership off-site sessions regarding NSQI implementation
• Integration of quality goals in management annual performance reviews
• Incorporation of INPO error precursors and HPI principles into CAR follow-up
• Engineering safety envelope stand-down and personal commitment statements
• Engineering Guide for Augmented Monitoring of New Employees/ Employees with New Assignments
• Discipline-specific coaching
– codes and standards
– design tools
– work process requirements
– feedback from surveillances and corrective actions
– feedback from technical and compliance checklists
• Revised training matrices based on current production deliverables
• Technical completeness checklists in key production areas
• Formal safety envelope training and knowledge check
• PSAR update - training and review
• Additional staff training and utilization in Root Cause Analysis
• Procedure compliance actions
– Compliance checklists/metrics (18)
– Improved procedure change processes
– Procedure compliance statements
– New employee orientation regarding expectations
– WTP document hierarchy clarified and published
• Procedure adequacy actions– Clarification of top-level
requirements in procedures– Review of Engineering Guides for
mandatory requirements – Discipline action on compliance
checklist metrics• Additional specific actions
– Engineering Material Coordinator Guide revised (1)
– Equipment database quality metrics and ongoing screening of tagged components
– Additional E&NS reviews and safety screen signature added to design documents
– Improved implementation feedback for safety envelope and design criteria changes
• Advisory Board• Confirmatory Analysis
Bold and italicized items indicate Compensatory Actions
17
Effect
Large Scope
Easier to get 1 through
Not Enough Info
Inconsistent
Structure
Details Lost
Complexity
Amount of Reviewers
New Nuke Job
Amount of Requirements
Findings ProceduresNot Value Added
#/Titles
Tools
Reqs - Where are they
Flow chart -
Out of date info
Examples not updated
Flow Process not updated
Change Process
Appendicies
ShouldsConsistent use of forms/inst.
Duplicate Overlap Procedures
Conflict instructions & forms & Reqs
Mgt Override
Mgt Direction
User Expectations
Loop Holes
Alternatives
Wordiness
Compensating for Training
too much detail
Based on Competence
Based on Training
Guide vs. Procedure
Procedures Vs. Alternatives
Who Decides
Criteria
Detail
Understanding Definitions
Mandatory vs. Not
Procedure Creep (full circle)
Failure to understand impacts
Incidents
Lessons Learned
Requirements
Findings
Political Expectations
Human Factors
Finding Details
Frustration / Find
Procedural Adequacy
Verbatim Compliance
Should vs shall
Too detailed
Guide vs procedure
More opps for failure
No Project Standards
Sloppiness
Failure to Clearly ID reqs in proc.
Forcing Process / Flow
Shall vs. Should
Perceived Definitions
Inconsistent Definitions
Improper usage of shall vs should
Use of passive vs active voice
increases wordinessincreased # interpretations
Where's the balance?
misuse of application
CARs (Time/Rep/$)
violated shall
inproper use of shall
violation
Inconsistent Consequences
Definitions (reqs in)
management expectations
irrelevant reqs.
inconsistent instructions vs forms
division of resp.
detail philosophy vs procedure
judgement vs procedure checklists
EvolutionFormat
Form Driven
1 pg form vs 20pgs instruct.
Interpretations / Reqs
clarifications
clarifications
interpretations
Who writes the procedures
trained
competent
questioning attitudeSME
Tech Writer
Limited Procedure Resources (overhead)
Binning / less duplication
Less procedures to look at
Review & Approval
Mult. Functs InvolvedGet all views
Guide vs. Procedure
Defensive MedicineCorp Approval
Lack of TeamworkIterations / Socpe
LogisticsEarly approver invovlement
Rules MixingUniqueness
Allow Flexability
Training
Assignment of Procedures
Linking Procedures
Job specific
Visibility
Incidents drive addtions
'Clarification'
percieved Reqs
why vs. what and how
Reqs change
Missed change flowdowns
can update seperately
Different ownerships
Comms between Depts
Complexity
Revision Process
Linkage
CAR Fix
Easy to fix procedure vs. behavior
Idea posturing
Background
Easy to provePriority Perception in Procedure
People learn differently
Experiences / Bias
Assumptions of common knowledge
Logical flow
Workload
appropriate length
KISS Structure / Language
Poor Structure
Precedence
Absent in directions
Human Factors
Schedule
Change process limited
Changing Strategy
Tech Comptency of Writer
Can't write
Apathy
Scope of review / Interface
ID of flowdowns
Human Factors
Scope
Purpose
Cycle Times
Approval / Concure processs
Proc. Creep
Structure
Level of Detail
Alternative not utilized
Human Factors
Verbiage Choice
Characteristic Selection MatrixResults
0%
2%
4%
6%
8%
10%
12%
14%
16%
Sh
all v
s. S
ho
uld
Hu
man
Fac
tors
Str
uct
ure
/No
Pro
ject
Std
s.
