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2. 2 Best Practices Implementing Human Performance Improvement (HPI) ISM Workshop – Developing Effective Safety Culture Session D-1 Kim Leffew Larry Supina Richard S. Hartley, Ph.D., P.E. November 28, 2007

3. 3 What We Are Going To Cover HPI Accomplishments How HPI Sustains the HRO HPI+ to Sustain the HRO at Pantex Future Direction for HPI Reduce gap between worker – supervisor HPI Integration into Causal Factors Analysis

4. 4 HPI Accomplishments at Pantex HPI/BBS Integration with data tracking from error precursors Using HPI Tools to review weapon system procedures to mitigate error likely steps HPI designated within the Lessons Learned Program Supervisors perform HPI review with new employees Division specific HPI objectives to identify and mitigate LOWs HPI Coordinators active in improving Critiques, CAMPs, and CFAs 8 HPI Accident Investigations Completed

5. 5 Maintain HPI 5 Year Plan EFCOG & INEL Pro-force Benchmarking (adopted in Security) Co-Chair of EFCOG HPI Task Group Plant-Wide Training 19 Sr. Management (2 ½ day HPI classes) 8 HPI Program Coordinators (40 hour HPI class) 275 - Managers (8 hour HPI class)/HW/Test All Workforce (2.5 hours HPI Introduction) - 09/2007 Continue with Supervisory Training - 09/2008 8 HPI Accident Investigators (32 hour class) HPI Fully Integrated into Causal Factors Analysis and CA/MPs Trained HPI Coordinators/Cause Analysis/ORPS Personnel HPI Accomplishments at Pantex

6. 6 HRO Attribute #3: Decentralized, Culture, Continuity Decentralized decision making Culture of Reliability Continuous Operations Vision, Beliefs, & Values Mission Goals Policies Processes Programs HRO Attribute #2: Redundancy Duplication Overlap HRO Attribute #4: Learning Organization Vision, Beliefs, & Values High Reliability Theory of Preventing an Event HRO Attribute #1: Leadership Safety Objectives Safety held as priority by mgt. Redundancy, constant training Clear Operational Goals Adjust procedures Simulate events Lean from Info rich events No Event

7. 7 How Organizational Accidents Occur Vision, Beliefs, & Values Latent Organizational Weaknesses Mission Goals Policies Processes Programs Different Vision, Beliefs, & Values Event Flawed Defenses Human Errors Initiating Action

8. 8 How HPI Sustains the HRO Proactively Prevents Accidents – Protect Plant from Worker Reduce Human Errors Vision, Beliefs, & Values Latent Organizational Weaknesses Mission Goals Policies Processes Programs Manage Defenses HPI Re + Md =  E Re = reduce occurrence of errors Md = manage defenses  E = no significant events Flawed Defenses Human Errors Re Minimize Initiating Action No Event Different Vision, Beliefs, & Values 1 2 Md

9. 9 The problem is not that different images of work exists Problems arise when organization not sufficiently aware of gap between images Having a gap is not an indication of a dysfunctional organization -- but not knowing about it, and not learning why it exist, is More ignorance about gap, more difficult it is to make effective organizational investments in safety, as you may be investing in the wrong thing Sidney Dekker BWXT Pantex HPI + Learning Verification Evaluate and Address Effectiveness as a Learning Organization Evaluate the Gap Between “Work-As Imagined” and “Work-As-Done”

10. 10 HPI+ Practice of Preventing an Event Proactively Preventing Accidents – Protect Plant from Worker Reduce Human Errors Vision, Beliefs, & Values Identify & Fix Latent Organizational Weaknesses Mission Goals Policies Processes Programs Md Manage Defenses Flawed Defenses Human Errors Re Minimize Initiating Action No Event Re = reduce occurrence of errors Md = manage defenses Wg = reduce gap between “work-as-imagined” and “work-as-done  E = no significant events BWXT Pantex HPI+ (Re + Md) * Wg =  E Work-as-done Reduce Gap Work-as imagined Wg Closer Vision, Beliefs, & Values 1 2 3

