*Re-Invigorating ISM and Developing Effectiveness Measures: Experiences from Pantex

Larry Supina ISM Program Manager,BWXT Pantex LLC

*What is Pantex?16,000 Acre WWII Munitions FactoryNuclear Weapons Final AssemblyHigh Explosives Formulation, Synthesis, Fabrication and Machining3300 EmployeesMost Importantly for Todays Discussion, Pantex is

Bldg. 12-1 as built in 1945

*What is Pantex? (cont)Hands-on Mechanical ActivitiesVery Linear, Not InteractiveVery Simple, Passive SystemsComplex, Intricate, Arcane RulesPantex is, perhaps, the ultimate in low probability, high consequence event scenariosDan Swaim General Manager, BWXT Pantex

*Pantex, circa 2002Good OperationsSix-Sigma Processes Improving Quality, CostsIncreasingly Difficult and Complex Regulatory Basis Driving Operational ErrorsExpectations for sustainable, error-free, superior plant performance not being met

*BWXT Pantex ISM Performance Improvement FocusShift from Manufacturing Bias to Nuclear Operations CultureAdopt High Reliability OrganizationEstablish a Superior Management Team at All LevelsMove from Skills Training to Nuclear Operations Training

*Tactically, We Needed New Plant Norms

*Performance Objectives & Key Behaviors cited from INPO 05-003 and INPO Excellence in Human Performance Sept, 199712Performance Objectives:Sustainable, Superior Plant PerformanceSustainable, Event-Free OperationsAvoidance of Unplanned, Long-Duration ShutdownsWell-Managed & Understood Safety, Design, and Operational MarginsSuperior Levels of Plant Worker SafetyHighly Skilled, Knowledgeable and Collaborative Workforce

*Performance Objectives & Key Behaviors cited from INPO 05-003 and INPO Excellence in Human Performance Sept, 199712Key Individual Behaviors:Communicate to create shared understandingAnticipate error-likely situationsConfirm the integrity of defensesImprove personal capabilities

*Performance Objectives & Key Behaviors cited from INPO 05-003 and INPO Excellence in Human Performance Sept, 199712Key Leader Behaviors:Facilitate open communicationPromote teamwork to eliminate error-likely situations and strengthen defensesSearch for and eliminate organizational weaknesses that create conditions for errorReinforce desired jobsite behaviorsValue the prevention of errors

*Performance Objectives & Key Behaviors cited from INPO 05-003 and INPO Excellence in Human Performance Sept, 199712Key Organizational Behaviors:Foster a culture that values prevention of errorsStrengthen the integrity of defenses to prevent or mitigate the consequences of errorPreclude the development of error-likely situationsInstill a learning mindset and encourage continuous improvement

*

Pantex ISM Approach

*

*

*Credits & References

Mr. Dan J. Swaim, General Manager BWXT PantexHuman Performance Improvement at Pantex presented at the DOE HPI Confernce 2005Mr. John G. Meyer, Deputy General Manager BWXT PantexCreating a Safety Culture presented at the Pantex Executive Safety Council 2006Mr. Richard S. Hartley Phd. BWXT Pantex Nuclear Safety OversightISM Program Model 2005

Performance Objectives & Key Behaviors cited from INPO 05-003 and INPO Excellence in Human Performance Sept, 1997Managing the Risks of Organizational Accidents by James ReasonSupport of benchmarking activities, LANL, LLNL, SNL Livermore, ORNL,

*

Near Miss Data

Chart1

37

16

21

31

6

7

6

15

5

7

20

12

Near Miss Analysis

Data

Type of WorkSupervisionTo PreventCausePlanned ByType of Work

Site# of eventsControlledSkill of the craftIntermittentConstantBetter ProcessBetter ControlsBetter JHABetter SupervisionMgmtPersonal errorPoor Risk AnalysisChanging ConditionsTechnicalWork PlannerWork TeamBothNoneOps/MtceD&DConstructionTrainingTrans

WSRC7167122140421

WVNSCO44412112413

WIPP41331111112114

LANL11111

B37133031111213

Total1991014536234483

ORPS18710171414103272

Total3716203167201237615059820019

9451914

33

Analysis

Type of WorkSupervisionTo PreventCause

# of eventsContolledSkill of the craftIntermittentConstantBetter ProcessBetter ControlsBetter JHABetter SupervisionMgmtPersonal errorPoor Risk AnalysisTechnical

1991014836235482

Type of WorkSupervisionISMS Deficiency AreaType of Work

# of eventsContolledSkill of the craftIntermittentConstantDefine ScopeAnalyze HazardsDevelop ControlsPerform WorkFeedbackOps/MtceD&DConstructionTrainingTrans

18710191210146312331120

98219

211151139

162033951616981611511

Analysis

Near Miss Analysis

Combined

18

17

1

2

10

14

6

3

12

3

3

1

1

ORPS Near Miss Analysis

Sheet1

Type of WorkSupervisionCauseTo PreventType of Work

# of eventsContolledSkill of the craftIntermittentConstantMgmtPersonal errorPoor Risk Analysis/ControlsTechnicalBetter ProcessBetter ControlsBetter JHAOps/MtceD&DConstructionTrainingTrans

37162131676155720121911511

37373339

Sheet1

Near Miss Analysis

Conclusions

ORPS

SiteNear missesHazard analysis a factorPlanner onlyWork team onlyPlanner & work team combinationPlanner & review cmteNone

WSRC9413

LANL211

WIPP4211

B371511

WVNSCO333

Total231120531

ConclusionsActions

Poor JHAs and/or work controls account for majority of near missesReemphasize importance of good JHA and complete control set

Improved Supervision is best measure to prevent incidentsSponsoring Safety Trained Supervisor course, Issuing rotation policy

Change in work scope frequently leads to un-analyzed conditionClarify pre-shift briefing policy to ensure work conditions are as planned.

