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Lessons Learned May 2005 Revision

Lessons Learned May 2005 Revision. 12T 12L 9M. LESSONS LEARNED Sources & Subjects. Each Report has Lesson Learned (LL) Section EH ORR/RA Web Site has LL Section (handout) Team Leaders Handbook has LL section LL topics include: Achieving Readiness;

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Lessons Learned May 2005 Revision

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  1. Lessons LearnedMay 2005 Revision 12T 12L 9M

  2. LESSONS LEARNEDSources & Subjects • Each Report has Lesson Learned (LL) Section • EH ORR/RA Web Site has LL Section (handout) • Team Leaders Handbook has LL section • LL topics include: • Achieving Readiness; • Considerations before proceeding with the ORR/RA; • Logistics and Support; • Managing the team and the process; • Developing the Implementation Plan; • Conduct of Drills and Evolutions; • Development of the Report and CAPs; • Individual Specific ORR/RAs; • LL DOE/NNSA Site and Field Office Concerns and Issues. 12T 12 L 9M May 2005 Revision

  3. ACHIEVING READINESS • Management Line preparation . . . • Premature ORR/RA Start . . . • AB Implementation . . . • Inadequate MSA . . . • DOE/NNSA Line Oversight not prepared . . . • Lack of Operational Proficiency . . . • Procedural problems . . . • Flowdown of requirements . . . • Not Validated and Verified (V&V) . . . • “Not yet implemented,” usually new facilities . . . 12T 12 L 9M May 2005 Revision

  4. MANAGEMENT LINE PREPARATIONS • Objective should be successful startup/restart not “passing” Readiness Review: - Passing the ORR/RA is just a by-product . . . • Establish guidance/procedures for Subject Matter Experts (SMEs who are contractors and Federal personnel) involvement during MSA/preparation phase . . . 12T 12 L 9M May 2005 Revision

  5. MANAGEMENT LINE PREPARATIONS • Flexibility needs to be incorporated into procedures for: • First-time-use including hold points for verifying assumptions and actions to take if assumptions are incorrect . . . • Management oversight during startup preparations to adjust level of oversight based on performance . . . 12T 12 L 9M May 2005 Revision

  6. MANAGEMENT LINE PREPARATIONS • For systems or mockups not capable of operating under real conditions or with real material: • Establish requirements for the surrogate material . . . • Integrate operator training with simulated conditions to identify differences . . . 12T 12 L 9M May 2005 Revision

  7. MANAGEMENT LINE PREPARATIONS • Lessons Learned adjustments include: • Mischaracterization of type, form, quantity is not uncommon for legacy material. Consider use of non-destructive techniques for better characterization and/or open a container in a controlled environment to help prepare for readiness planning. • Still be prepared and flexible for the unexpected. 12T 12 L 9M May 2005 Revision

  8. MANAGEMENT LINE PREPARATIONS • Some facilities by-pass readiness preparations by designating known deficiencies for post start repair, thereby getting through the readiness review easier but then are not ready for product production. • Limit the use of these designations to equipment that is not possible to function before readiness is declared. 12T 12 L 9M May 2005 Revision

  9. MANAGEMENT LINE PREPARATIONS • Use of a Joint Test Group has been proposed and being implemented successfully at some Sites, and they also are developing a process to capture knowledge from the test engineers to the system engineers that much of the time is lost. • Learn from others’ experiences. 12T 12 L 9M May 2005 Revision

  10. ISSUES BEFORE PROCEEDING • Team members not trained or ready to proceed . . . • Operational Demonstration schedule not defined . . . • Counterparts not assigned, available, or trained . . . • Documentation for review not identified or not available . . . • Example forms and report content not provided to team . . . • Evidence files not prepared . . . • Contractor does not communicate to DOE team until arrival that delayed start of ORR has resulted in new procedures, programs, references . . . 12T 12 L 9M May 2005 Revision

  11. LOGISTICS AND SUPPORT • Not adequate work space . . . • Not adequate computers, copiers, phones . . . • No arrangements for electronic document access . . . • No arrangements for classified support . . . 12T 12 L 9M May 2005 Revision

  12. MANAGE THE ORR TEAM • Workable review scope assignments . . . • Full time dedication to the review . . . • Team members stay focused, remain on schedule . . . • Document results; deliverables on schedule . . . • Performance based review vice a compliance audit . . . 12T 12 L 9M May 2005 Revision

  13. CONDUCT OF OPERATIONAL DEMONSTRATIONS • Conduct of Operational Demonstrations: • Team Leader to communicate drill/evolution expectation to facility with sufficient lead time . . . • See it all; pre-job brief to post-job debrief . . . • Team is not part of operational/drill team . . . • Avoid distraction or influence to operators . . . • Copious notes including times, and procedure steps . . . • Assign complete observer coverage of action sites . . . 12T 12 L 9M May 2005 Revision