Inco
nsi
sten
cy/S
lop
py
Pro
c. C
on
ten
t
Ch
ang
e P
roce
ss
CA
R F
ix
Pro
ced
ure
vs.
Alts
Lev
el o
f Det
ail
(Co
mp
lexi
ty)
Co
nfli
ctin
gF
orm
s/In
st.
Du
plic
ate/
Ove
rlap
Cle
arly
ref
eren
cin
gR
eqs
Input Characteristic
Ch
arac
teri
stic
Imp
ort
ance
(%)
Procedure Creation
Ext
ern
al F
unct
ional R
evi
ew
Inte
rnal F
unct
ional R
evi
ew
Pro
cedure
Gro
up
Pro
cedure
Auth
or
Yes
No
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
No
Yes
No
Yes
No
No
Yes
No
No
Yes
Yes
No
Yes
No
Yes
No
No
Yes
Yes
No No
No
Yes
All commentsincorporated?
ResolutionAccepted?
ResolutionAccepted?
Forwardcomments to
author forresolution*
Commentsfrom review?
Reviewer Criteria-Defined by procedure(MGT-007)-Affected Functions
-SME-Corporate Review(Chief’s Review)
-Minimum Reviewers-EN&S-QA-Config Mgt-Safety Assurance
Initiate commentresolution with
reviewer
Commentsfrom review?
Incorporateeditorial changesCreate DHR and
review requestemail. Send
review request torequired reviewers
File no commentsemail
Functionalconcurrence
required?
Resolve and/orincorporate all
reviewercomments into
procedure
Send concurrencerequest email toDHR reviewers
Editorialchanges?
Send final versionof procedure to PG
Start concurrenceprocess
ID Reviewers
Concurrence?
Forwardcomments to
author forresolution
Start reviewprocess
CollectRequirements Informal/Internal
Reviews
Decide who writesprocedure
Write ProcedureDraft
Who-EstablishedProcedure Groups-SME-User-Mgmt-Corp
Decide-Time-Budget-Est. Group-Competence/Qualified-Multiple-Risk-Ghost Writer
Collect reqs.-Content-Flowdowns-BNI policy/procedure-Codes/standards-QAM-ABMGMT. Reqs.-LicensingDocs/Permits-Other OutsideGroups-Internal Funct.Groups-Other WTPProcedures
Procedure Drafting-Templates-Style Guide-ExistingProcedure-Forms-Flow charts_______________
GuideProcedure/
Guide/DesktopInstruction
Decision Criteria-Implementing?ProcedureGuides/Instructions-Shall-Procedure/Corp. Proc/SWPP-Directed to by QA/ Mngr.-Quality/Safety-Time Constraints-Who is going to review it?
Procedure
ID Need
DesktopInstruction
CreateConstruction
review checklist*
QA Manager Signand return
procedure to PG
Send approvedprocedure to PDC
for issuance.
Incorporateeditorial changes
PG Submits forMOC approval
Route for QAchecklist
signatures. (PerGPP-QA-207).
Incorporateeditorial changes
FM Approves?
Print final versionfor signature
Maintain non-record copy of
approvedprocedure
Editorialchanges?
QA Mgt App. Criteria-Rev. 0-QAM
QA Concurs?
Editorialchanges?
Start approvalprocess
Additionalconstructionreviewers?
Complete checklistand sign*
procedure asapplicable. Returnprocedure to PG
Editorialchanges?
FM Signs andreturns to PG
QAManagersignaturerequired?
Concur?
Incorporateeditorial changes
QA ManagerConcurs?
