1. ISMS Best Practices Workshop Just Culture Panel Workshop Hanford Contractors DOE Office of River Protection DOE Richland Operations Office

2. ISMS Best Practices Workshop 2 Just Culture Definition Definition: An environment that clearly defines acceptable behavior and recognizes human potential for error in a consistent manner Attributes: ▪Recognition of fairness related to the identification and resolution of human performance problems ▪Distinction between honest mistakes and intentional shortcuts with respect to discipline ▪Free flow of plant information across all levels of an organization ▪High level of self-reporting

3. ISMS Best Practices Workshop 3 Just Culture Background EPRI study on power plant leading indicators of human performance identified 7 themes ▪Executive commitment ▪Awareness of hazards ▪Preparedness for errors and events ▪Flexibility to meet operational demands ▪Just culture ▪Learning culture ▪System opacity

4. ISMS Best Practices Workshop 4 Organizational Elements Related to Just Culture Organizational Attributes ▪Trust, respect, and fairness ▪Communication that can affect performance highly valued ▪Management communication and reinforcement of desired behaviors Process Contributors ▪Processes eliminate human performance weaknesses ▪Procedure deficiencies promptly corrected ▪Root cause analysis identifies organizational process, and individual contributors to human performance events Individual Values and Behaviors ▪Deficiencies and suggested improvements are promptly reported and openly evaluated ▪Personnel use questioning attitude and don’t proceed in face of uncertainty

5. ISMS Best Practices Workshop 5 Why is Just Culture Important? Encourages participation at all levels of an organization in the identification of problems and continuous improvement Minimizes the probability of an event with consequences by maximizing organizational awareness of non consequential problems Promotes a learning culture and honest investigation of true weaknesses

6. ISMS Best Practices Workshop 6 What Do Contractors Need From DOE  Foster a Learning Environment  Avoid judgment, blame, & punishment for non- consequential events if right actions are being taken to address the issue. Introduce the analog of culpability matrix  Recognize errors will occur in implementation of 10 CFR 851. PAAA and 851 enforcement approach inhibits, rather than encourages reporting  Positively reinforce right preventive actions  Recognize and Promote reporting  Recognize & Promote HPI Concepts of Identifying Error- Likely Situations & Strengthening Defenses  Focus on Lessons Learned Rather than Number of Errors. Rationalize approach to recurrence  SPC => Every process has defects  Success lies in changing frequency and severity

7. ISMS Best Practices Workshop 7 What Do Workers Need in a Just Culture Trust - What’s Said Gets Done by Management Respect for the Individual Zero tolerance for HIRD Worker involvement in ISMS A Belief that Discipline is Fairly Administered Use of coaching process Respect for the Labor Contract Multiple Avenues to Communicate Worker participation in event investigations Confidence in broader organizational cause investigations

8. ISMS Best Practices Workshop 8 What the Field Needs from HQ Focus on Setting DOE policy and high level expectations Identify HQ, Field, and contractor R2A2 and work to drive consistent performance Establish consistent corporate metrics that draw from established sources (e.g. ORPS, CAIRS, ORPS performance analysis) to monitor performance Resist the need for instant identification of root causes, consequences, and final actions for events Allow Field to address inconsequential events and precursors Recognize Field office attempts to foster self-reporting of lower level events without punishing for increased volume of minor events

9. ISMS Best Practices Workshop 9 What HQ can do to foster Just Culture Continue to support and sponsor HPI across the complex Identify and Celebrate success Incorporate HPI into the Corporate Performance Metrics (e.g. Discovery Clock)

10. ISMS Best Practices Workshop 10 What is RL Doing? Developed a joint HPI Strategic Plan Training Key RL staff on HPI Principles (36 for 8 hr and 7 for 4-day course through 7/7/06) Striving to celebrate performance (e.g. HEC R response, SWSD safety day, others…) Consideration of HPI aspects in contract actions Direct communication of RL perspective on key performance areas (HEC, elec, near miss) RL acceptance of non-traditional corrective actions to strengthen barriers/defenses to address latent organizational weaknesses

