bechtel national inc. 1 engineering maintains quality by using error precursors presented september...

1Bechtel National Inc.

Engineering Maintains Quality by Using Error Precursors

Presented September 12, 2006DOE Integrated Safety Management Best Practices Workshop

Jim HummerConfiguration Management Bechtel National, Inc.Hanford Waste Treatment and Immobilization Plant

2

53 million gallons radioactive waste

149 single-shell tanks built from 1943-1964

28 double-shell tanks built from 1968-1986

67 are presumed to have leaked

Hanford Site Cleanup is an Unprecedented Challenge

3

Vitrification offers the best solution for immobilizing Hanford’s high-level radioactive waste and preventing an environmental catastrophe

The Solution: Immobilize the Waste in Glass

Sturdy waste form – impervious

to the environment

Proven Technology – used at other

DOE sites and internationally

Requires significant infrastructure –

several large facilities constructed to

nuclear standards

See www.waste2glass.com for additional information on WTP

4

Pretreatment Building

HLW Vitrification

Building

LAW Vitrification Building

Analytical Laboratory

Hanford’s Waste Treatment

Plant will be the world’s

largest chemical-radioactive

waste treatment plant to

treat Hanford’s underground

tank waste

WTP is the Cornerstone of Hanford Tank Waste Cleanup

Pretreatment Facility Low-Activity Waste

Vitrification Facility High-Level Waste Vitrification Facility Analytical Laboratory Balance of Facilities – Utilities, Operations Facility, and Offices

5

Current Focus of Design ActivitiesProcess and Layout Definition Equipment and Controls Definition Detail Design

Process FlowDiagrams

3-D Model and GeneralArrangement Drawings

Equipment Location

Software Specifications

Supplier Submittals

Concrete Drawings

Steel Drawings

Support Drawings

Raceway Layout

Circuit Routing

DCS Software Development

HVAC Orthographic

Instrument Location Drawings

Pipe Isometric Drawings

Design Criteria:ContractSafety EnvelopeBasis of DesignPermitsFunctional SpecificationOperational RequirementsFlowsheetsR&TRisk Issue Resolution

Plot Plan

Single Line Diagrams

Ventilation and Instrumentation

Diagrams

Mechanical HandlingDiagrams

Piping andInstrumentation

Diagrams

Material Specifications

Equipment List

6

Error Precursors are Used to Maintain Engineering Quality

Error precursors, adopted from the Institute for Nuclear Power Operations (INPO), promote a human performance approach to error prevention.

80 % Caused by Human Error

20 % Equipment Failure and

Other Causes

All Error Occurrences

Human Error Occurrences

70 % Latent Organizational Weaknesses

30 % Individual

Errors

7

Human Performance Error Precursors (Short List)

Task DemandsTime pressure (in a hurry)High workload (memory

requirements)Simultaneous, multiple tasks

Repetitive actions (monotonous)Irrecoverable acts

Interpretation requirementsUnclear goals, roles, responsibilities

Lack of, or unclear, standards

Work Environment Distractions / Interruptions

Changes / Departures from routineConfusing displays or controls

WorkaroundsHidden system response

Unexpected equipment conditionsLack of alternative indication

Personality conflicts

Individual CapabilitiesUnfamiliarity with task / First time performed

Lack of knowledge (mental model)New technique not used beforeImprecise communication habits

Lack of proficiency / InexperienceIndistinct problem solving skills

“Hazardous” attitude for critical taskIllness / Fatigue

Human Nature

Stress (limits attention)Habit patterns

Assumptions (inaccurate mental picture)Complacency / Overconfidence

Mindset (“tuned” to see) Inaccurate risk perceptions (“Pollyanna”)

Mental shortcuts (biases)Limited short-term memory

8

The ISM Model for Engineering Quality

Scope of Work:Engineering Procedures and Guides

Identify/Analyze Hazards: EQA Chart for identification of common themes

Develop/Implement Controls: Action Plans

ISMS Model for

Engineering Improvement

Perform Work Within Controls: Procedure Compliance Checklists

Feedback / Improvement: Leading Indicator Metrics, Assessments, Identification of Error Precursors

9

Engineering Procedures and Guides

Procedure topics include General Information Organization Planning and Control Design Execution Personnel Qualification Procurement

SCOPE OF WORK

10

Procedures Maintain Quality using Error Precursors

Task Demands------------------------------------------------------------------------------------------

Work Environment ------------------------------------------------------------------------------------------