Procedures PIP – Process
Phases: Identify
– Requirements
– Process Mapping Measure
– Fishbone
– XY Matrix
– Data Collection Analyze
– Analyzed Data Collected
– Review other sites procedures
18
Procedures PIP – Process
X’s (largest contributors): Human Factors
– Length
– Complexity Should vs. Shall Structure Inconsistencies
19
Procedure improvements
Identified potential improvement opportunities Compared procedures with Savannah River Site Improvement action items:
– Revision of Document Administration ProcedureStandard structureClearer definitionsInclude attributes of an adequate procedure
– Better flowdown and change management
– Evaluation/revision of AB/QAM affecting proceduresThree-phased approach; Phase I nearing completion
• Revised organization to centralize support to standardized process and procedures
• Revised project schedule
• Construction Safety Alliance
• Motivational off-site team building and alignment
• Improved long range planning and scheduling
• Monthly all employee meetings
• Safety Rallies
• April 2006 Front line supervisor NSQI/HPI
• Crucial conversations
• Procedural adequacy surveys
• Cross-functional 360° procedure review process
• VPP Steering Committee
• VPP Application Process
Engineering
Construction • Established NSQI expectation at new hire orientation by manager of Construction
• Safety Leadership Development Training
–Communications
–Planning
–Trending/Forecasting
–Motivation
• Cross-functional team develop approach to training (Systematic Approach to Training) (20)
• Identify positions and schedule for job analysis (34)
• Analyze positions, develop and deliver training per SAT
• Establish Training Advisory Board (35)
• Create Training Implementation Matrix per DOE 0rder 5480.20A (36)
• Revise training procedures per systematic approach (37)
• Issue Training Program Plan per schedule (38)
Project- Wide • Develop Centralized Issues Tracking System (PIERs) (2)
• Revise Management Assessment Procedure
• Provide training to managers regarding behaviors to achieve a Safety Conscious Work Environment attitude (4)
• Conduct management alignment sessions (5)
• Management briefing sessions (6)
• Conduct Management Behavioral Gap Analysis (9)
• Conduct WTP All Hands Meeting (7)
• Conduct one-hour NSQI stand-down sessions (11)
• Conduct quiz on management expectations (12)
• Revise annual HGET training to include NSQI module (13)
• Establish new hire expectations at new hire orientation by senior project management (14)
• Develop website for anonymous questions (15)
• Implement Human Performance (16)
• Develop communication strategy (17)
• Conduct employee survey (19)
• Identify actions from survey results (33)
• Develop Differing Professional Opinion program
• Recognizing and rewarding desired employee behaviors
• Cross-functional team develop approach to address procedure adequacy (21)
• Baseline procedure format and content to Savannah River Site
• Revise Document Administration procedure to increase clarity (22)
• Identify set of procedures which will undergo review for clarification and revision if necessary (23)
• Revise Phase 1 procedures (24-28)
• Establish database to track requirement flowdown through procedures (31)
• Establish method to hyperlink procedures (32)
• Direct link to procedures from homepage (30)
• Procedure writers attend Human Performance training (29)
• Rapid procedure change process
Oversight & Assessment
Training
• Assign NSQI Project Manager (3)• Develop business case for procedure compliance (8)
ProceduresBehavior
Nuclear Safety and Quality Imperative
• Balancing Safety, Quality, Cost, and Schedule
• Communication and Feedback
• Management Oversight & Assessment
• Verification and Approval of Work Activities
• Quality Improvement
• Adequacy of Procedures
• Procedure Adherence
• Training Personnel to Execute Procedures
• Consolidated engineering organization
– Central technical leadership and design production
– Co-located expertise
– Common equipment groups
– One-stop assessment, feedback, and corrective action
– Consolidated checking and verification functions
– Cross-discipline design support organization for issue tracking, analysis, and improvement actions
– Improved integration of planning tools and resources
• Engineering Quality Analysis tool, monthly updates, action plans
• Revised off-project review procedure
• Process Assurance and E&NS sponsored assessments, including safety envelope and procedural conformance
• Requirements verification process integrated with system description development
• Outside review of key technical risk areas
• Revised project schedule
– Increased durations to support construction and procurement
– Improved sequencing and logical ties of engineering discipline activities
– Improved durations to resolve open technical risk issues
• NSQI communications
– Monthly Engineering Quality presentation on NSQI attributes to all hands
• Engineering leadership off-site sessions regarding NSQI implementation
• Integration of quality goals in management annual performance reviews
• Incorporation of INPO error precursors and HPI principles into CAR follow-up
• Engineering safety envelope stand-down and personal commitment statements
• Engineering Guide for Augmented Monitoring of New Employees/ Employees with New Assignments
• Discipline-specific coaching
– codes and standards
– design tools
– work process requirements
– feedback from surveillances and corrective actions
– feedback from technical and compliance checklists
• Revised training matrices based on current production deliverables
• Technical completeness checklists in key production areas
• Formal safety envelope training and knowledge check
• PSAR update - training and review
• Additional staff training and utilization in Root Cause Analysis
• Procedure compliance actions
– Compliance checklists/metrics (18)
– Improved procedure change processes
– Procedure compliance statements
– New employee orientation regarding expectations
– WTP document hierarchy clarified and published
• Procedure adequacy actions– Clarification of top-level
requirements in procedures– Review of Engineering Guides for
mandatory requirements – Discipline action on compliance
checklist metrics• Additional specific actions
– Engineering Material Coordinator Guide revised (1)
– Equipment database quality metrics and ongoing screening of tagged components
– Additional E&NS reviews and safety screen signature added to design documents
– Improved implementation feedback for safety envelope and design criteria changes
• Advisory Board• Confirmatory Analysis
Bold and italicized items indicate Compensatory Actions
20
Characteristic Selection MatrixResults
0%
5%
10%
15%
20%
25%
30%
35%
Ful
l SA
T
Exi
stin
g +
Som
eS
AT
Exi
stin
g +
Dem
onst
rate
com
pete
ncy
and
supe
rvis
or v
erify
by
sign
atur
e in
divi
dual
is q
ualif
ied.
