1. The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program Manager Palo Verde: A Case Study Frederic Lake Corrective Action Program Manager

3. 8 7 6 5 4 3 2 1 9 Potential Stages of Power Plants ABCDE

4. Coming off a Long Period of Strong Performance Attributes –Mature Culture –Stable Operations –Performance indicators Green –Positive recognition by industry (INPO, Peers) Attributes –Mature Culture –Stable Operations –Performance indicators Green –Positive recognition by industry (INPO, Peers)

5. Coming off a Long Period of Strong Performance Behaviors –Overconfidence –Believing your own press –Arrogance –Withdrawal –Managers not reinforcing behaviors to set high standards –Managers distracted (external changes, regulatory, major projects) Behaviors –Overconfidence –Believing your own press –Arrogance –Withdrawal –Managers not reinforcing behaviors to set high standards –Managers distracted (external changes, regulatory, major projects)

6. Unaware Culture Some members may challenge current behaviors but face denial from other members CAP owners may be dealing with poor behaviors Strength of the Culture: –Length of time –Stability of membership –Emotional intensity of past experiences Some members may challenge current behaviors but face denial from other members CAP owners may be dealing with poor behaviors Strength of the Culture: –Length of time –Stability of membership –Emotional intensity of past experiences

7. Palo Verde…..Early 2000s Plant running well PV recognized as excellent by INPO The place where people come to benchmark Insular Staff Plant running well PV recognized as excellent by INPO The place where people come to benchmark Insular Staff

8. Mounting Problems….. 2004 – 2006: –NRC Substantive Cross-Cutting Issues (SCCI) in Human Performance and PI&R –Decreasing Equipment Reliability –Increased Forced Loss Rate –Decreasing Regulatory Confidence 2007 –INPO Evaluation: significant weaknesses in several areas –NRC ROP Column 4 2004 – 2006: –NRC Substantive Cross-Cutting Issues (SCCI) in Human Performance and PI&R –Decreasing Equipment Reliability –Increased Forced Loss Rate –Decreasing Regulatory Confidence 2007 –INPO Evaluation: significant weaknesses in several areas –NRC ROP Column 4

9. What Problems? Attributes –Increasing emergent issues/equipment failures/Forced Outages –Poor CAP Behaviors/Accountability –Efforts to Turn Performance Overly focused on process/procedure changes

10. Efforts to Turn Performance Not Successful Using old solutions Cause Analysis fails to correct underlying problems Using old solutions Cause Analysis fails to correct underlying problems The problems that exist today cannot be solved by the same level of thinking that created them. …Albert Einstein

11. What Problems? Behaviors –Event significance not recognized –Signs of performance decline rationalized –Teamwork declines; groups become isolated –Training is minimized –Reluctance to challenge each other Behaviors –Event significance not recognized –Signs of performance decline rationalized –Teamwork declines; groups become isolated –Training is minimized –Reluctance to challenge each other

12. Who me? Attributes –Problems persist –Increasing backlogs –Sub-optimizing –Rapid decline in performance indicators - station is measuring against themselves –Ineffective Evaluations

13. Who me? Behaviors –Finger pointing; low accountability –Poor CAP support: loopholes Poor closures & resolution CAP vs. real work –Declining CARB performance Poor support High use of alternates Driving down level of participation Behaviors –Finger pointing; low accountability –Poor CAP support: loopholes Poor closures & resolution CAP vs. real work –Declining CARB performance Poor support High use of alternates Driving down level of participation

14. Interim Measures Metrics showing magnitude of backlogs Outside cause analysis expertise Team established to determine scope and magnitude of issues Comparison of station performance to the industry (Epiphany) Metrics showing magnitude of backlogs Outside cause analysis expertise Team established to determine scope and magnitude of issues Comparison of station performance to the industry (Epiphany)

15. Communication Message: –Unless we change something bad will happen –Objective is sustained performance; not just getting out of trouble Weekly alignment meetings Executive level CAP message Safety message Relentless repetition………. Message: –Unless we change something bad will happen –Objective is sustained performance; not just getting out of trouble Weekly alignment meetings Executive level CAP message Safety message Relentless repetition……….

16. Stop the Bleeding Direct and targeted actions to break the culture patterns and stop the declining performance: –Problem definition & triage –Causal analysis to determine underlying drivers and actions –Training using outside expertise in the essential functions of CAP, including causal analysis and CARB –Refining metrics and reinforcing accountability for CAP Direct and targeted actions to break the culture patterns and stop the declining performance: –Problem definition & triage –Causal analysis to determine underlying drivers and actions –Training using outside expertise in the essential functions of CAP, including causal analysis and CARB –Refining metrics and reinforcing accountability for CAP

17. Safety Nets Increased oversight Closure Review Boards for actions important to the recovery 100% CAP Closure Reviews Increased management control of CAP administrative functions Increased oversight Closure Review Boards for actions important to the recovery 100% CAP Closure Reviews Increased management control of CAP administrative functions

