Just Culture Panel Workshop Hanford Contractors DOE Office of River Protection DOE Richland Operatio

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Just Culture Panel WorkshopHanford
ContractorsDOE Office of River ProtectionDOE
Richland Operations Office
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Just Culture Definition

• Definition An environment that clearly defines
  acceptable behavior and recognizes human
  potential for error in a consistent manner
• Attributes
• Recognition of fairness related to the
  identification and resolution of human
  performance problems
• Distinction between honest mistakes and
  intentional shortcuts with respect to discipline
• Free flow of plant information across all levels
  of an organization
• High level of self-reporting

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Just Culture Background

• EPRI study on power plant leading indicators of
  human performance identified 7 themes
• Executive commitment
• Awareness of hazards
• Preparedness for errors and events
• Flexibility to meet operational demands
• Just culture
• Learning culture
• System opacity

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Organizational Elements Related to Just Culture

• Organizational Attributes
• Trust, respect, and fairness
• Communication that can affect performance highly
  valued
• Management communication and reinforcement of
  desired behaviors
• Process Contributors
• Processes eliminate human performance weaknesses
• Procedure deficiencies promptly corrected
• Root cause analysis identifies organizational
  process, and individual contributors to human
  performance events
• Individual Values and Behaviors
• Deficiencies and suggested improvements are
  promptly reported and openly evaluated
• Personnel use questioning attitude and dont
  proceed in face of uncertainty

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Why is Just Culture Important?

• Encourages participation at all levels of an
  organization in the identification of problems
  and continuous improvement
• Minimizes the probability of an event with
  consequences by maximizing organizational
  awareness of non consequential problems
• Promotes a learning culture and honest
  investigation of true weaknesses

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What Do Contractors Need From DOE

• Foster a Learning Environment
• Avoid judgment, blame, punishment for
  non-consequential events if right actions are
  being taken to address the issue. Introduce the
  analog of culpability matrix
• Recognize errors will occur in implementation of
  10 CFR 851. PAAA and 851 enforcement approach
  inhibits, rather than encourages reporting
• Positively reinforce right preventive actions
• Recognize and Promote reporting
• Recognize Promote HPI Concepts of Identifying
  Error-Likely Situations Strengthening Defenses
• Focus on Lessons Learned Rather than Number of
  Errors. Rationalize approach to recurrence
• SPC gt Every process has defects
• Success lies in changing frequency and severity

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What Do Workers Need in a Just Culture

• Trust - Whats Said Gets Done by Management
• Respect for the Individual
• Zero tolerance for HIRD
• Worker involvement in ISMS
• A Belief that Discipline is Fairly Administered
• Use of coaching process
• Respect for the Labor Contract
• Multiple Avenues to Communicate
• Worker participation in event investigations
• Confidence in broader organizational cause
  investigations

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What the Field Needs from HQ

• Focus on Setting DOE policy and high level
  expectations
• Identify HQ, Field, and contractor R2A2 and work
  to drive consistent performance
• Establish consistent corporate metrics that draw
  from established sources (e.g. ORPS, CAIRS, ORPS
  performance analysis) to monitor performance
• Resist the need for instant identification of
  root causes, consequences, and final actions for
  events
• Allow Field to address inconsequential events and
  precursors
• Recognize Field office attempts to foster
  self-reporting of lower level events without
  punishing for increased volume of minor events

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What HQ can do to fosterJust Culture

• Continue to support and sponsor HPI across the
  complex
• Identify and Celebrate success
• Incorporate HPI into the Corporate Performance
  Metrics (e.g. Discovery Clock)

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What is RL Doing?

• Developed a joint HPI Strategic Plan
• Training Key RL staff on HPI Principles (36 for 8
  hr and 7 for 4-day course through 7/7/06)
• Striving to celebrate performance (e.g. HEC R
  response, SWSD safety day, others)
• Consideration of HPI aspects in contract actions
• Direct communication of RL perspective on key
  performance areas (HEC, elec, near miss)
• RL acceptance of non-traditional corrective
  actions to strengthen barriers/defenses to
  address latent organizational weaknesses

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What is ORP Doing?

