Just Culture Definition

1. Just Culture Panel WorkshopHanford ContractorsDOE Office of River ProtectionDOE Richland Operations Office

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. 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. 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. 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. 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. 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. 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. What HQ can do to fosterJust 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. 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. 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. Just Culture Panel Workshop – Hanford ExperienceCH2M HILL Hanford Group, Inc.

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

14. Vapor Resolution CH2M HILL Improvement Cycle Human Performance Improvement Training Integration of SWE, ISMS & HPI Safe Work Environment (SWE) Culture Assessment Vapor Issues ISMS Expectations 4/15/05 Follow-up SWE Survey WFO VPP Star Status Accident Injury Rate Released Sub-Contracted Staff Augmentation SWE Mentoring Mandatory Respirator Usage in Farms A-Prefix Farms – Mask Cessation ISMS/ CONOPS Improvement Training 244-CR Vault Event 7/22/04 Mission Alignment Process (MAP) Involuntary Reduction of Force PIP Addressing OA Vapor Issues Management Changes Project Delivery System Tank Farm Acceleration Strategy Integrated Mission Acceleration Plan (IMAP) Organi-zational Readiness ISMS PIP CAP Completed for 244-CR Event Problem Evaluation Report System CH2M Prime Contractor ESTARS 1999 2000 2001 2002 2003 2004 2005 2006 GAP

15. CH2M HILL ECP Requests

17. 5 Year DART and Recordable Injury Rates

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. 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

22. Comparison of Disciplinary Actions by Employee Group

23. Response Time From Event to Review Days

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

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

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

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

31. River CorridorClosure Project Safety • People • Results HPI Just CultureWorkshop Panel On Hanford Experience Phillip Keuhlen Director, Safety, Health & Quality September 12, 2006 U.S. Department of EnergyRichland Operations Office

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. 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. 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. 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. WCH Metrics Indicate Just Culture is “Taking” • Employee Concerns • Grievances • Safety Performance

37. Questions and Answers