Individual Capabilities------------------------------------------------------------------------------------------

Human Nature

------------------------------------------------------------------------------------------

SCOPE OF WORK

Objective: Avoid using procedures to address performance gaps

Clarify requirements

Remove ambiguity

Provide alternatives

Use examples

Build in defenses, barriers, and safeguards

Analyze for error likely situations

Develop cost effective solutions

Apply lessons learned

11

LOCAL SCOPE OF EFFECT BROAD

CAR-06-047 / PR / ENSCAR-06-161 / BE / ENSCAR-06-205 / CP / PD^CAR-06-207 / SE / ENS^

CLOSED:CAR-04-153 / PC / MSCAR-05-052 / PC / ENGCAR-05-058 / BE / PDCAR-05-062 / PC / CSACAR-05-063 / PC / PDCAR-05-093 / BE / ENSCAR-05-110 / PC / ENSCAR-05-112 / SE / MSCAR-05-117 / PC / PDCAR-05-143 / SE / ECAR-05-215 / PR / CICAR-06-010 / BE / ENGCAR-06-042 / DD / MS


CIVIL, STRUCTURAL & ARCHITECTURAL

CONTROLS & INSTRUMENTATION

ELECTRICAL

ENGINEERING PROCESSES

ENVIRONMENTAL & NUCLEAR SAFETY

HVAC / FIRE PROTECTION

DISCIPLINE CODES

CSA

CI

E

EP

ENS

HFP

MECHANICAL HANDLING

MECHANICAL SYSTEMS

PLANT DESIGN

PROCESS ENGINEERING

PROCUREMENT ENGINEERING

PRODUCTION ENGINEERING

MH

MS

PD

PE

PR

PO

BEHAVIOR - These are CARs that document issues in whichqualified personnel failed to perform as required. An example isCAR-05-164 in which a Safety Screener failed to identifydiscrepancies between the document being screened and thedescriptive text of the SED.

CAUSE CODES

BE

PROCEDURE COMPLIANCE - These are CARs that documentprocedure requirements have not been met. An example is CAR05-139, Calculation did not provide reference to V&V reports, asrequired.

PC

CODE IMPLEMENTATION - These are CARs that documentissues in correctly implementing code requirements. An exampleis CAR-05-024 in which NDE requirements for critical welds werenot consistently implemented.

CI

PROCESS GAP - These are CARs that illustrate gaps inprocesses or implementing forms. An example is CAR-05-188 inwhich the calculation procedure allows design inputs to be takenfrom numeric revision system Descriptions (SDs) without regardto the original source of the information.

PR

CONFIGURATION PROBLEM - These are CARs to documentinconsistencies in design documents. An example is CAR-05-138, which documents that information shown on a P&ID isinconsistent with an instrument data sheet with respect to qualitylevel.

CP

SAFETY ENVELOPE COMPLIANCE - These are exampleswhere issued design media are inconsistent with therequirements of the Safety Envelope. An example is CAR 05-101, TEMA Type B standard for heat exchangers.

SE

DESIGN DOCUMENTATION GAP - These are CARs thatdocument issues in which the design basis is not adequatelydocumented. An example is CAR-05-179 in which a calculationdoes not adequately substantiate vessel over pressurizationprotection.

DD

ENGINEERING QUALITY ANALYSIS - JUNE 2006

BEHAVIOR (BE)

CONFIGURATION PROBLEM (CP)

OTHER

SAFETY ENVELOPE COMPLIANCE (SE)

CODE IMPLEMENTATION (CI)

PROCESS GAP (PR)

DESIGN DOCUMENTATION GAP (DD)

PROCEDURE COMPLIANCE (PC)

JUNE DISTRIBUTION - ALL CAR LEVELS

50.0%

18.2%

18.2%

9.1%

4.5%

0.0%

0.0%

0.0%

MECHANICAL SYSTEMS (MS)

ENVIRONMENTAL & NUCLEAR SAFETY (ENS)

CIVIL, STRUCTURAL & ARCHITECTURAL (CSA)

PLANT DESIGN (PD)

MECHANICAL HANDLING (MH)

PROCUREMENT ENGINEERING (PR)

ELECTRICAL (E)

CONTROLS & INSTRUMENTATION (CI)

ENGINEERING PROCESSES (EP)

PRODUCTION ENGINEERING (PO)

HVAC & FIRE PROTECTION (HFP)

ENGINEERING (ENG)