• Developing a safety conscious work environment
  for all personnel (Feds and Contractors)
• HPI Training for Fed Staff (all in ORP will be
  trainied in 8 hr and about 40 in 4 day)
• Encouraging Contractor implementation of HPI
  principles
• Promoting VPP to our Contractors
• Encouraging personnel (Fed Contractor
  personnel) to report at below event levels so
  lessons can be learned without the cost of an
  event
• Using HPI tools to investigate events

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Just Culture Panel Workshop Hanford
ExperienceCH2M HILL Hanford Group, Inc.
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ISMS at CH2M HILL
Employee involvement
Event Prevention
Problem identification and resolution
Our ISMS strategy is based on an open work
environment where everyone feels free to raise
issues without fear of HIRD
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CH2M HILL Improvement Cycle
Human Performance Improvement Training
Integration of SWE, ISMS HPI
Safe Work Environment (SWE) Culture Assessment
Vapor Issues
ISMS Expectations 4/15/05
Follow-up SWE Survey
WFO VPP Star Status
Accident Injury Rate
Released Sub-Contracted Staff Augmentation
SWE Mentoring
Mandatory Respirator Usage in Farms
A-Prefix Farms Mask Cessation
ISMS/ CONOPS Improvement Training
244-CR Vault Event 7/22/04
Mission Alignment Process (MAP)
Involuntary Reduction of Force
PIP Addressing OA Vapor Issues
Management Changes
Project Delivery System
Tank Farm Acceleration Strategy
Integrated Mission Acceleration Plan (IMAP)
Organi-zational Readiness
ISMS PIP
CAP Completed for 244-CR Event
Problem Evaluation Report System
CH2M Prime Contractor
ESTARS
1999
2000
2001
2002
2003
2004
2005
2006
GAP
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CH2M HILL ECP Requests
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5 Year DART and Recordable Injury Rates
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CH2M HILL Actions Taken to Implement Just Culture

• Alternative avenues expanded more union safety
  representatives Hanford concerns council
• All employee surveys conducted
• Improved IROF process communication and fairness
• Cause analysis process changed to identify
  organizational contributors to human performance
  events
• Single, web based problem identification process
• Trust, respect, and fairness expectations issued
• HPI Training conducted
• Discipline process revised to improve fair
  treatment

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2004 Employee Survey Process Improvement Issues

• Accountability Issues
• Improve consistency in holding everyone
  accountable for their behavior
• Improve fairness and consistency of disciplinary
  process
• Improve timeliness of disciplinary process

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Comparison of Disciplinary Actions by Employee
Group
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Response Time From Event to Review
Days
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2005 HILL All Employee Survey
99 of respondents say they will take action if
potentially unsafe conditions, work practices, or
products are seen
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Question 10 Do you take action if you see
potentially unsafe conditions, work practices, or
products?
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Safety Excellence-Creating a Just CultureFluor
Hanford Inc.
ISM Best Practice Workshop Aurora, CO Sept
12-13, 2006
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Safety Excellence-Just Culture Hows Fluor
Hanford Promoting a Just Culture

• Path to a Just Culture began in August 1996
• Fluors Zero Accident Program
• Provided a Firm belief that Injuries are not the
  cost of progress.
• Presidents Employee Zero Accident Councils
• Provided voice in program ownership of work
  area
• HAMTC Safety Rep. Program
• Provided the Communication, Built Trust, Win-Win
• STOP Work Responsibility
• Pursuit of VPP
• The avenue to worker involvement in work planning
  execution.
• ISMS
• Standardized the process program
• Provided a consistent process for projects
  workers

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Safety Excellence-Just Culture Furthering the
Fluor Hanford Culture

