patrick walsh nine mile point – human performance

26
Patrick Walsh Nine Mile Point – Human Performance HPRTC Conference -June 10 Improving Administrative Procedure Use and Adherence

Upload: cormac

Post on 06-Jan-2016

35 views

Category:

Documents


0 download

DESCRIPTION

Improving Administrative Procedure Use and Adherence. Patrick Walsh Nine Mile Point – Human Performance. HPRTC Conference -June 10. Let’s get started. Levels of Lucky. What’s the Big Deal with Admin Procedures?. What’s the Big Deal with Admin Procedures?. - PowerPoint PPT Presentation

TRANSCRIPT

Page 1: Patrick Walsh Nine Mile Point – Human Performance

Patrick WalshNine Mile Point – Human Performance

HPRTC Conference -June 10

Improving Administrative Procedure Use and Adherence

Page 2: Patrick Walsh Nine Mile Point – Human Performance

Let’s get started

Levels of Lucky

Page 3: Patrick Walsh Nine Mile Point – Human Performance

What’s the Big Deal with Admin Procedures?

Page 4: Patrick Walsh Nine Mile Point – Human Performance

What’s the Big Deal with Admin Procedures?

Required by Technical Specifications Provide uniform standards and expectations Protect the people Protect the reactor Protect the public

Page 5: Patrick Walsh Nine Mile Point – Human Performance

How’s your station doing?

Page 6: Patrick Walsh Nine Mile Point – Human Performance

Consequences

What can happen when we fail to follow our standards and

expectations, as outlined in our administrative procedures?

Page 7: Patrick Walsh Nine Mile Point – Human Performance

Gulf Oil Spill

Page 8: Patrick Walsh Nine Mile Point – Human Performance

Gulf Oil Spill

Page 9: Patrick Walsh Nine Mile Point – Human Performance

Exxon Valdez ?

Page 10: Patrick Walsh Nine Mile Point – Human Performance

Bhopal, India

Page 11: Patrick Walsh Nine Mile Point – Human Performance
Page 12: Patrick Walsh Nine Mile Point – Human Performance

Consequences? Challenges to nuclear safety Challenges to personnel safety Increased regulatory oversight Loss of stakeholder trust

Page 13: Patrick Walsh Nine Mile Point – Human Performance

NMP’s Journey?

Page 14: Patrick Walsh Nine Mile Point – Human Performance

What started it all? Dec 07 – Jan 08 incurred a significant amount

of unavailability on NMP Unit 2 Service Water System.

Nov 08 – Service Water Foreign Material Intrusion event while cleaning the NMP Unit 2 intake. This event moved our component cooling water performance indicator to white. Station moved to NRC regulatory response column.

Failed NRC 95-001 inspection.

Page 15: Patrick Walsh Nine Mile Point – Human Performance

Actions taken? Each Department identified the top 3 admin

procedures that challenge them and created an improvement plan

Procedure Compliance Review Report Admin Procedure “In Hand” Day Supervisor 20 day habit changing activity Required 1 documented observation per month

of administrative procedure compliance Frequent communications to the station in our

weekly Station Updates regarding actions to raise our standards for compliance with administrative procedures

Page 16: Patrick Walsh Nine Mile Point – Human Performance

Procedure Compliance Review Report Initiated for procedure violations as

determined by procedure compliance review team.

Requires the supervisor and the employee(s) that contributed to the procedure compliance event to discuss the issue, evaluate culpability and determine what actions are required to improve performance.

Reviewed by the next level supervisor. Evaluated by the HU lead when completed.

Page 17: Patrick Walsh Nine Mile Point – Human Performance

Procedure Compliance Review ReportAttachment 1 – Procedure Compliance Review Report CR Number:  Short Description of procedure non-compliance event:  1. Procedure(s) and section(s) not complied with:  2. Person(s) not complying with procedures listed above:  3. Why is this a procedure non compliance event?  

Page 18: Patrick Walsh Nine Mile Point – Human Performance

Procedure Compliance Review Report 4. Review/discuss the issue with personnel involved and, using the “Culpability

Model” (Human Error Review and Decision Tree, determine where the culpability lies for the procedure non compliance event.

 Results of Review:  Was the task and specific action covered by written work instructions or

through standards and expectations? __ Yes __No Were the instructions, standards, and expectations available, workable,

intelligible, and correct? __ Yes __No

Pass the substitution test? __ Yes __No Is there a history of inappropriate acts involving procedure adherence?