Exi
stin
g Tr
aini
ngP
rogr
am
Input CharacteristicC
ha
rac
teri
sti
c Im
po
rta
nc
e (
%)
WTP Training
DesignPosition Analysis DevelopAnalyze EvaluateImplement
Fun
ctio
nal
Org
aniz
atio
nT
rain
ing
w/ F
unct
iona
l SM
E
STARTContact Trainingfor Job Analysis
New positionidentified?
Schedule JobAnalysis with
FunctionalOrganization
EvaluateFunctional Areas /
Positions usingcriteria to
determine if SATrequired
Meet SATCriteria?
Identify and listduties of a job
Yes
Meet GradedSAT Criteria?
Perform GradedSAT
Yes
No FurtherAssessment
No
Determine trainingrequirements forposition based on
experience &knowledge of
manager
Characterize tasksby difficulty,
importance, andfrequency
Determineappropriate
training(classroom, CBT,
reading)
Identify theknowledge andskills of future
students
Documentdetermination and
justification
Determine whatstudent will learnin class & how
learning willtransfer to job
(LearningObjectives)
Evaluate trainingeffectiveness on
the job
Material is taughtto students
Evaluateeffectiveness of
the program
End
Develop anexamination plan
to test competency
Determine whatwill be taught and
instructionalmethods
Studentcompetency is
assessed
Identifyimprovements for
the course
Determine howcompetency will be
demonstrated
Approve CourseDesign
Turn trainingdesign into training
material
Training PIP
Phases: Identify & Measure
– Requirements
– Existing Process Mapping Analyze
– Identify Process (XY Matrix) Design
– Detailed Process Mapping Verify
– Plans and Schedules
21
Training PIP – Process
Potential Solutions:
Continue existing training program
Systematic Approach to Training on Positions
that meet criteria (Graded Approach)
Systematic Approach to Training on all Positions
Supervisor verifies competency
22
Training improvements
Prior Approach
– Manage/Supervisor accountability
– On-target; procedure-focused
– Narrow; limited classroom
– Basis not well documented
– No measure of effectiveness Interim Actions
– Discipline-specific enhancements to address identified shortcomings
Overall objective
– Documented basis
– Broad perspective
– Effective media
• Revised organization to centralize support to standardized process and procedures
• Revised project schedule
• Construction Safety Alliance
• Motivational off-site team building and alignment
• Improved long range planning and scheduling
• Monthly all employee meetings
• Safety Rallies
• April 2006 Front line supervisor NSQI/HPI
• Crucial conversations
• Procedural adequacy surveys
• Cross-functional 360° procedure review process
• VPP Steering Committee
• VPP Application Process
Engineering
Construction • Established NSQI expectation at new hire orientation by manager of Construction
• Safety Leadership Development Training
–Communications
–Planning
–Trending/Forecasting
–Motivation
• Cross-functional team develop approach to training (Systematic Approach to Training) (20)
• Identify positions and schedule for job analysis (34)
• Analyze positions, develop and deliver training per SAT
• Establish Training Advisory Board (35)
• Create Training Implementation Matrix per DOE 0rder 5480.20A (36)
• Revise training procedures per systematic approach (37)
• Issue Training Program Plan per schedule (38)
Project- Wide • Develop Centralized Issues Tracking System (PIERs) (2)
• Revise Management Assessment Procedure
• Provide training to managers regarding behaviors to achieve a Safety Conscious Work Environment attitude (4)
• Conduct management alignment sessions (5)
• Management briefing sessions (6)
• Conduct Management Behavioral Gap Analysis (9)
• Conduct WTP All Hands Meeting (7)
• Conduct one-hour NSQI stand-down sessions (11)
• Conduct quiz on management expectations (12)
• Revise annual HGET training to include NSQI module (13)
• Establish new hire expectations at new hire orientation by senior project management (14)
• Develop website for anonymous questions (15)
• Implement Human Performance (16)
• Develop communication strategy (17)
• Conduct employee survey (19)
• Identify actions from survey results (33)
• Develop Differing Professional Opinion program
• Recognizing and rewarding desired employee behaviors
• Cross-functional team develop approach to address procedure adequacy (21)
• Baseline procedure format and content to Savannah River Site
• Revise Document Administration procedure to increase clarity (22)
• Identify set of procedures which will undergo review for clarification and revision if necessary (23)
• Revise Phase 1 procedures (24-28)
• Establish database to track requirement flowdown through procedures (31)
• Establish method to hyperlink procedures (32)
• Direct link to procedures from homepage (30)
• Procedure writers attend Human Performance training (29)
• Rapid procedure change process
Oversight & Assessment
Training
• Assign NSQI Project Manager (3)• Develop business case for procedure compliance (8)
ProceduresBehavior
Nuclear Safety and Quality Imperative
• Balancing Safety, Quality, Cost, and Schedule
• Communication and Feedback
• Management Oversight & Assessment
• Verification and Approval of Work Activities
• Quality Improvement
• Adequacy of Procedures
• Procedure Adherence
• Training Personnel to Execute Procedures
• Consolidated engineering organization
