Transcript Walsh - Admin Procedure Presentation

Improving Administrative
Procedure Use and
Adherence
Patrick Walsh
Nine Mile Point – Human Performance
HPRTC Conference -June 10
Let’s get started
 Levels
of Lucky
What’s the Big Deal with Admin
Procedures?
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
How’s your station doing?
Consequences
What can happen when we fail to
follow our standards and
expectations, as outlined in our
administrative procedures?
Gulf Oil Spill
Gulf Oil Spill
Exxon Valdez ?
Bhopal, India
Consequences?
 Challenges
to nuclear safety
 Challenges to personnel safety
 Increased regulatory oversight
 Loss of stakeholder trust
NMP’s Journey?
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:






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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
Human Error Review & Decision Tree
START==> For each
specific error . . .
Unauthorized
substance?
No
Were the actions as
intended?
No
Was the task and specific
action covered by written
work instructions or
through standards and
expectations?
No
Pass the
substitution
test?
No
Yes
Were the
consequences
as intended?
Medical
condition?
Were the instructions,
standards, and
expectations available,
workable, intelligible, and
correct?
Deficiencies in
training &
selection or
inexperience?
No
Yes
Yes
Did Supervisor
negatively
influence
behavior?
Yes
No
Sabotage,
malevolent
damage,
suicide, etc.
Substance
abuse
without
mitigation
Substance
abuse with
mitigation
Poor Individual/
Team
Performance
(poor use of HU
Tools) OR
Possible reckless
violation
No
Yes
Blameless
error
Yes
Yes
No
History of
inappropriate
acts?
Yes
No. Others would not
have taken the same
action.
No
Yes
Yes
Yes, Most others would
probably have taken the same action
or likely could have made the same
error.
No
Management
Control
System
induced
violation/
Supervisor
culpability
Poor
Individual or
Team
Performance Possible
negligent
error
Management
Control
System
induced error
Reason, Managing the Risks of
Organizational Accidents, 1997
Corrective
training or
counselling
indicated
May still warrant
management actions
to prevent recurrence,
e.g., enhance
procedure
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.
Date
1
2
3
4
Personnel
observed
Activity
Applicable
Procedures
Referenced
Coaching
required?
Positive reenforcement?
Initials
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.
How’s it working?
Summary