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Human Performance Improvement (HPI) Implementation at ORNL - “A Grass

Roots Approach.”

Sam McKenzieSNS Site Operations

Manager

August 19, 2009

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Human Performance Initiative at ORNL

· ORNL began human performance initiative in November 2005 after 6 staff from each major directorate attended a Human Performance course by DOE (Shane Bush).

· These “advocates” began preparing a Fundamentals Class with Training Department

· Parallel Process began to introduce the DuPont Safety Observation for Supervisors Program (STOP)

· Facilities and Operations Directorate (Bargaining Unit) decide to implement the STOP for supervisors as mandatory.

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HPI @ ORNL con’t

· A modified STOP for Supervisors “Program” and HPI Fundamentals Training were presented to Leadership Team as options for Lab wide adherence.

· Mandatory Management Observation Training (modified STOP) held for all Division Directors and Group Leaders with expectation of 2 surveillances per month.

· HPI grass roots effort rolled out by offering optional 8 hour class to lab employees (mandatory for Investigators and Critique Facilitators).

· Optional aspect rendered limited success with lab employees

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HPI @ SNS

· 2007 SNS acknowledges HPI as high priority· Research Accelerator Division (RAD) requires all

Group Leaders, Lead Engineers and Physicists to attend mandatory 8 hours Fundamentals Class

· Identified need for next level employees to be exposed to HPI Principles (4 hours)

· Above levels of training were expanded to other SNS Divisions

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ORNL Focus Group

· Mission to identify opportunities to incorporate HPI principles into operation and maintenance of the complex/site, to fully implement and integrate HPI into our space management, work processes, operations and work execution, and to develop tools to aid in our management of errors.

· Several opportunities were identified to include:

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Radiological Events

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Postings

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Postings con’t

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Next Steps @ SNS

· Re-Tool Training to allow more daily use applications “Paper vs Physical Plant”

· Develop Error Management Tool “Tripod Delta” based on James Reason’s scheme

· Conduct campaigns on processes within our Major Operating entities looking Latent Weaknesses.

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Next Steps @ORNL

· Continue HPI evaluations as issues arise· Enhance the Steering Committee’s charter to

assume more Safety role· Drill HPI principles down to greater cross

section of employees· Continue HPI Spotlight with High Level

Messages· Get the Culpability Flow Chart incorporated

into Event Analysis Subject Area (SBMS)

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Yes

No Yes

Yes

No

YesNoNo

Yes No

Culpability Evaluation Flowchart

Intentional Act (not an error)

Intentional Act Intentional Act (not an error)(not an error)

Were expectations reasonable, available,

workable, intelligible, and correct?

Were expectations reasonable, available,

workable, intelligible, and correct?

Deficiencies intraining, selection,

assignment, or experience?

Deficiencies intraining, selection,

assignment, or experience?

Blameless error

Blameless Blameless errorerror

Correctivetraining or

otherintervention

may be warranted

CorrectiveCorrectivetraining ortraining or

otherotherinterventionintervention

may be may be warrantedwarranted

Possiblenegligent

error

PossiblePossiblenegligentnegligent

errorerror

System induced

error

System System inducedinduced

errorerror

Possiblerecklessviolation

PossiblePossiblerecklessrecklessviolationviolation

Organization induced violation

Organization Organization induced induced violationviolation

Discipline requiredAccountability PR&DProcess Issue

YesNoYes

Yes

Diminishingculpability

NoWere actions as intended?

Were actions as intended?

Knowingly violate expectations?

Knowingly violate expectations?

Passsubstitution

test?

Passsubstitution

test?

History ofhuman

performance problems?

History ofhuman

performance problems?

Attachment A

Were consequences as intended?

Were consequences as intended?

Evaluate OrganizationalProcesses & Management /

Supervisory Methods

Evaluate OrganizationalProcesses & Management /

Supervisory Methods

No Selfreported?

Selfreported?

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Signs and Postings