– Central technical leadership and design production
– Co-located expertise
– Common equipment groups
– One-stop assessment, feedback, and corrective action
– Consolidated checking and verification functions
– Cross-discipline design support organization for issue tracking, analysis, and improvement actions
– Improved integration of planning tools and resources
• Engineering Quality Analysis tool, monthly updates, action plans
• Revised off-project review procedure
• Process Assurance and E&NS sponsored assessments, including safety envelope and procedural conformance
• Requirements verification process integrated with system description development
• Outside review of key technical risk areas
• Revised project schedule
– Increased durations to support construction and procurement
– Improved sequencing and logical ties of engineering discipline activities
– Improved durations to resolve open technical risk issues
• NSQI communications
– Monthly Engineering Quality presentation on NSQI attributes to all hands
• Engineering leadership off-site sessions regarding NSQI implementation
• Integration of quality goals in management annual performance reviews
• Incorporation of INPO error precursors and HPI principles into CAR follow-up
• Engineering safety envelope stand-down and personal commitment statements
• Engineering Guide for Augmented Monitoring of New Employees/ Employees with New Assignments
• Discipline-specific coaching
– codes and standards
– design tools
– work process requirements
– feedback from surveillances and corrective actions
– feedback from technical and compliance checklists
• Revised training matrices based on current production deliverables
• Technical completeness checklists in key production areas
• Formal safety envelope training and knowledge check
• PSAR update - training and review
• Additional staff training and utilization in Root Cause Analysis
• Procedure compliance actions
– Compliance checklists/metrics (18)
– Improved procedure change processes
– Procedure compliance statements
– New employee orientation regarding expectations
– WTP document hierarchy clarified and published
• Procedure adequacy actions– Clarification of top-level
requirements in procedures– Review of Engineering Guides for
mandatory requirements – Discipline action on compliance
checklist metrics• Additional specific actions
– Engineering Material Coordinator Guide revised (1)
– Equipment database quality metrics and ongoing screening of tagged components
– Additional E&NS reviews and safety screen signature added to design documents
– Improved implementation feedback for safety envelope and design criteria changes
• Advisory Board• Confirmatory Analysis
Bold and italicized items indicate Compensatory Actions
23
Oversight & Assessment
Training ProceduresBehavior
• Balancing Safety, Quality, Cost, and Schedule
• Communication and Feedback
• Management Oversight & Assessment
• Verification and Approval of Work Activities
• Quality Improvement
• Adequacy of Procedures
• Procedure Adherence
• Training Personnel to Execute Procedures
• Consolidated engineering organization
– Central technical leadership and design production
– Co-located expertise
– Common equipment groups
– One-stop assessment, feedback, and corrective action
– Consolidated checking and verification functions
– Cross-discipline design support organization for issue tracking, analysis, and improvement actions
– Improved integration of planning tools and resources
• Engineering Quality Analysis tool, monthly updates, action plans
• Revised off-project review procedure
• Process Assurance and E&NS sponsored assessments, including safety envelope and procedural conformance
• Requirements verification process integrated with system description development
• Outside review of key technical risk areas
• Revised project schedule
– Increased durations to support construction and procurement
– Improved sequencing and logic ties of engineering discipline activities
– Improved durations to resolve open technical risk issues
• NSQI communications
– Monthly Engineering Quality presentation on NSQI attributes to all hands
• Engineering leadership off-site sessions regarding NSQI implementation
• Integration of quality goals in management annual performance reviews
• Incorporation of INPO error precursors and HPI principles into CAR follow-up
• Engineering safety envelope stand-down and personal commitment statements
• Augmented Monitoring of New Employees/ Employees with New Assignments
• Discipline-specific coaching
– codes and standards
– design tools
– work process requirements
– feedback from surveillances and corrective actions
– feedback from technical and compliance checklists
• Revised training matrices based on current production deliverables
• Technical completeness checklists in key production areas
• Formal safety envelope training and knowledge check
• PSAR update - training and review
• Additional staff training and utilization in Root Cause Analysis
• Procedure compliance actions
– Compliance checklists/metrics (18)
– Improved procedure change processes
– Procedure compliance statements
– New employee orientation regarding expectations
– WTP document hierarchy clarified and published
