Background

1. Initial Steps to Integrate HPI into ISMSContinuous ImprovementCH2M HILL Hanford Group, Inc.September 12-13, 2006

2. Background • Senior management received DOE sponsored HPI fundamentals training – Dec 05 • Hanford contractors selected to participate in EM HPI pilot – Jan 06 • Joint DOE/CH2M HILL implementation plan established based on INPO recommended approach – Jan 06 • Senior management commitment to implement HPI – Jan 06 • Senior management decision to include HPI as ISMS continuous improvement initiative – Mar 06

3. HPI Implementation Plan • Senior management commitment established • HPI steering committee formed • Gap analysis performed between INPO HPI attributes and existing event prevention activities • ISMS improvement plan revised to include HPI • Implemented the improvement plan

4. HPI Steering Committee • Charter created • Composed of operations and support program personnel, including bargaining unit • Chaired by senior operations leadership • Includes organizational and process HPI champions • Approved GAP analysis and implementation plan • Provided program oversight for the training needs analysis • Tracks progress of implementation plan and makes course corrections as needed • Identifies and reviews communication needs

5. HPI Steering Committee Strategy Shift the organizational focus From:Emphasizing administration in our processesRobust defense against second guessingRobust reaction to events To: Robust hazard identification and mitigation Processes built for the user Robust prevention of events

6. GAP Analysis Provides current state of the organization and forms basis for improvement plan • Multi-disciplined team selected • GAP Analysis focused on event prevention • Assessment criteria obtained from 3 INPO sources • The Human Performance Improvement Initiative Site Gap Analysis Tool • Performance Objectives and Criteria, (INPO 05-003, May 2005) Human Performance Criteria OR.3 • Job-Site Conditions Self-Assessment Questionnaire • Criteria based on commercial nuclear operational excellence • Criteria were modified for DOE activities • Assessment plan discussed with INPO representatives

7. GAP Analysis Methodology

8. GAP Analysis Opportunities • Use of the critical task concept • Proactive planning defending against error likely situations • Tailoring controls to the critical task • Ensuring controls are not buried in extraneous information • Training for field/support personnel and management • Ensuring workers attention is properly focused • Recognition of error likely situations and error precursors • Defenses to minimize errors

9. Event Prevention Integration into ISMS Implementation Examples • Procedures development • Human resource processes • Work Planning • Walkdowns • Design engineering considerations • Pre-Job briefings • Post-Job briefings • Lessons learned • Management / self assessments • Event analysis / investigation

10. Example of HPI Integration into ISMS Implementation: Critical Task • Not all aspects of a job are equally important • Some actions/tasks are irrecoverable; once the action is taken, the reverse action cannot recover. • Some steps have more chances for error • Need to consider as part of hazards analysis • Is changing the state of the facility, system, component, or the well-being of the individual dependent on the individual worker? • Is the outcome of the error intolerable from a personnel safety or facility perspective? • Helps focus attention on potential consequences so appropriate defenses can be put in place

11. Training Needs Analysis • Purpose and approach • Consistent with SAT approach to training • GAP Analysis recommendations included • Guidance provided by HPI Steering committee • Objectives • Identify intended students (planners, procedure writers, managers, event investigators, etc) • Identify training emphasis and objectives • Identify timeframe & duration • Multidiscipline Analysis Team • Represented employees • Support Programs • First Line Supervisors • Line Management

12. Training Needs Analysis Results Identify and Train 3 Audiences • Subject Matter Experts • Focus on line organizations (work planning & operations) • Include support program staff as needed • Personnel that can facilitate implementation • Line managers, first line supervisors • Support program staff • General field workers on basic event prevention tools

13. ISMS Integration Using HPI • Define Scope of Work • Application to facility specific processes • Hazards Identification and Controls • Critical task emphasis • Shift from static to dynamic hazards analysis • Procedure development and use • HPI procedure checklist • Perform Work • Critical task • Error precursors • Error likely situations • Tools to prevent errors • Feedback & Improvement • Self-assessment process using INPO warning flags (based on Davis-Besse organizational behaviors) • INPO jobsite self-assessment

14. Early Successes • Trained • 43 SMEs • Approximately 80 Managers (ongoing) • Approximately 400 Employees (ongoing) • Work Planning • Simplified process • Critical task focus improved hazards identification and control • Improved usability • Clearly identify hazards (dynamic hazards analysis) • Plans and Procedures • Event prevention focus simplified process (e.g., Waste Programs eliminated over 25 plans, procedures, etc) • Improved usability • Compliance is more easily demonstrated

15. Lessons Learned • Senior management vision and commitment is essential • Adapting NRC/INPO safety culture principles (SWE) helped HPI implementation • Benchmarking was necessary and critical for effective change • HPI improvement initiatives must be integrated with ISMS • VPP initiative helped HPI implementation • Gap analysis was a good tool to focus initial improvement plan • Involvement of union safety representatives in event investigations helped support free flow of information • Involvement of bargaining unit personnel in procedure development has strengthened procedure usability and compliance