18.2%

13.6%

13.6%

9.1%

9.1%

9.1%

9.1%

9.1%

4.5%

4.5%

0.0%

0.0%

CAUSE DISCIPLINE

DESIGN CHANGE

LO

WS

IGN

IFIC

AN

CE

HIG

H


CAR-05-208 / SE / ENS^

CLOSED:CAR-05-019 / PC / ENGCAR-05-053 / PC / PDCAR-05-076 / PC / ENGCAR-05-130 / PC / PR^

CLOSED:CAR-05-202 / PC / EP^

CLOSED:CAR-05-001 / PC / MS / MHCAR-05-008 / BE / CSACAR-05-119 / SE / ENS^CAR-05-132 / PR / PRCAR-05-137 / PC / MHCAR-05-194 / PC / MS

SUPPLIER SUBMITTALS

LO

WS

IGN

IFIC

AN

CE

HIG

H


CAR-06-082 / PR / PO

CAR-05-186 / BE / MS^CAR-06-070 / BE / PRCAR-06-135 / BE / MS

CLOSED:CAR-05-010 / PC / MSCAR-06-032 / BE / MS

CAR-05-262 / PR / PD^CAR-06-025 / BE / E^CAR-06-077 / BE / PRCAR-06-149 / BE / MS^CAR-06-188 / BE / PR^

CLOSED:CAR-05-177 / PC / MSCAR-05-203 / BE / MHCAR-05-283 / BE / CSA^CAR-06-065 / PC / MH

CAR-06-089 / BE / MS^CAR-06-201 / OT / MH

CLOSED:CAR-05-059 / CI / MSCAR-05-288 / BE / CSA^CAR-06-076 / OT / PR^

MANAGEMENT ASSESSMENT

LO

WS

IGN

IFIC

AN

CE

HIG

H


CLOSED:CAR-05-095 / PC / ENS

SPECIFICATIONS

LO

WS

IGN

IFIC

AN

CE

HIG

H

CLOSED:CAR-05-212 / CI / PD

CAR-05-264 / BE / MS^CAR-05-277 / SE / MS^CAR-06-154 / BE / MS^CAR-06-169 / SE / MH^

CAR-06-075 / BE / E^CAR-06-179 / PC / MS^CAR-06-186 / CP / E^

CLOSED:CAR-05-017 / PR / ENGCAR-05-041 / PC / ENGCAR-05-266 / PC / PD^CAR-06-024 / CP / E^

DESIGN VERIFICATION

LO

WS

IGN

IFIC

AN

CE

HIG

H


CAR-06-073 / PC / MS

CLOSED:CAR-05-267 / PC / PO^

CLOSED:CAR-05-221 / PC / MS^

CAR-06-190 / BE / MH

CLOSED:CAR-06-015 / PC / PD

CALCULATIONS

LO

WS

IGN

IFIC

AN

CE

HIG

H


CAR-05-140 / CP / MS^CAR-05-179 / DD / MS^CAR-06-130 / BE / MS^

CLOSED:CAR-05-067 / DD / MS^

CAR-06-040 / PC / PD^CAR-06-183 / CP / PDCAR-06-210 / OT / MS^

CLOSED:CAR-04-237 / PR / ENGCAR-05-175 / BE / CSA^CAR-05-188 / PR / MS / EP^CAR-05-275 / PC / PO^

CAR-06-122 / PC / PD^CAR-06-193 / BE / ENS

CLOSED:CAR-05-039 / PC / ECAR-05-108 / PC / EPCAR-05-133 / PC / ENSCAR-05-141 / BE / ENSCAR-05-166 / BE / ENSCAR-05-206 / CI / CSACAR-05-249 / PR / EPCAR-06-050 / DD / MS

DRAWINGS

LO

WS

IGN

IFIC

AN

CE

HIG

H


CAR-06-129 / CP / PDCAR-06-178 / CP / MS^CAR-06-203 / CP / MS

CLOSED:CAR-04-151 / PR / EP^CAR-05-009 / CP / MSCAR-05-012 / BE / MSCAR-05-079 / DD / MS^CAR-05-090 / PC / EP^CAR-05-118 / BE / CSACAR-05-120 / PC / HFP^CAR-05-217 / PC / MS

CAR-05-159 / CI / MS^CAR-05-328 / PR / ENS^CAR-06-049 / CI / CICAR-06-051 / SE / MSCAR-06-156 / BE / MS^CAR-06-195 / CI / CSA

