Improving Administrative Procedure Use and Adherence Patrick WalshNine Mile Point – Human Performance HPRTC Conference -June 10
Let’s get started • Levels of Lucky
What’s the Big Deal with Admin Procedures? • Required by Technical Specifications • Provide uniform standards and expectations • Protect the people • Protect the reactor • Protect the public
Consequences • What can happen when we fail to follow our standards and expectations, as outlined in our administrative procedures?
Consequences? • Challenges to nuclear safety • Challenges to personnel safety • Increased regulatory oversight • Loss of stakeholder trust
What started it all? • Dec 07 – Jan 08 incurred a significant amount of unavailability on NMP Unit 2 Service Water System. • Nov 08 – Service Water Foreign Material Intrusion event while cleaning the NMP Unit 2 intake. This event moved our component cooling water performance indicator to white. Station moved to NRC regulatory response column. • Failed NRC 95-001 inspection.
Actions taken? • Each Department identified the top 3 admin procedures that challenge them and created an improvement plan • Procedure Compliance Review Report • Admin Procedure “In Hand” Day • Supervisor 20 day habit changing activity • Required 1 documented observation per month of administrative procedure compliance • Frequent communications to the station in our weekly Station Updates regarding actions to raise our standards for compliance with administrative procedures
Procedure Compliance Review Report • Initiated for procedure violations as determined by procedure compliance review team. • Requires the supervisor and the employee(s) that contributed to the procedure compliance event to discuss the issue, evaluate culpability and determine what actions are required to improve performance. • Reviewed by the next level supervisor. • Evaluated by the HU lead when completed.
Procedure Compliance Review Report Attachment 1 – Procedure Compliance Review Report CR Number: Short Description of procedure non-compliance event: 1. Procedure(s) and section(s) not complied with: 2. Person(s) not complying with procedures listed above: 3. Why is this a procedure non compliance event?
Procedure Compliance Review Report 4. Review/discuss the issue with personnel involved and, using the “Culpability Model” (Human Error Review and Decision Tree, determine where the culpability lies for the procedure non compliance event. Results of Review: • Was the task and specific action covered by written work instructions or through standards and expectations? __ Yes __No • Were the instructions, standards, and expectations available, workable, intelligible, and correct? __ Yes __No • Pass the substitution test? __ Yes __No • Is there a history of inappropriate acts involving procedure adherence? __ Yes __No • Poor individual or Team Performance? __ Yes __No • Reckless Procedure Noncompliance? __ Yes __No • Management Control System Induced Violation? __ Yes __No • Blameless Error? __ Yes __No
Procedure Compliance Review Report 5. Why did the listed personnel not comply with the procedure? (Check one and describe below) • Did not know the requirement. • Did not understand the requirement. • Understood the requirement, but decided not to comply. • Thought they understood the requirement • Did not reference the procedure • Procedure guidance was vague Explanation: 6. What could be done to prevent others from making the same procedure error? 7. Are there procedure changes or other actions (e.g., training, coaching etc) required based on this review? 8. Has a PCR been initiated? (List CA and PCR Numbers below)
Administrative Procedure “In Hand Day” Weekly activity for the station to review an administrative procedure. The procedure of the day is communicated each Tuesday as part of the weekly Station Update that is reviewed at shop / department meetings. Expectations for “In Hand Day”. • Each site supervisor will have a copy of the procedure with them that day. • Supervisors are expected to review the procedure as part of shop / department briefings. • Work groups are expected to have the procedure available for review.
20-Day Habit Changing Activity All supervisors and above are issued cards to document at least two interactions per day to verify that employees are performing work in accordance with the applicable administrative procedure. Purpose of the exercise is to develop habits for: • Daily interaction and discussion of administrative procedure compliance between leaders and employees. • Frequent reviews of administrative procedure requirements for activities being performed. • Supervisors to observe and coach on administrative procedure compliance. • Personnel validating what the procedure requires
20 Day Habit changing activity Administrative Procedure Compliance 20-Day Habit Changing Program Name: __________________________ Title: ______________ Department: _________________ Purpose: To focus the stations supervisory team on compliance with our administrative requirements by implementing a daily requirement for station leaders to verify that they and the personnel working for them are performing activities in accordance with our station administrative procedures. • Each supervisor and above will document daily that they have observed and re-enforced compliance with our site administrative procedures. • Each supervisor will interact with at least 2 direct reports each working day to evaluate compliance with administrative procedures. • Each supervisor is required a minimum of 40 documented reviews of administrative procedure compliance. • Each supervisor will have their supervisor review progress weekly and initial on back page.
Observation Documentation The station’s management observation program expectations were revised to require each participant in the observation program to clearly document in at least one observation per month that they evaluated compliance with at least one administrative procedure and provided feedback to the personnel being observed.