Corrective Action Program and the Safety Culture.ppt...
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Transcript of Corrective Action Program and the Safety Culture.ppt...
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Integrated Safety Management Best Practice:
Corrective Action Program and the Safety Culture
August 27, 2007
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Introduction• Electronic Suspense Routing and Tracking System
(E-STARS®)– Web based action tracking and work flow management
system• Problem Evaluation Request (PER)
– Web based corrective action management system– Module of E-STARS®
• Together– Problem identification– Graded approach management– Cause to corrective action assignment and tracking– Objective evidence closure– Record repository
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HistoryNumerous challenges at Hanford necessitated
change: • DOE performance letter in 2001
– PER and E-STARS® deployed• Multiple layoffs, mission acceleration, restructuring,
funding cuts• Significant legacy issues emerged
– lower level assessment = robust issue identification
• Increased injury and event rates• Increased stop works and union grievances
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HPI Steering Committee Strategy
From:
Emphasizing administration in our processes
Robust defense against second guessing
Robust reaction to events
To:
Robust hazard Identification and mitigation
Processes built for the user
Robust prevention of events
- Shift the organizational focus -
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Gap Analysis
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PER/E-STARS® as an ISM Best Practice
• Enhances productivity through web-based technologies– Built for the users– Single problem identification and action tracking
system• Retired legacy tracking systems
• Optimizes processing time through system automation– Easier to use = more use– Process drives immediate assignment to management
• Provides real time feedback for continual improvement– Increased user confidence in process
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PER/E-STARS® as an ISM Best Practice (cont.)
• Single point of entry for timely identification and evaluation of conditions and the correction of deficiencies adverse to:– Quality – Safety – Health – Operability – Environment
• Graded approach application to corrective action management
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Worker Level Assessment• Enables personnel the ability to:
– Identify quality and safety-related deficiencies– Request process improvement evaluation– Request clarification of requirements– Evaluate lessons learned reports– Manage concerns, findings, or observations from
surveillances, audits, or inspections, and– Manage action items, overall
• Overall increased information flow up and down the chain
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ISMS Continuous Improvement based on effective ISMS Continuous Improvement based on effective problem identification, worker involvement, and event problem identification, worker involvement, and event
preventionprevention
ISMS Continuous Improvement
Event prevention
Worker
involvement
Problem identification
and resolution
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ISMS continuous improvement is based on an ISMS continuous improvement is based on an open work environment where everyone feels open work environment where everyone feels free to raise issues without fear of retaliationfree to raise issues without fear of retaliation
Safe Work Environment (SWE)
Problem identification
and resolution
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Employee involvement•Originator defined level of participation
•Automated e-mail notification system– @ key process steps– @ closure
•Process Improvement Initiative tracking
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Corrective Action Management (CAM) Process Flow
PER Initiation and Shift Office Screening
PER Screening and Senior Management Review
PER Resolution
PER Closure
NOTE: System sends e-mail to originator
NOTE: Responsible Manager contacts Originator
3
4
56
Problem Identification
PERScreening
SeniorManagement
Review
PERResolution
PERClosure
Shift OfficeScreening
2
Problem EvaluationRequest (PER)
Initiation 1
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ISM in Action
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Problem Identification• Employee identifies key attributes:
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Trending Based on Key Attributes• Screening committee assigns trend codes:
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Problem Resolution• Responsible Mangers evaluate problem and
plan corrective actions:
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Investigation and Analysis
• Event investigation and critiques– Consider human factors
• Root Cause Analysis– Consider organizational weaknesses– Consider error likely situations and error
precursors
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Event
ErrorPrecursors
Vision, Beliefs, &
Values
LatentOrganizationalWeaknesses
Mission
Goals
Policies
Processes
Programs
FlawedDefenses
Human Performance (Initiating Action)
Vision, Beliefs, &
Values
Investigation and Analysis
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Results • Dramatic injury and event reduction • Robust problem identification and resolution• Worker safety perception of company has
improved significantly • Worker trust of management high• Raising issues through immediate
supervisor has improved• Integrated ISMS expectations clear and
evident
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Tank Farm ContractorImprovement Cycle
CH2M Prime
Contractor
1999
*DART 3.6
2000 2001 2002 2003 2004 2005 2006
Problem Evaluation Report
(PER) System
ESTARS
Vapor Issues
Safe Work Environment (SWE) Culture
AssessmentMandator
y Respirator Usage in
Farms
ISMS Expectations
4/15/05
Human Performance Improvement
Training
Integration of SWE,
ISMS & HPI
Follow-up SWE
Survey
Acc
iden
t Inj
ury
Rat
e
PIP Addressin
g OA Vapor Issues
244-CR Vault Event
7/22/04
Mission Alignment Process (MAP)
SWE Mentoring
IROF ISMS
PIP
DART 1.0
DART 0.1
IROF
A-Prefix Farms –
Mask Cessation
WFO VPP Star Status
IROFDisciplinary Process Revised
*DART – Days Away and Restricted Time
Not to scale – For illustration only
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PERs Initiated
010002000300040005000600070008000
2001 2002 2003 2004 2005 2006
Year
Num
ber
Problem Evaluation Request Cycle
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Employee Concerns Cycle
2002 2003 2004 2005 2006
Number ECPRequests
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DART and Recordable Injury Cycles
DART RatesFive Year Summary
3.64
2.82
0.11
1.83
1.02
0.0
1.0
2.0
3.0
4.0
5.0
FY02FY03FY04FY05
FY06 Y
TD
Cas
es/2
00,0
00 H
rs
Recordable RatesFive Year Summary
3.08
5.39
3.78
1.54
3.14
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
FY02FY03FY04FY05
FY06 Y
TD
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Conduct of Operations Index Frequency
0
10
20
30
40
50
60
70
80
90
100
A) Skin and clothing Contaminations 8 8 2 2 0
B) Procedure Not Folllowed 11 2 0 0 0
C) Procedure Problem 15 3 8 3 2
D) Training Issues 3 2 1 1 0
E) Management Issues 40 19 12 7 5
F) Lockout/Tagout 5 1 1 0 1
G) Work Control Issues 9 11 7 2 1
FY2002 FY2003 FY2004 FY2005 FY2006 (Year to date)
Conduct of Operations Cycle
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Systems Integration
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Contact InformationMarnelle Sheriff, Project Manager, Lockheed Martin Information Technology
For a demonstration of this and other process automation please call:
509-205-7520