CLOSED:CAR-05-160 / PC / PD^CAR-05-199 / CP / PD^CAR-05-268 / CI / CSA

CAR-06-173 / BE / MS^CAR-06-174 / CP / CSA^CAR-06-177 / PC / CSACAR-06-191 / BE / ENSCAR-06-197 / BE / PD^CAR-06-199 / SE / CSA^CAR-06-208 / BE / PO

CLOSED:CAR-05-068 / PR / ENGCAR-05-103 / DD / PDCAR-05-273 / DD / MS^CAR-05-327 / DD / MS^CAR-06-008 / CP / PD^CAR-06-072 / PC / ENS

ON / OFF PROJECT REVIEWS

LO

WS

IGN

IFIC

AN

CE

HIG

H


DESIGN CRITERIA

LO

WS

IGN

IFIC

AN

CE

HIG

H

CLOSED:CAR-05-024 / CI / CSA^CAR-05-083 / PC / ENG^

CAR-06-096 / CP / CSACAR-06-099 / DD/ MS

CLOSED:CAR-05-022 / CI / MSCAR-05-115 / SE / MS^CAR-05-121 / PC / ENGCAR-05-145 / PC / ENSCAR-05-146 / PR / ENGCAR-05-148 / DD / MSCAR-05-193 / DD / MS^CAR-05-198 / DD / HFPCAR-05-295 / BE / ENG^CAR-06-046 / BE / POCAR-06-052 / PR / ENS

CLOSED:CAR-04-229 / SE / MSCAR-04-243 / PR / PDCAR-05-006 / SE / ENGCAR-05-038 / SE / CSACAR-05-066 / PR / PDCAR-05-127 / BE / ENSCAR-05-213 / PR / CI^CAR-06-035 / BE / ENS^

CM DATABASES

LO

WS

IGN

IFIC

AN

CE

HIG

H


CAR-06-100 / PR / PO

CLOSED:CAR-04-238 / PC / MSCAR-05-099 / PR / ENG

CAR-06-202 / CP / CI^

CAR-06-196 / BE / EP

CLOSED:CAR-05-035 / PR / ENG

MR / SUBCONTRACTS

LO

WS

IGN

IFIC

AN

CE

HIG

H


CAR-06-215 / OT / PR^

CAR-05-293 / BE / CSA / PE^CAR-06-061 / PR / PRCAR-06-092 / PR / PR^CAR-06-133 / PR / PR^

CLOSED:CAR-04-185 / PC / CICAR-05-051 / BE / PDCAR-05-098 / PC / EPCAR-05-299 / PC / CSA^CAR-05-310 / PC / PRCAR-06-087 / PR / PR^

CAR-06-080 / PR / PR^

CLOSED:CAR-05-150 / PC / HFPCAR-05-156 / DD / MS^CAR-05-180 / DD / MSCAR-05-228 / BE / MSCAR-06-017 / BE / PD^

CAR-06-060 / PR / CICAR-06-104 / OT/ PR^CAR-06-206 / BE / MS

CLOSED:CAR-04-220 / PR / ENGCAR-05-153 / PC / EPCAR-05-305 / PC / CSA^CAR-06-030 / PR / PRCAR-06-048 / OT / CSA

RECORDS MANAGEMENT / PROCEDURES

LO

WS

IGN

IFIC

AN

CE

HIG

H


CAR-06-058 / PR / POCAR-06-134 / PR / EP

CAR-06-044 / PC / PR

CAR-06-022 / PC / EP^CAR-06-211 / BE / CSACAR-06-213 / OT / CI

CLOSED:CAR-05-089 / PC / EPCAR-05-218 / BE / ENS

CAR-05-200 / BE / ENG^CAR-06-204 / BE / MS

CAR-06-209 / BE / E

CLOSED:CAR-05-056 / BE / PD

ENGINEERING PROCESSESENGINEERING PRODUCTS

OT OTHER

SUMMARY OF ALL PROCESSES AND PRODUCTS“CHARTED CARs”

19JUL06

EVENT DATE: LATENT^

IVIII

IIISee 24590-WTP-GPG-ENG-0096,

Engineering CAR Management, Trending, and Follow-Up,Section 5.2.2 and 5.2.3 for quadrant information

June Current on Chart

2%

25%

31%

42% H / B

H / L

L / B

L / L

Engineering Quality Analysis Chart Features

Relative significance and scope

CAR binning according to topic

Distribution by gap area

Performance and process gaps

Distribution by significance

ANALYZE HAZARDS

12

EQA Provides the Basis to Assess Error Precursors

Task Demands------------------------------------------------------------------------------------------