• Procedure adequacy actions– Clarification of top-level
requirements in procedures– Review of Engineering Guides for
mandatory requirements – Discipline action on compliance
checklist metrics• Additional specific actions
– Engineering Material Coordinator Guide revised (1)
– Equipment database quality metrics and ongoing screening of tagged components
– Additional E&NS reviews and safety screen signature added to design documents
– Improved implementation feedback for safety envelope and design criteria changes
• Revised organization to centralize support to standardized process and procedures
• Revised project schedule
• Construction Safety Alliance
• Motivational off-site team building and alignment
• Improved long range planning and scheduling
• Monthly all employee meetings
• Safety Rallies
• April 2006 Front line supervisor NSQI/HPI
• Crucial conversations
• Procedural adequacy surveys
• Cross-functional 360° procedure review process
• VPP Steering Committee
• VPP Application Process
Engineering
Construction • Established NSQI expectation at new hire orientation by manager of Construction
• Safety Leadership Development Training
–Communications
–Planning
–Trending/Forecasting
–Motivation
• Cross-functional team develop approach to training (Systematic Approach to Training) (20)
• Identify positions and schedule for job analysis (34)
• Analyze positions, develop and deliver training per SAT
• Establish Training Advisory Board (35)
• Create Training Implementation Matrix per DOE 0rder 5480.20A (36)
• Revise training procedures per systematic approach (37)
• Issue Training Program Plan per schedule (38)
Project- Wide • Develop Centralized Issues Tracking System (PIERs) (2)
• Revise Management Assessment Procedure
• Provide training to managers regarding behaviors to achieve a Safety Conscious Work Environment attitude (4)
• Conduct management alignment sessions (5)
• Management briefing sessions (6)
• Conduct Management Behavioral Gap Analysis (9)
• Conduct WTP All Hands Meeting (7)
• Conduct one-hour NSQI stand-down sessions (11)
• Conduct quiz on management expectations (12)
• Revise annual HGET training to include NSQI module (13)
• Establish new hire expectations at new hire orientation by senior project management (14)
• Develop website for anonymous questions (15)
• Implement Human Performance (16)
• Develop communication strategy (17)
• Conduct employee survey (19)
• Identify actions from survey results (33)
• Develop Differing Professional Opinion program
• Recognizing and rewarding desired employee behaviors
• Cross-functional team develop approach to address procedure adequacy (21)
• Baseline procedure format and content to Savannah River Site
• Revise Document Administration procedure to increase clarity (22)
• Identify set of procedures which will undergo review for clarification and revision if necessary (23)
• Revise Phase 1 procedures (24-28)
• Establish database to track requirement flowdown through procedures (31)
• Establish method to hyperlink procedures (32)
• Direct link to procedures from homepage (30)
• Procedure writers attend Human Performance training (29)
• Rapid procedure change process
Oversight & Assessment
Training
• Assign NSQI Project Manager (3)• Develop business case for procedure compliance (8)
ProceduresBehavior
Nuclear Safety and Quality Imperative
• Balancing Safety, Quality, Cost, and Schedule
• Communication and Feedback
• Management Oversight & Assessment
• Verification and Approval of Work Activities
• Quality Improvement
• Adequacy of Procedures
• Procedure Adherence
• Training Personnel to Execute Procedures
• Consolidated engineering organization
– Central technical leadership and design production
– Co-located expertise
– Common equipment groups
– One-stop assessment, feedback, and corrective action
– Consolidated checking and verification functions
– Cross-discipline design support organization for issue tracking, analysis, and improvement actions
– Improved integration of planning tools and resources
• Engineering Quality Analysis tool, monthly updates, action plans
• Revised off-project review procedure
• Process Assurance and E&NS sponsored assessments, including safety envelope and procedural conformance
• Requirements verification process integrated with system description development
• Outside review of key technical risk areas
• Revised project schedule
– Increased durations to support construction and procurement
– Improved sequencing and logical ties of engineering discipline activities
– Improved durations to resolve open technical risk issues
• NSQI communications
– Monthly Engineering Quality presentation on NSQI attributes to all hands
• Engineering leadership off-site sessions regarding NSQI implementation
• Integration of quality goals in management annual performance reviews
• Incorporation of INPO error precursors and HPI principles into CAR follow-up
• Engineering safety envelope stand-down and personal commitment statements
• Engineering Guide for Augmented Monitoring of New Employees/ Employees with New Assignments
• Discipline-specific coaching
– codes and standards
– design tools
– work process requirements
– feedback from surveillances and corrective actions
– feedback from technical and compliance checklists