Stop Work authority needs to be emphasizedIssued Timeout policy to all projects

SupervisionISMS Deficiency AreaType of Work

# of eventsIntermittentConstantDefine ScopeAnalyze HazardsDevelop ControlsPerform WorkFeedbackOps/MtceD&DConstructionTrainingTrans

181712101463123311

Cause

MgmtPersonal errorPoor Risk AnalysisChanging ConditionsTechnical

3273

11

11

1

1

111

1

1

11

11

1

1

11

44413319

ORPS Near Miss Analysis

Data

Type of WorkSupervisionTo PreventCausePlanned ByType of Work

Site# of eventsControlledSkill of the craftIntermittentConstantBetter ProcessBetter ControlsBetter JHABetter SupervisionMgmtPersonal errorPoor Risk AnalysisChanging ConditionsTechnicalWork PlannerWork TeamBothNoneOps/MtceD&DConstructionTrainingTrans

WSRC7167122140421

WVNSCO44412112413

WIPP41331111112114

LANL11111

B37133031111213

Total1991014536234483

ORPS18710171414103272

Total3716203167201237615059820019

9451914

33

Analysis

Type of WorkSupervisionTo PreventCause

# of eventsContolledSkill of the craftIntermittentConstantBetter ProcessBetter ControlsBetter JHABetter SupervisionMgmtPersonal errorPoor Risk AnalysisTechnical

1991014836235482

Type of WorkSupervisionISMS Deficiency AreaType of Work

# of eventsContolledSkill of the craftIntermittentConstantDefine ScopeAnalyze HazardsDevelop ControlsPerform WorkFeedbackOps/MtceD&DConstructionTrainingTrans

18710191210146312331120

98219

211151139

162033951616981611511

Analysis

Near Miss Analysis

Combined

18

17

1

2

10

14

6

3

12

3

3

1

1

ORPS Near Miss Analysis

Sheet1

Type of WorkSupervisionCauseTo PreventType of Work

# of eventsContolledSkill of the craftIntermittentConstantMgmtPersonal errorPoor Risk Analysis/ControlsTechnicalBetter ProcessBetter ControlsBetter JHAOps/MtceD&DConstructionTrainingTrans

37162131676155720121911511

37373339

Sheet1

Near Miss Analysis

Conclusions

ORPS

SiteNear missesHazard analysis a factorPlanner onlyWork team onlyPlanner & work team combinationPlanner & review cmteNone

WSRC9413

LANL211

WIPP4211

B371511

WVNSCO333

Total231120531

ConclusionsActions

Poor JHAs and/or work controls account for majority of near missesReemphasize importance of good JHA and complete control set

Improved Supervision is best measure to prevent incidentsSponsoring Safety Trained Supervisor course, Issuing rotation policy

Change in work scope frequently leads to un-analyzed conditionClarify pre-shift briefing policy to ensure work conditions are as planned.

Stop Work authority needs to be emphasizedIssued Timeout policy to all projects

SupervisionISMS Deficiency AreaType of Work

# of eventsIntermittentConstantDefine ScopeAnalyze HazardsDevelop ControlsPerform WorkFeedbackOps/MtceD&DConstructionTrainingTrans

181712101463123311

Cause

MgmtPersonal errorPoor Risk AnalysisChanging ConditionsTechnical

3273

11

11

1

1

111

1

1

11

11

1

1

11

44413319

ORPS Near Miss Analysis

*Management Development A Three Year Drive!Instilling Competency and AccountabilityCross-cutting All LevelsBuilding Mutual Commitment, Agreed Upon Methods of BusinessImproved Selection (and Off-Ramp!) Processes No End in Sight

*How Different Organizational Cultures Handle Safety InformationSource: Managing the Risks of Organizational Accidents by James Reason

Pathological CultureBureaucratic CultureGenerative CultureDont want to knowMessengers are shotResponsibility is shirkedFailure is punished or concealedNew ideas are actively discouragedMay not find outMessengers are listened to if they arriveResponsibility is compartmentalizedFailure leads to local repairsNew ideas often present problemsActively seek itMessengers are trained and rewardedResponsibility is sharedFailures lead to far-reaching reformsNew ideas are welcomed

*

Relative Progression Toward HRO

Total Effort

Improvement

Initial GapAnalysis

ISM Implemented

HRO

ISM FullyFunctioning

Learning OrganizationStriving TowardHRO

We meet DOE/NNSA customers expectations

We exceed DOE/NNSA customers expectations & pass muster w/ external HROs

Strong Nuclear Weapon Safety Culture

*Getting the Lesson LearnableActually Learning the LessonContinued Efforts in Progress

*

ISMS

Define the ScopeAnalyze the HazardsImplement controlsPerform the work safelyProvide feedback

Part of all baseline planning effortsRemove high hazards firstIncreases safety of workers, the public and the environment.

ISMS is our safety program