  14. PREPARE THE REPORT • Timely input of compliant forms and parts . . . • Draft complete and delivered before team leaves site. . . • Expeditious factual accuracy . . . • Classification review; Classification brief before ORR/RA starts . . . 12T 12 L 9M May 2005 Revision

  15. LESSONS LEARNED FOR DOE/NNSA FIELD OFFICES • Criteria and process for DOE/NNSA Field verification of contractor readiness lacking . . . • Criteria and process for DOE/NNSA Field verification of DOE/NNSA oversight readiness lacking . . . • Lack of adequate review of SNR determinations by Contractor . . . • Corrective Action closeout process lacking, or either acceptance criteria not communicated to contractor or not understood by DOE/NNSA line personnel . . . 12T 12 L 9M May 2005 Revision

  16. IFIT DWPF NWCF SNFP W-62 W-56 (Y-12) Wet Chemistry SRS TCON WETF W-56 (PANTEX) West Valley Demonstration Project F-Canyon Y-12 Disassembly / Assembly operations Supernate Process at TRU Y-12 Reduction Process AHCF WVPD Lessons LearnedReview Examples 12T 12 L 9M May 2005 Revision

  17. IFIT • DOE Oversight • Procedure Validity • Review Started before Readiness Achieved • DOE ORR suspended 12T 12 L 9M May 2005 Revision

  18. DWPF • TSR Implementation • Equipment Operability • RadCon Environment • Good Drill Program 12T 12 L 9M May 2005 Revision

  19. NWCF • All simulation • Midnight dose • Not trained on procedures • Generally not ready • Too many first-timers and/or no training • ORR exceeded scope in POA 12T 12 L 9M May 2005 Revision

  20. Spent Nuclear Fuels Project(Major Construction Project) • Include Schedule Time to Implement SAR • Flexible Scope to Support Readiness Status • Track ALL Open Issues to Resolution • Line Management Manage ORR Activities • Stay Connected • Deal with Emerging Issues • IP Must reflect Scope of POA • DOE Line Management Process Flawed 12T 12 L 9M May 2005 Revision

  21. W-62 Readiness Assessment • Inadequate Time for Observation • Team Member Qualification not Adequate • Too Few Team Members to Review all Core Requirements • Difficulty in Completion of Assessment Forms 12T 12 L 9M May 2005 Revision

  22. W-56 RA at Y-12 • Scope of CRA not consistent with new activity • Support systems and components not ready • Fire suppression • Glovebox Ventilation System • Past Modifications and commitments not completed • Some procedures did not work • MSA was not adequate • CRA did not stop • DOE RA stopped based on number and breadth of issues. • Recovery was long and difficult 12T 12 L 9M May 2005 Revision

  23. Wet Chemistry • Ten chemical process systems after 8 yr Shutdown • CORR Suspended and then failed • Schedule pressure drove readiness decisions • Project plan underestimated test program impacts • Procedure development and operational training time compressed to recover schedule • Closure of Change packages and Test Packages • MSA started late; Inadequate response to MSA indicators 12T 12 L 9M May 2005 Revision

  24. W-56 Readiness Assessment (PANTEX) • Premature Start - AB not Implemented • Inadequate Closure of CORR Findings • RA Suspended • Competent Team to Support Hard Choices • POA & IP Scopes Varied • POA not Timely 12T 12 L 9M May 2005 Revision

  25. West Valley Demonstration Project • Not Performance-Based • DOE Oversight - inadequate • Poor DOE understanding of ORR process 12T 12 L 9M May 2005 Revision

  26. F-Canyon • “Dream Team” • Phased startup • Linking database • Corrective Action Team 12T 12 L 9M May 2005 Revision

  27. Y-12 Receipt, Storage & Shipment • DOE validation of contractor ORR • Finding closure/Root cause • OSR Implementation/Bases • Procedure Implementation and Control 12T 12 L 9M May 2005 Revision

  28. SRS TCON • Poorly written POA can (will) reduce scope and effectivness of associated readiness reviews • NNSA TL change late in process 12T 12 L 9M May 2005 Revision

  29. Y-12 BLDG 9212 REDUCTION PROCESS • On-The-Floor workers not bought-in to ISM • Skill of the craft vs objective standards 12T 12 L 9M May 2005 Revision

  30. TRU Supernate Process at Oak Ridge • Privatized contracts tend to be highly schedule driven • One week for DOE ORR is not enough 12T 12 L 9M May 2005 Revision

  31. AHCF • Facility Hazard Category questionable • Repeat Findings from MSA • Facility procedures showed hasty revisions with missing steps 12T 12 L 9M May 2005 Revision

  32. WETF • Insufficient lead time given to NNSA Team for preparation • NNSA Line Management validation of contractor and Fed readiness was lacking 12T 12 L 9M May 2005 Revision

  33. WVPD • A sub-tem leader pulled off ORR team by his home management at 1600 on the Friday prior to start of ORR • A 1 week ORR schedule is not desirable 12T 12 L 9M May 2005 Revision

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