11. 11 HPI Focus for FY08  Reduce W g Focus HPI Resources on Gap Between the Supervisor  Worker Pre-emptive analyze work to identify: Error Precursors (Re) Look at impact of the work process if something goes wrong Flawed Defenses (Md) Workers must know barriers to be effective Barrier Analysis performed to evaluate existing work processes Latent Organizational Weaknesses (Wg) Interviews to evaluate gap between “work-as-imagined” vs. “work-as-done” Corrective Actions to prevent events/accidents Close loop – track, evaluate corrective actions, reevaluate ISM Process 1 2 3

12. 12 Human Error Precursors Human Error Precursors (TWIN Analysis) T ASK DEMANDS I NDIVIDUAL CAPABILITIES Interpretation RequirementsSchedule Pressure to Get Work Done High Workload (memory requirements)First Time Task Simultaneous – Multiple TasksKnowingly Broke a Rule Unexpected Conditions EncounteredProblem Solved Wrong (inaccurate mental model) Time PressureFatigue or Illness Repetitive Actions/ MonotonyLack of Experience With Task Unclear Goals, Roles, or ResponsibilitiesInaccurate Mental Model of Tasks Lack of, or Unclear StandardsMisunderstood Communication Confusing Procedure/ Vague GuidanceNo Communications Delays; Idle Time; Worker Got LostPersonal Issue Lost Focus (medical, financial, emotional) W ORK ENVIRONMENTHUMAN N ATURE Confusing Controls/DisplayMade Bad Assumption OverconfidenceMind Set (I could have sworn it was right) Distractions/ InterruptionsComplacency (done task many times before) Unexpected Equipment ConditionDisoriented or Confused During Task Production Emphasis by SupervisorMental Shortcut (assumptions easily confirmed) Unavailable Parts or Tools – Made DoBoring Task Changes/ Departures from RoutineWork with People I Do Not Know or Like Personality ConflictsOn the Job Stress (perceived threat to well-being) Work-AroundsHabit Patterns Caused by Wrong Actions Left Unchecked for Long Time Hidden Systems ResponseInaccurate Risk or Hazard Perception Adverse Environmental Condition (Heat/Cold)Focused on Task – Missed Big Picture Poor Access to Equipment /Human FactorsLimited Short-Term Memory Swing Shift WorkUncertain About Job Requirements Used with permission from TXU Cause Analysis Handbook, Rev 7, June 28, 2005 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Largest Number of Human Performance Errors Occurring Due to Task Demands 1

13. 13 The Basics of Barrier Analysis ( ) The Basics of Barrier Analysis (Protect the Plant from the Worker ) Threat Target Defense-in-Depth 2

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15. 15 Pre-Emptive HPI Analysis & Corrective Action Tool Pre-Emptive HPI Analysis & Corrective Action Tool (Evaluate & Close Gap Between “work-as-imagined” vs. “work-as-done”) 3 StepWhat Is Planned Target to be Protected Barriers in Place (Md) Human Performance Error Precursors (Re) What Could Go Wrong (Wg) How We Are Going to Compensate to Avoid Issue Barrier Analysis TWIN Analysis Gap Reduction 21

16. 16 Evaluate Effectiveness & Learn Lead to An Event Investigation Learn Evaluate Problem Identification AND OR Analysis Lessons To Be Learned? Corrective Actions Did We Learn? Evaluate Corrective Actions Initiated by the Team

17. 17 Mission Goals Policies Processes Programs Causal Factors Analysis 5 Identify Latent Organizational Weaknesses  HRO Attribute #1 CFA Feedback to HRO Attributes Re-Actively Preventing Accidents – Protect Plant from Worker 3 Identify Human Performance Error Precursors  HRO Attribute #3 Work-as imagined Work-as-done Evaluate Failure to Learn as an Organization 2 Identify Gaps between “work-as-imagined” and “work-as-done”  HRO Attribute #4 Initiating Action 1  “What” Happened Event Facts 4 Identify Flawed Defenses  HRO Attribute #2 Event

18. 18 Conclusions Pre-emptive HPI process to prevent events HPI sustains HRO HPI Complements CFA Tools from CFA used in HPI Next Phase of HPI: Close Gap between Management and 1 st Line Supervision (Wg) Evaluate the corrective actions and lessons to be learned to prevent future events