Human Nature

------------------------------------------------------------------------------------------

Objective: Provide a statistical basis to analyze common themes

Communicate scope and relative significance of quality issues

Relate issues to common cause codes for analysis

Initiate discipline-specific assessment of error precursors

Trigger action plan development to address common themes

ANALYZE HAZARDS

Cross-discipline and cross-product assessment of quality issues for error precursors

Engineering products

Engineering processes

13

Our Roadmap to Engineering Improvement

• Action Plans• Monitor Results

Analysis for Gaps

• Corrective Action Reports• Management Assessments• Surveillance Reports• Checklists

• Checklist Metrics• Engineering Quality Analysis

Input Action Plan

Document Type Checklists4/24/06 - 6/19/06

0.00%

3.00%

6.00%

9.00%

12.00%

15.00%

CALCULATION DRAWING SPECIFICATION MR SDDR

CALCULATION

DRAWING

SPECIFICATION

MR

SDDR

IMPLEMENT CONTROLS

14

Action Plans Correct Organizational Weaknesses

Task Demands------------------------------------------------------------------------------------------



Human Nature

------------------------------------------------------------------------------------------

IMPLEMENT CONTROLS Input from many sources

Corrective Action Reports

Self Assessments

Surveillance Reports

Checklists

Objective: Address underlying causes of common problems

Clarify goals, roles, and responsibilities

Interpret and relate requirements to upper tier source

Improve performance on new techniques / tasks

15

Procedure Compliance Checklists

Purpose: Leading indicator to identify error precursor conditions

Implemented by document checker as part of normal, pre-approval, document review

Used for calculations, drawings, specifications, material requisitions, and supplier deviation disposition requisitions

Metrics pinpoint actionable areas of improvement opportunity

WORK WITHIN CONTROLS

16

Procedure Compliance Checklists (Examples) All Discipline Drawing Checklists (1450)

0.00%

1.00%

2.00%

3.00%

4.00%

2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

2

Per

cen

t

Electrical Drawing Checklists (220)

0.00%

3.00%

6.00%

9.00%

12.00%

15.00%

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

2

Per

cen

t



17

Compliance Checklists Stop Errors in their Tracks

Task Demands------------------------------------------------------------------------------------------



Human Nature

------------------------------------------------------------------------------------------

Objective: Improve organizational factors to prevent errors

Peer checking with timely documented feedback

Ensures product compliance to procedural requirements

Promotes a questioning attitude

Software compiles performance data as work progresses

Promotes teamwork – removes emotion form the process

Checklists do away with human nature traps

Accurate mental model

Errors easy to recognize

No blame cycle


18

The EQP Provides Feedback and Awareness

Positive feedback Upcoming events Process changes Metrics

Feedback / Improvement

19

The EQP Focuses Attention on What’s Important

Task Demands------------------------------------------------------------------------------------------



Human Nature

------------------------------------------------------------------------------------------

Objective: Influence values and behaviors through awareness

Reinforce priorities and expectations

Recognize and reward good performance

Openly discuss mistakes, near-mistakes, and lessons learned

Put value of error prevention in plain words

Feedback to get what we want, and avoid what we don’t want

Improvement information cycles back into scope of work

FEEDBACK / IMPROVEMENT

20

Error Precursor Assessment is Applied in Several Ways

Engineering Corrective Action Report (CAR) management process includes an assessment of relevant error precursors to promote error reduction

Action plans are used to address latent organizational weaknesses Employees post the potential error precursors (short list) in their

workspace for review and application to their assigned work. Engineers are advised to discuss potential error precursor conditions

with their supervisors and seek resolution. Engineering uses a monthly quality presentation to introduce quality

topics and trigger detailed discussion among the staff. The EQP was used to introduce the concept to Engineering staff.

21

In the Words of our Engineering Manager

“In the fast-paced and challenging engineering and construction environment our engineers thrive in, error precursors like time pressures, high workloads, and simultaneous multiple tasks are the norm rather than the exception. What sets our engineers apart is not the environment they find themselves in, but how they find ways to adapt to their environment while maintaining quality and compliance with requirements.”

Leon LammWTP Engineering

Manager

bechtel national inc. 1 engineering maintains quality by using error precursors presented september...

Documents

hanford waste treatment

gallons radioactive

error prevention

wtp slide

immobilization plant

operations facility

unprecedented challenge

equipment failure