__ Yes __No Poor individual or Team Performance? __ Yes __No Reckless Procedure Noncompliance? __ Yes __No Management Control System Induced Violation? __ Yes __No Blameless Error? __ Yes __No 

Page 19: Patrick Walsh Nine Mile Point – Human Performance

No

START==> For each specific error . . .

Were the actions as intended?

Pass the substitution

test?Unauthorized

substance?

History of inappropriate

acts?

Were the consequences as intended?

Medical condition?

Were the instructions, standards, and

expectations available, workable, intelligible, and

correct?

Deficiencies in training & selection or

inexperience?

Sabotage, malevolent

damage, suicide, etc.

Substance abuse

without mitigation

Substance abuse with mitigation Poor Individual/

Team Performance

(poor use of HU Tools) OR

Possible reckless violation

Management Control System induced

violation/ Supervisor culpability

Poor Individual or

Team Performance -

Possible negligent

error

Management Control System

induced error

Corrective training or counselling indicated

Blameless error

NoYes

Yes

Yes

No Yes

Yes

Yes

Yes

No

No

Yes

Yes

Human Error Review & Decision Tree

Reason, Managing the Risks of Organizational Accidents, 1997

Was the task and specific action covered by written

work instructions or through standards and

expectations?

NoNo

Yes, Most others would probably have taken the same action or likely could have made the same

error.

No. Others would not have taken the same

action.

No

May still warrant management actions to prevent recurrence,

e.g., enhance procedure

No

Did Supervisor negatively influence behavior?

NoYes

Page 20: Patrick Walsh Nine Mile Point – Human Performance

Procedure Compliance Review Report 5. Why did the listed personnel not comply with the procedure? (Check one

and describe below) Did not know the requirement. Did not understand the requirement. Understood the requirement, but decided not to comply. Thought they understood the requirement Did not reference the procedure Procedure guidance was vague

 Explanation: 6. What could be done to prevent others from making the same procedure

error?

7. Are there procedure changes or other actions (e.g., training, coaching etc) required based on this review?

8. Has a PCR been initiated? (List CA and PCR Numbers below) 

Page 21: Patrick Walsh Nine Mile Point – Human Performance

Administrative Procedure “In Hand Day”Weekly activity for the station to review an administrative

procedure.

The procedure of the day is communicated each Tuesday as part of the weekly Station Update that is reviewed at shop / department meetings.

Expectations for “In Hand Day”. Each site supervisor will have a copy of the procedure

with them that day. Supervisors are expected to review the procedure as part

of shop / department briefings. Work groups are expected to have the procedure

available for review.

Page 22: Patrick Walsh Nine Mile Point – Human Performance

20-Day Habit Changing ActivityAll supervisors and above are issued cards to document at least two interactions per day to verify that employees are performing work in accordance with the applicable administrative procedure.

Purpose of the exercise is to develop habits for:

Daily interaction and discussion of administrative procedure compliance between leaders and employees. Frequent reviews of administrative procedure requirements for activities being performed. Supervisors to observe and coach on administrative procedure compliance. Personnel validating what the procedure requires

Page 23: Patrick Walsh Nine Mile Point – Human Performance

20 Day Habit changing activityAdministrative Procedure Compliance 20-Day Habit Changing Program

Name: __________________________ Title: ______________ Department: _________________

Purpose: To focus the stations supervisory team on compliance with our administrative requirements by implementing a daily requirement for station leaders to verify that they and the personnel working for them are performing activities in accordance with our station administrative procedures.

Each supervisor and above will document daily that they have observed and re-enforced compliance with our site administrative procedures.

Each supervisor will interact with at least 2 direct reports each working day to evaluate compliance with administrative procedures.

Each supervisor is required a minimum of 40 documented reviews of administrative procedure compliance.

Each supervisor will have their supervisor review progress weekly and initial on back page.

 Date Personnel

observedActivity Applicable

Procedures Referenced

Coaching required?

Positive re-enforcement?

Initials

1

2

3

4

Page 24: Patrick Walsh Nine Mile Point – Human Performance

Observation DocumentationThe station’s management observation program expectations were revised to require each participant in the observation program to clearly document in at least one observation per month that they evaluated compliance with at least one administrative procedure and provided feedback to the personnel being observed.

Page 25: Patrick Walsh Nine Mile Point – Human Performance

How’s it working?

Page 26: Patrick Walsh Nine Mile Point – Human Performance

Summary