• Revised training matrices based on current production deliverables
• Technical completeness checklists in key production areas
• Formal safety envelope training and knowledge check
• PSAR update - training and review
• Additional staff training and utilization in Root Cause Analysis
• Procedure compliance actions
– Compliance checklists/metrics (18)
– Improved procedure change processes
– Procedure compliance statements
– New employee orientation regarding expectations
– WTP document hierarchy clarified and published
• Procedure adequacy actions– Clarification of top-level
requirements in procedures– Review of Engineering Guides for
mandatory requirements – Discipline action on compliance
checklist metrics• Additional specific actions
– Engineering Material Coordinator Guide revised (1)
– Equipment database quality metrics and ongoing screening of tagged components
– Additional E&NS reviews and safety screen signature added to design documents
– Improved implementation feedback for safety envelope and design criteria changes
• Advisory Board• Confirmatory Analysis
Bold and italicized items indicate Compensatory Actions
Engineering Actions
24
Procedure compliance checklists
Purpose: Leading indicator to identify error precursor conditions Implemented by document checker as part of normal, pre-
approval, document review Used for calculations, drawings, specifications, material
requisitions, and supplier deviation disposition requisitions Initial results:
– High originator compliance by attribute (0.25% checker “holds” for correction by originator)
– About 8% of design documents had at least one compliance “hold” for correction that was identified during checking
– Metrics pinpoint actionable areas of improvement opportunity
25
Procedure compliance checklists (examples)
26
Procedure compliance checklists
Actions based on metrics:
– Continue using checklists for all calculations, drawings, specifications, material requisitions, and supplier deviation disposition requests
– Discipline-specific actions based on metrics:Originator feedback for non-recurring checker “holds” Staff coaching for recurring checker “holds” Procedure clarification
27
Potential At Risk Practices
Performing a task with two or more procedures Following procedures cookbook style Removing several danger tags quickly without annotating removal
of the tags on the clearance sheet Performing critical checks without peer review or
concurrent verification Having several review and
approval steps Attempting to lift too much
weight to avoid multiple trips Signing off several steps of
a work plan or procedure before performing the steps
28
• Revised organization to centralize support to standardized process and procedures
• Revised project schedule
• Construction Safety Alliance
• Motivational off-site team building and alignment
• Improved long range planning and scheduling
• Monthly all employee meetings
• Safety Rallies
• April 2006 Front line supervisor NSQI/HPI
• Crucial conversations
• Procedural adequacy surveys
• Cross-functional 360° procedure review process
• VPP Steering Committee
• VPP Application Process
• Established NSQI expectation at new hire orientation by manager of Construction
• Safety Leadership Development Training
–Communications
–Planning
–Trending/Forecasting
–Motivation
Oversight & Assessment
Training ProceduresBehavior
Nuclear Safety and Quality Imperative
• Balancing Safety, Quality, Cost, and Schedule
• Communication and Feedback
• Management Oversight & Assessment
• Verification and Approval of Work Activities
• Quality Improvement
• Adequacy of Procedures
• Procedure Adherence
• Training Personnel to Execute Procedures
• Revised organization to centralize support to standardized process and procedures
• Revised project schedule
• Construction Safety Alliance
• Motivational off-site team building and alignment
• Improved long range planning and scheduling
• Monthly all employee meetings
• Safety Rallies
• April 2006 Front line supervisor NSQI/HPI
• Crucial conversations
• Procedural adequacy surveys
• Cross-functional 360° procedure review process
• VPP Steering Committee
• VPP Application Process
Engineering
Construction • Established NSQI expectation at new hire orientation by manager of Construction
• Safety Leadership Development Training
–Communications
–Planning
–Trending/Forecasting
–Motivation
• Cross-functional team develop approach to training (Systematic Approach to Training) (20)
• Identify positions and schedule for job analysis (34)
• Analyze positions, develop and deliver training per SAT
• Establish Training Advisory Board (35)
• Create Training Implementation Matrix per DOE 0rder 5480.20A (36)
• Revise training procedures per systematic approach (37)
• Issue Training Program Plan per schedule (38)
Project- Wide • Develop Centralized Issues Tracking System (PIERs) (2)
• Revise Management Assessment Procedure
• Provide training to managers regarding behaviors to achieve a Safety Conscious Work Environment attitude (4)
• Conduct management alignment sessions (5)
• Management briefing sessions (6)
• Conduct Management Behavioral Gap Analysis (9)
• Conduct WTP All Hands Meeting (7)
• Conduct one-hour NSQI stand-down sessions (11)