11. ISMS Best Practices Workshop 11 What is ORP Doing? Developing a safety conscious work environment for all personnel (Feds and Contractors) HPI Training for Fed Staff (all in ORP will be trainied in 8 hr and about 40% in 4 day) Encouraging Contractor implementation of HPI principles Promoting VPP to our Contractors Encouraging personnel (Fed & Contractor personnel) to report at below event levels so lessons can be learned without the cost of an event Using HPI tools to investigate events

12. ISMS Best Practices Workshop Just Culture Panel Workshop – Hanford Experience CH2M HILL Hanford Group, Inc.

13. ISMS Best Practices Workshop 13 Our ISMS strategy is based on an open work environment where everyone feels free to raise issues without fear of HIRD ISMS at CH2M HILL Event Prevention Employee involvement Problem identification and resolution

14. ISMS Best Practices Workshop 14 CH2M Prime Contractor 19992000200120022003200420052006 Tank Farm Acceleration Strategy Problem Evaluation Report System ESTARS Integrated Mission Acceleration Plan (IMAP) Vapor Issues Organi- zational Readiness Safe Work Environment (SWE) Culture Assessment Released Sub- Contracted Staff Augmentation Mandatory Respirator Usage in Farms ISMS/ CONOPS Improvement Training ISMS Expectations 4/15/05 Vapor Resolution WFO VPP Star Status Human Performance Improvement Training Management Changes Integration of SWE, ISMS & HPI Follow-up SWE Survey GAP CH2M HILL Improvement Cycle Accident Injury Rate PIP Addressing OA Vapor Issues A-Prefix Farms – Mask Cessation 244-CR Vault Event 7/22/04 CAP Completed for 244-CR Event Project Delivery System Mission Alignment Process (MAP) SWE Mentoring Involuntary Reduction of Force ISMS PIP

15. ISMS Best Practices Workshop 15 CH2M HILL ECP Requests

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17. ISMS Best Practices Workshop 17 5 Year DART and Recordable Injury Rates

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19. ISMS Best Practices Workshop 19 CH2M HILL Actions Taken to Implement Just Culture Alternative avenues expanded – more union safety representatives; Hanford concerns council All employee surveys conducted Improved IROF process communication and fairness Cause analysis process changed to identify organizational contributors to human performance events Single, web based problem identification process Trust, respect, and fairness expectations issued HPI Training conducted Discipline process revised to improve fair treatment

20. ISMS Best Practices Workshop 20 2004 Employee Survey Process Improvement Issues Accountability Issues ▪Improve consistency in holding everyone accountable for their behavior ▪Improve fairness and consistency of disciplinary process ▪Improve timeliness of disciplinary process

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22. ISMS Best Practices Workshop 22 Comparison of Disciplinary Actions by Employee Group 200320042005 Non Exempt1 (3%)02 (5%) Exempt8 (27%)6 (29%)20 (45%) Bargaining Unit21 (70%)15 (71%)22 (50%) Total 3021 44

23. ISMS Best Practices Workshop 23 Response Time From Event to Review Days

24. ISMS Best Practices Workshop 24 99% of respondents say they will take action if potentially unsafe conditions, work practices, or products are seen 2005 HILL All Employee Survey Question 10: Do you take action if you see potentially unsafe conditions, work practices, or products? 98

25. ISMS Best Practices Workshop 25 ISM Best Practice Workshop Aurora, CO Sept 12-13, 2006 Safety Excellence- Creating a Just Culture Fluor Hanford Inc.

26. ISMS Best Practices Workshop 26 Safety Excellence-Just Culture How’s Fluor Hanford Promoting a Just Culture Path to a Just Culture began in August 1996 ▪Fluor’s Zero Accident Program Provided a Firm belief that Injuries are not the cost of progress. ▪Presidents’ & Employee Zero Accident Councils Provided voice in program & ownership of work area ▪HAMTC Safety Rep. Program Provided the Communication, Built Trust, Win-Win STOP Work Responsibility ▪Pursuit of VPP The avenue to worker involvement in work planning & execution. ▪ISMS Standardized the process & program Provided a consistent process for projects & workers

