1. External Operations Experience Update: Integrated Safety Management as a Tool for Change
Department of Energy
Operating Experience Work Group
April 4, 2017
Larry Stirling
Office of Analysis (AU-23)

2. Take Aways for Today
ISMS is a performance based, continual improvement system
ISMS can be used as a tool to manage change in a dynamic environment
Performance Improvement Process built into Integrated Safety Management
Linking Core Function 5 (Feedback and Improvement) to Core Function 1, (Defining the Work )to redefine how work is structure can result in changed work standards and processes
Good performance metrics are essential to feedback and improvement
Here are the major take aways from this presentation.
I will share some examples from outside of DOE which demonstrate the importance of properly managing change.

3. Background
Integrated Safety Management is DOE’s approach to safety management
A five step process based on traditional model established by industry
One example is the aviation industry
OSHA also has a five step approach
Adapted by DOE to meet unique missions and activities

4. Background
Integrated Safety Management is DOE’s approach to safety management
A five step process based on traditional model established by industry
One example is the aviation industry
OSHA also has a five step approach
Adapted by DOE to meet unique missions and activities

5. Why is Management of Change Important?
Integrated Safety Management is a mature system
DOE is a dynamic organization, where change occurs
Mission changes
New/old facilities
Reorganizations
New Technologies
External circumstances
ISMS is a mature system operating in a dynamic environment.
Change is part of the nature of DOE and it’s environment, and change frequently introduces new risks and challenges
Therefore, ISMS must also be dynamic in response to changes
In addition, ISMS can also be a active tool for change.
Can help DOE become less reactive and more proactive in managing change.
This presentation will focus on using feedback and improvement (ISMS Step 5) to help redefine work (ISMS Step 1) in order to continually improve how DOE organizations manage change

6. Why is Management of Change Important?
To avoid the consequences of unforeseen safety and health hazards through planning and coordinating the implementation of change in your facility.
Minimize unplanned adverse impacts on system integrity, security, stability, and reliability for the process being altered or added.
Maximize the productivity and efficiency of staff planning, coordinating, and implementing the changes.
Actively managing change can:
Big picture: Why is management of change important? (READ SLIDE)
I offer some examples from outside of DOE where change was not adequately managed and the consequences were substantial, both in terms of lives and costs to mission accomplishment.
I will touch on these briefly
But I will say a just couple of words about the linkage between core function 1, Define Work, and core function 5, Feedback and Improvement

7. Feedback Link Between Core Functions 1 and 5 is Crucial
But first, a few on the linkage between core functions 1 and 5
As I said earlier ISMS has a built in performance improvement process in the linkage of these two functions.
Performance metrics are important in making this work
If it doesn’t get measured it can’t be managed.
Useful to the field in helping redefine work to improve system performance, resulting in continual improvement
Useful to HQ in helping identify what kind of guidance, at a general level, might be helpful to the DOE complex
Focus on Core Function 5 Feedback and Improve And how it can link to Core Function 1, Defining the work to redefine how work is defined
Takes advantage of the Performance Improvement Process built into Integrated Safety Management

8. How Can Integrated Safety Management be a Tool for Managing Change?
Focus on Core Function 5 Feedback and Improve And how it can link to Core Function 1, Defining the work to redefine how work is defined
Takes advantage of the Performance Improvement Process built into Integrated Safety Management
Performance metrics are important to making the process work
AU-23 is one source of performance metrics
Useful to facilities in the field
Useful to HQ in helping identify guidance needed
For the purposes of this presentation I will focus on

9. Failure to Manage Change Can Have Substantial Consequences
Some external examples
University of Hawaii Laboratory Accident 2016
ARCO Channelview Explosion 1990
Formosa Plastics Vinyl chloride release 2005

10. Lessons Learned University of Hawaii Lab Accident 2016
We can understand the importance of managing change by looking at what can go wrong when change is not managed. During the last webinar, we discussed the lab accident at the University of Hawaii. An explosion occurred and a researcher was badly injured when changing experimental parameters were not evaluated with respect to their individual risks. This was a systemic failure to adequately identify risk and use feedback and improvement to redefine the work.

11. Lessons Learned ARCO Channelview explosion 1990
Chemical plant with associated wastewater tank
Maintenance operations on the wastewater tank proceeded without management of change review of decisions
Changes resulted in the
buildup of a flammable
atmosphere in the tank,
which were ignited upon
compressor startup
17 people killed
$100m in damages
About 25 years ago, an accident occurred at the ARCO chemical plant in Houston, Texas. The Chemical Safety Board investigated the accident and found that it was contributed to by failure to properly manage changing conditions of the process with regards to maintenance work. After maintenance was completed, a failed attempt to restart a compressor drew flammable vapors into the line, which ignited when the compressor was restarted. The flame flashed back to the wastewater tank, which exploded, causing 17 deaths and 100 million dollars in damages.
Here, a failure to adequately incorporate feedback into the planning of work, resulting in a failure to redefine the work and associated risks.
Ness, Albert. “Lessons Learned from Recent Process Safety Incidents.” Center for Chemical Process Safety.