• Continuing to Build on Union Safety Reps. , EZACs
  VPP
• Initiating Human Performance Improvement
• Over 700 trained in HPI Fundamentals
• 40 HPI Practitioners Trained to Implement at
  Project Level
• Learning that Errors will happen, and building
  defenses to mitigate consequences.
• Investigating Incidents using HPI techniques
• Looking deeper into the organization for errors
  conditions
• Greater chance of fixing more than just the
  immediate event
• Integrating Culpability Matrix into decisions on
  discipline
• Understanding better why good people make
  mistakes
• Removing the latitude of poor performers to hide
  in the organization
• Focusing on Early Conflict Resolution
• Supervisor Leadership Training on Mediation
• Trained Intervention Mentors
• Outside Consultants As Necessary

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Culpability Evaluation Flowchart
Were actions as intended?
Knowingly violate expectation?
Pass substitution test? (see note)
History of human performance problems?
Yes
Yes
Yes
No
No
No
Were expectations reasonable, available,
workable, intelligible, and correct?
Were the consequences intended?
Deficiencies in training and selection or
inexperience?
Self-Reported
No
Yes
Yes
Yes
Yes
No
Yes
No
Organization induced violation
System induced error
Blameless error
Intentional act (not an error)
Corrective training or other intervention may be
warranted
Possible reckless violation
Possible negligent error
Evaluate organizational processes and
management/supervisory methods
Note Would other employees have made the same
error?
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Safety Excellence Just CultureFluor Hanford
Results

• Metrics Tell the Story
• VPP Culture Survey Chart
• Employee Safety Concern Chart
• Total Injury Rate Chart
• Number of Safety Related Grievances Chart

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Contacts

• George Jackson, Executive Vice President
• Fluor Hanford
• [phone] George_jackson_at_rl.gov
• Tony Umek, Vice President
• Safety Health
• [phone] Anthony_m_umek_at_rl.gov
• Dave Jackson, Deputy Vice President
• Safety Health
• [phone] Dave_jackson_at_rl.gov
• John Jeskey, HAMTC Safety Rep Director
• Fluor Hanford
• [phone] John_J_Jeskey_at_rl.gov
• P.O. Box 1000 H8-67, Richland, WA 99352

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River CorridorClosure Project
Safety People Results
HPI Just CultureWorkshop Panel On Hanford
Experience
Phillip Keuhlen Director, Safety, Health
Quality
September 12, 2006
U.S. Department of EnergyRichland Operations
Office
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Achieving Just Culture During Transition To A
New Contract

• Special situation
• Contract in public domain, often in public
  discussion, before transition
• New management new means methods
• Uncertainty about future in work force
• Rumors about intentions precede you
• WCH approached as part of establishing strong
  industrial and nuclear safety culture

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INPO Principles for a Strong Nuclear Safety
Culture as a Blueprint

• Everyone is personally responsible for nuclear
  safety
• Leaders demonstrate commitment to safety
• Trust permeates the organization
• Decision making reflects safety first
• Nuclear technology is recognized as special and
  unique
• A questioning attitude is cultivated
• Organization learning is embraced
• Nuclear safety undergoes constant examination

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How WCH Approached Development of a Just Culture
(1)

• Embraced ISMS as the integrating umbrella
• Instituted robust communication process
• Conveyed Zero is the only goal for employee
  injuries
• Actively promoted Time Out for Safety
• Management highly visible and approachable at
  work sites
• Trained FLS as the critical interface with the
  craft
• How do we convey by our actions that people are
  our most valuable resource?
• Tools and exercises in FLS Leadership Workshop
• Incentivized safety performance for all employees

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How WCH Approached Development of a Just Culture
(2)

• Instituted Local Safety Improvement Teams (LSIT)
• Employee led (often by union stewards),
  management supported
• Prompt action feedback are key elements
• Strengthened HAMTC Safety Representative Program
• Weekly drive builds mutual trust confidence
• Built supporting processes
• HPI event investigation
• Culpability matrix considered in constructive
  discipline
• Cultivated employee leadership for pursuit of VPP

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WCH Metrics Indicate Just Culture is Taking

• Employee Concerns
• Grievances
• Safety Performance

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Questions and Answers