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D2800-2009-00031

D O C U M E N T A T I O N & I N F O R M A T I O N S E R V I C E S 1

Achieving and Maintaining High Reliability through Human

Performance and Risk Reduction Leadership Practices

Director, Analytical Laboratories & F-Area Operations

Chair, SRS HPI Working Group

Savannah River Nuclear Solutions, LLC

August 7, 2009

Darlene G. Murdoch

D2800-2009-00031

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D2800-2009-00031 Biography

Darlene G. Murdoch

• Director of the SRS, Analytical Laboratories & F-Area Operations

• Chairman of the SRS, HPI Working Group

• Line Management Responsibilities for Nuclear Operations, for 20

years at SRS

• Worked at SRS for 27 years, and 3 years at Argonne National Labs. A

total of 30 years in Nuclear Operations

• Co-authored five publications, Reactor Safety System Improvements

• Attended the INPO Senior Nuclear Plant Management 5-week course

• B.S. Degree in Chemical Engineering, from the Illinois Institute of

Technology

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D2800-2009-00031

“Risk is inherent in any nuclear, chemical, and/or industrial operation. Risk is governed by

the plant, the programs and the people. Engineering controls and plant design,

administrative controls, programs, and training mitigate risk.

“Human Performance is another factor that enters into every aspect, can reduce risk and

achieve high performance.”

-- Darlene Murdoch

August 2009

Risk How to manage it

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D2800-2009-00031

There Must be BALANCE –

Risk vs. Plant - Programs - People

Overlaying Human Performance Concepts and Integration

into existing processes effectively reduces RISK and

achieves High Performance

And this is HOW……………….

Reducing errors (Re) and Managing

defenses (Md) leads to Zero

Significant injuries & events (Oe).

Plant

Programs People

Re + Md Oe

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D2800-2009-00031 Effective Plant Leadership Must Consider:

Plant

• Plant Design

• Ergonomics

• Programs and Procedures

• Maintaining the Plant

• Human Interaction

Programs

• Human Performance Elements

& Reminders (ISMS)

• Training & Procedures

• Self-Assessments

• Corrective Action Program

(MRT & CARBS)

• Trending programs

• Fact Finding

• Lessons Learned

People

• Last Line of Defense

• Must be Trained

• Need Positive Reinforcement

• Need Tools

• Need Reminders

• Need to be Aware

• Need a Just Culture

• Must have Personal Accountability

• Must get Feedback

Leaders take it seriously! Leaders must take action!

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D2800-2009-00031 The Leader (subset)

• People achieve high levels of performance based largely on the encouragement and reinforcement received from leaders, peers, and subordinates

• Leaders influence the Plant, the Programs, and the People

• Leaders influence the Culture

• How leaders IMAGINE work is being done

How work IS being done

GAP

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D2800-2009-00031 How Work IS Being Done

Significant amounts of combustible dust

Imperial Sugar plant in Louisiana

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D2800-2009-00031

People

Plant

When disaster occurs….

Programs

Interactions not working or non-existent

• Leaders are not paying attention, ignoring indicators, and/or negligent

• No one is checking

• A number of insignificant errors can lead to a disaster

The programs are non-existent or

extremely weak.

The plant is degrading

The people operate only

on what they remember

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D2800-2009-00031 Disasters- Case Studies

• Crash of Eastern flight 401,

December 1972

• Bhopal, December 1984

• Exxon–Valdez ran aground,

March 1989

• Chernobyl, April 1986

• Challenger, January 28 1986

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D2800-2009-00031 Trying to Achieve High Performance

• Determine what’s needed and what are the issues

- Assessments (training, ConOps, chemical management, technical

capabilities, etc.)

• Can the organization determine what’s needed and handle

the issues?

• Balance between staff members and expertise

- Does it exist?

- Can it be created?

- Is change necessary?

Assess, Assess, Assess Evaluate Prioritize Execute

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D2800-2009-00031 People

A culture must be in place for people to feel free to report errors and

conditions. Errors are trended and conditions are corrected.

Frequency

Sev

erity

Frequency

Sev

erity

Serious

accidents

Major

events

Near misses

Non-consequential

errors

Near

misses

Non-

consequential

errors

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D2800-2009-00031 Just Culture & Reporting

• Encourage reporting

- Value errors as leading safety data and indicators.

• Create and sustain a “just” work environment

- Don’t punish errors

- Hold individuals accountable

• Learning organization

- Create opportunities for observation, reflection, and feedback

Learning is key

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D2800-2009-00031 Why Implement Human Performance Tools?

• Cost-effective results

• People are more confident - Plant

- Programs

- Leadership

• People are happier - Better work environment

• Reduces risk and achieves High Performance

And it’s nothing new !

A healthier workplace

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D2800-2009-00031 Implementing HPI

• HPI is not just training

• HPI is not a program

• It is a way of doing business that includes: - Behavioral observation and walk-around

- Conduct of Operations

- Work Management

- Systems and program development with integration of HPI Tools

- Simulations and training (drills)

- Leadership

- Error Reporting

- Corrective Action Program

- Event investigation and lessons learned

- Feedback

A way of doing business

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D2800-2009-00031 Reducing Risk by Seamless Integration

Plant

• Better designed plants

• Engineering controls

• Predictive maintenance

• People / plant interface

People

• Training

• Just Culture

• Self-Assessments

• Work gets done safely

• Personal satisfaction

• More confident

• Learning organization

Programs

• Corrective Maintenance

• Preventive Maintenance

• Better documents for workers

• Error reporting

• Observations

• Corrective Action Program

• Event investigations

• Lessons Learned & feedback

• BBS / HPI

• Metrics

Plant

Programs People

Better all around

Start Achieving High Performance

What gets measured, gets done!

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D2800-2009-00031 SRS HPI Implementation

Working:

Error Reporting & Trending

HPI Metrics

Self-Assessments (MFO, SSW, etc.)

Completed: Training of all Site employees 9/9 Error Reduction Tools 18 Days of Excellence Matrix Safety Conference

Gap Analysis

HPI Steering Team Charter

HPI Oversight Structure

Site HPI Procedure

HPI Training Material

Site HPI Communication Posters

HPI Web Page

Disciplinary Process

Fact Finding/Post Job Review

Corrective Action Process & Error Coding

Pre-job Briefs Checklist

Work Control Guide

HPI Booklet

BBS / HPI Integration

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D2800-2009-00031 Trending from Error Reporting

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Current Month Results

Oct 08 - Apr 09 Baseline

TRIT STAR CTS Documents by Flawed

Defense, May 2009

Top 20

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D2800-2009-00031

Remember the Past

Excel in the Present

Anticipate the Future

Continuous Improvement…

ISM