18. Behaviors Directive Management from Executive Leadership and CAP Program Owner Focus on Specific CAP Behaviors: –Identification of Issues –Causal Analysis Quality –Quality Completion of Corrective Actions Training to close skills and knowledge gaps and to improve performance Directive Management from Executive Leadership and CAP Program Owner Focus on Specific CAP Behaviors: –Identification of Issues –Causal Analysis Quality –Quality Completion of Corrective Actions Training to close skills and knowledge gaps and to improve performance

19. Evaluate Gaps Team devoted to analyses of performance Results grouped into Fundamental Overall Problem Areas : –Causal analysis performed for each area –Outside expertise –Actions formed the basis for the Site Integrated Improvement Plan (SIIP), and the NRC Confirmatory Action Letter (CAL) Team devoted to analyses of performance Results grouped into Fundamental Overall Problem Areas : –Causal analysis performed for each area –Outside expertise –Actions formed the basis for the Site Integrated Improvement Plan (SIIP), and the NRC Confirmatory Action Letter (CAL)

20. 1.Organizational Effectiveness 2.Operational Focus 3.Emergency Preparedness 4.Engineering Programs 5.Design Control / Configuration Management 6.Engineering Technical Rigor 7.Equipment Reliability 8.Industrial Safety 9.Problem Identification & Resolution 10.Procedures / Work Instructions 11.Managing Plant Work Loads 12.Training & Qualification 13.EDG K-1 Relay (White Finding) 14.RAS Event (Yellow Finding) 1.Organizational Effectiveness 2.Operational Focus 3.Emergency Preparedness 4.Engineering Programs 5.Design Control / Configuration Management 6.Engineering Technical Rigor 7.Equipment Reliability 8.Industrial Safety 9.Problem Identification & Resolution 10.Procedures / Work Instructions 11.Managing Plant Work Loads 12.Training & Qualification 13.EDG K-1 Relay (White Finding) 14.RAS Event (Yellow Finding) Cause Analysis

21. Palo Verde Leadership Model We SAFELY and efficiently generate electricity for the long term

22. Turning the Tide Attributes –High volume of identification, causal analysis, and reliance on compensatory measures –Station begins to recognize that problem identification and resolution is a behavior; not simply a process –Metrics drive performance –Consistent message to the organization on staying the course

23. Turning the Tide Behaviors –Leaders start to align around: Need to improve Improvement goals Operational focus –Leaders working down a level and exhibit a directive leadership style –WeBe – some workers take a wait and see attitude (well be here when youre gone) Behaviors –Leaders start to align around: Need to improve Improvement goals Operational focus –Leaders working down a level and exhibit a directive leadership style –WeBe – some workers take a wait and see attitude (well be here when youre gone)

24. Closing the Gaps Attributes –Overall plant performance improving –Fewer major equipment issues –Performance indicators continue to show improvement –High CAP backlog of conditions and actions, many of which may be no longer necessary

25. Closing the Gaps Behaviors –Using experience, self-assessment, and benchmarking to improve major processes –Leaders focus on improving accountability which allows for compensatory measures to be replaced by long-term processes –Improved coordination between departments –Some pockets of resistance; however, the gap between high performers and low performers is widening and becoming more evident Behaviors –Using experience, self-assessment, and benchmarking to improve major processes –Leaders focus on improving accountability which allows for compensatory measures to be replaced by long-term processes –Improved coordination between departments –Some pockets of resistance; however, the gap between high performers and low performers is widening and becoming more evident

26. The Plateau……….. Symptoms: –If you think this is bad…you should have seen it before Actions: –Focus on 3-5 year plans not just the immediate improvement plans –Communication and awareness –Overtly looking for signs of the plateau & continuous challenging Symptoms: –If you think this is bad…you should have seen it before Actions: –Focus on 3-5 year plans not just the immediate improvement plans –Communication and awareness –Overtly looking for signs of the plateau & continuous challenging

27. Demonstrating Performance Improvement Attributes –Plant operating reliably –Problems identified early and low level trending, analysis, and other performance improvement tools are used –Improved metrics that compare to industry –Involvement with the industry

28. Demonstrating Performance Improvement Behaviors –Highly accountable organization –Supervisors consistently reinforce expectations –Equipment failures are considered organizational failures –We find and fix our problems Behaviors –Highly accountable organization –Supervisors consistently reinforce expectations –Equipment failures are considered organizational failures –We find and fix our problems

29. ABCDE 8 7 6 5 4 3 2 1 9 Potential Stages of Power Plants

30. Common Warning Flags & Factors Overconfidence Isolationism Production Priorities –Safety is assumed and not explicitly emphasized –Significance of issues underplayed Operations and Engineering: –Poor application of fundamentals –Erosion of design margins Poor Change Management Defensive Leaders Poor Self-Critical Behaviors Overconfidence Isolationism Production Priorities –Safety is assumed and not explicitly emphasized –Significance of issues underplayed Operations and Engineering: –Poor application of fundamentals –Erosion of design margins Poor Change Management Defensive Leaders Poor Self-Critical Behaviors

31. Life is 10% what happens to you and 90% how you CHOOSE to react to it! Life is 10% what happens to you and 90% how you CHOOSE to react to it!