• Conduct quiz on management expectations (12)
• Revise annual HGET training to include NSQI module (13)
• Establish new hire expectations at new hire orientation by senior project management (14)
• Develop website for anonymous questions (15)
• Implement Human Performance (16)
• Develop communication strategy (17)
• Conduct employee survey (19)
• Identify actions from survey results (33)
• Develop Differing Professional Opinion program
• Recognizing and rewarding desired employee behaviors
• Cross-functional team develop approach to address procedure adequacy (21)
• Baseline procedure format and content to Savannah River Site
• Revise Document Administration procedure to increase clarity (22)
• Identify set of procedures which will undergo review for clarification and revision if necessary (23)
• Revise Phase 1 procedures (24-28)
• Establish database to track requirement flowdown through procedures (31)
• Establish method to hyperlink procedures (32)
• Direct link to procedures from homepage (30)
• Procedure writers attend Human Performance training (29)
• Rapid procedure change process
Oversight & Assessment
Training
• Assign NSQI Project Manager (3)• Develop business case for procedure compliance (8)
ProceduresBehavior
Nuclear Safety and Quality Imperative
• Balancing Safety, Quality, Cost, and Schedule
• Communication and Feedback
• Management Oversight & Assessment
• Verification and Approval of Work Activities
• Quality Improvement
• Adequacy of Procedures
• Procedure Adherence
• Training Personnel to Execute Procedures
• Consolidated engineering organization
– Central technical leadership and design production
– Co-located expertise
– Common equipment groups
– One-stop assessment, feedback, and corrective action
– Consolidated checking and verification functions
– Cross-discipline design support organization for issue tracking, analysis, and improvement actions
– Improved integration of planning tools and resources
• Engineering Quality Analysis tool, monthly updates, action plans
• Revised off-project review procedure
• Process Assurance and E&NS sponsored assessments, including safety envelope and procedural conformance
• Requirements verification process integrated with system description development
• Outside review of key technical risk areas
• Revised project schedule
– Increased durations to support construction and procurement
– Improved sequencing and logical ties of engineering discipline activities
– Improved durations to resolve open technical risk issues
• NSQI communications
– Monthly Engineering Quality presentation on NSQI attributes to all hands
• Engineering leadership off-site sessions regarding NSQI implementation
• Integration of quality goals in management annual performance reviews
• Incorporation of INPO error precursors and HPI principles into CAR follow-up
• Engineering safety envelope stand-down and personal commitment statements
• Engineering Guide for Augmented Monitoring of New Employees/ Employees with New Assignments
• Discipline-specific coaching
– codes and standards
– design tools
– work process requirements
– feedback from surveillances and corrective actions
– feedback from technical and compliance checklists
• Revised training matrices based on current production deliverables
• Technical completeness checklists in key production areas
• Formal safety envelope training and knowledge check
• PSAR update - training and review
• Additional staff training and utilization in Root Cause Analysis
• Procedure compliance actions
– Compliance checklists/metrics (18)
– Improved procedure change processes
– Procedure compliance statements
– New employee orientation regarding expectations
– WTP document hierarchy clarified and published
• Procedure adequacy actions– Clarification of top-level
requirements in procedures– Review of Engineering Guides for
mandatory requirements – Discipline action on compliance
checklist metrics• Additional specific actions
– Engineering Material Coordinator Guide revised (1)
– Equipment database quality metrics and ongoing screening of tagged components
– Additional E&NS reviews and safety screen signature added to design documents
– Improved implementation feedback for safety envelope and design criteria changes
• Advisory Board• Confirmatory Analysis
Bold and italicized items indicate Compensatory Actions
Construction ActionsChanging our culture
29
Changing our behavior
Safety leadership development training– Communications– Planning– Leading indicators and metrics– Motivation
Revising site work rules and discipline policy with the Safety Alliance
Implementing HPI Application process for VPP Star Status Specific goals in key managers’ annual reviews and performance
measurement plans
30
Events Occur . . .
More often due to error-prone tasks and error-prone work environments than from error-prone individuals.
Error prone tasks and work environments are usually created by latent organizational weaknesses.
31
How do we measure culture?
Continue to shift issue identification to originatorContinue to shift issue identification to originator
Reduce significance
ResponsibleIndividual
Functional Identification
(self assessment)
Quality Assurance
Identification(audit/
assessment)
DOE FindingOther External
Agency Findings