27. ISMS Best Practices Workshop 27 Safety Excellence-Just Culture Furthering the Fluor Hanford Culture Continuing to Build on Union Safety Reps., EZACs & VPP Initiating Human Performance Improvement ▪Over 700 trained in HPI Fundamentals ▪40 HPI Practitioners Trained to Implement at Project Level ▪Learning that Errors will happen, and building defenses to mitigate consequences. Investigating Incidents using HPI techniques ▪Looking deeper into the organization for errors & conditions ▪Greater chance of fixing more than just the immediate event Integrating Culpability Matrix into decisions on discipline ▪Understanding better why good people make mistakes ▪Removing the latitude of poor performers to hide in the organization Focusing on Early Conflict Resolution Supervisor Leadership Training on Mediation Trained Intervention Mentors Outside Consultants As Necessary

28. ISMS Best Practices Workshop 28 Culpability Evaluation Flowchart Were actions as intended? Knowingly violate expectation? Pass substitution test? (see note) History of human performance problems? Were expectations reasonable, available, workable, intelligible, and correct? Were the consequences intended? Deficiencies in training and selection or inexperience? Self- Reported Organization induced violation System induced error Blameless error Intentional act (not an error) Corrective training or other intervention may be warranted Possible reckless violation Possible negligent error No Yes No Yes Note: Would other employees have made the same error? Evaluate organizational processes and management/supervisory methods No Yes

29. ISMS Best Practices Workshop 29 Safety Excellence – Just Culture Fluor Hanford Results Metrics Tell the Story ▪VPP Culture Survey Chart ▪Employee Safety Concern Chart ▪Total Injury Rate Chart ▪Number of Safety Related Grievances Chart

30. ISMS Best Practices Workshop 30 Contacts George Jackson, Executive Vice President Fluor Hanford (509) 372-1050George_jackson@rl.gov Tony Umek, Vice President Safety & Health (509)373-5983Anthony_m_umek@rl.gov Dave Jackson, Deputy Vice President Safety & Health (509)376-0082Dave_jackson@rl.gov John Jeskey, HAMTC Safety Rep Director Fluor Hanford (509) 396-1009John_J_Jeskey@rl.gov P.O. Box 1000 H8-67, Richland, WA 99352

31. ISMS Best Practices Workshop 31 River Corridor Closure Project Safety People Results U.S. Department of Energy Richland Operations Office HPI Just Culture Workshop Panel On Hanford Experience Phillip Keuhlen Director, Safety, Health & Quality September 12, 2006

32. ISMS Best Practices Workshop 32 Achieving “Just Culture” During Transition To A New Contract Special situation: ▪Contract in public domain, often in public discussion, before transition ▪New management = new means & methods ▪Uncertainty about future in work force ▪Rumors about intentions precede you WCH approached as part of establishing strong industrial and nuclear safety culture

33. ISMS Best Practices Workshop 33 INPO Principles for a Strong Nuclear Safety Culture as a Blueprint Everyone is personally responsible for nuclear safety Leaders demonstrate commitment to safety Trust permeates the organization Decision making reflects safety first Nuclear technology is recognized as special and unique A questioning attitude is cultivated Organization learning is embraced Nuclear safety undergoes constant examination

34. ISMS Best Practices Workshop 34 How WCH Approached Development of a Just Culture (1) Embraced ISMS as the integrating umbrella Instituted robust communication process ▪Conveyed “Zero is the only goal” for employee injuries ▪Actively promoted “Time Out for Safety” ▪Management highly visible and approachable at work sites Trained FLS as the critical interface with the craft ▪How do we convey by our actions that people are our most valuable resource? ▪Tools and exercises in FLS Leadership Workshop Incentivized safety performance for all employees

35. ISMS Best Practices Workshop 35 How WCH Approached Development of a Just Culture (2) Instituted Local Safety Improvement Teams (LSIT) ▪Employee led (often by union stewards), management supported ▪Prompt action & feedback are key elements Strengthened HAMTC Safety Representative Program ▪Weekly drive builds mutual trust & confidence Built supporting processes ▪HPI event investigation ▪Culpability matrix considered in constructive discipline Cultivated employee leadership for pursuit of VPP

36. ISMS Best Practices Workshop 36 WCH Metrics Indicate Just Culture is “Taking” Employee Concerns Grievances Safety Performance

37. ISMS Best Practices Workshop Questions and Answers