12. Lessons Learned Formosa Plastics vinyl chloride release 2004
Operator overrode safety interlock and opened a valve on a vessel in operation
Vinyl chloride liquid and vapor filled building and explosions occurred
5 people killed; 2 seriously injured
Employer had eliminated a key staffing position, operator group leader, and gave its responsibilities to shift supervisors, who were not always as available as the group leaders had been
= failure to manage organizational change
Example of a systemic change
In 2004, vinyl chloride monomer- a raw material used to manufacture PVC- was accidentally released from a reactor that was in operation when an operator overrode a safety interlock without contacting a supervisor about the operating condition of the reactor. Vinyl chloride liquid and vapor filled the building and found an ignition source, causing an explosion which destroyed most of the facility, killed 5 workers, and forced a community evacuation due to the smoke. One of the contributing causes of the accident was a failure to manage organization change. When Formosa had taken over the plant from its previous owner, they made staffing changes, including reductions and reassignment of responsibilities. They did not conduct an official management review of how these changes would impact safe operation of the facility.
Again, proper metrics were not used and feedback was not used to redefine the work in a changing environment.
So lets turn our attention to metrics since they are a critical component of process improvement.
Ness, Albert. “Lessons Learned from Recent Process Safety Incidents.” Center for Chemical Process Safety.

13. AU-23 Performance Metrics Source
AU-23 is a source of performance metrics
Data can be used to help improve performance of field organizations
Also be used to help HQ identify what kind of guidance may be helpful on emerging issues
AU-23 maintains several data bases, provides analytic support, and produces reports- sources of data for feedback and improvement
ORPS, for example, has 235+ data elements

14. AU-23 Services, Reports and Data Bases
Operating Experience and Lessons Learned
Op Ex Documents: OE Level 1, OE Level 2, OE Level 3, OE Summary
Regular conference calls and Webinars with the Operating Experience Committee (members are from DOE and DOE contractors across complex)
Suspect/Counterfeit /Defective Items (S/C /DI) and Data Collection Sheets (DCSs), DOE Corporate Lessons Learned Database
External Operating Experience, Wikis, Blogs, Website Resources
Analysis and Trending for Management Decision Making
ORPS /CAIRS Monthly and Quarterly Analysis and Trending Reports
Tools: Nuclear Safety Information Dashboard, Injury and Illness Dashboard, ORPS Final Report Dashboard
ORPS Report Quality Reviews
Interface with EFCOG Feedback and Improvement Subgroup, ORPS Task Group, Electrical Safety Subgroup

15. Conclusions ISMS is a performance based, continual improvement system
ISMS can be used as a tool to manage change in a dynamic environment
Performance Improvement Process built into Integrated Safety Management
Linking Core Function 5 (Feedback and Improvement) to Core Function 1, (Defining the Work )to redefine how work is structure can result in changed work standards and processes
Good performance metrics are essential to feedback and improvement

16. Resources
DOE Chemical Process Hazards Analysis Handbook
DOE Process Safety Management for Highly Hazardous Chemicals Handbook

17. Resources
OSHA. Process Safety Management Standard. cument?p_table=STANDARDS&p_id=9760
OSHA. Process Safety Management. OSHA oc
Ness, Albert. “Lessons Learned from Recent Process Safety Incidents.” Center for Chemical Process Safety pdf
Here are some OSHA references on Process Safety Management. The Process Safety Management standard and guidebook have sections pertaining to Management of Change. The Ness article has some good Lessons Learned incidents involving management of change, which were cited in this presentation.

18. Resources
Center for Chemical Process Safety. Introduction to Management of Change. safety/manage-risks/management- change/introduction
Washington State Department of Labor & Industries. VPP. Management of Change. nerships/vpp/pdfs/vppmocbestpractices.pdf
Here are some safety bulletins that address management of change.

19. Resources
U.S. Chemical Safety and Hazard Investigation Board. Management of Change.
Georgia Tech. Management of Change presentation.
ASSE. Harrison, Carl. MOC Process: Managing Change in Manufacturing & Production Facilities. df
More references, including a really good presentation from Georgia Tech.

20. Resources
McNair, Sam. “Eight Common Misperceptions of Management of Change.” ions-management-change
Berube, Dave. “Management of Change vs. Change Management.” management-of-change-vs-change-management/
And finally, a few articles that dig into the intracacies of management of change a bit more than we have here.

21. Contact Information
Larry Stirling Office of Analysis (AU-23)