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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 sources subjects
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

achieving readiness
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

management line preparations
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

management line preparations1
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

management line preparations2
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

management line preparations3
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

management line preparations4
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

management line preparations5
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

issues before proceeding
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

logistics and support
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

manage the orr team
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

conduct of operational demonstrations
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

prepare the report
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

lessons learned for doe nnsa field offices
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

lessons learned review examples
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

slide17
IFIT
  • DOE Oversight
  • Procedure Validity
    • Review Started before Readiness Achieved
  • DOE ORR suspended

12T 12 L 9M May 2005 Revision

slide18
DWPF
  • TSR Implementation
  • Equipment Operability
  • RadCon Environment
  • Good Drill Program

12T 12 L 9M May 2005 Revision

slide19
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

spent nuclear fuels project major construction project
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

w 62 readiness assessment
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

w 56 ra at y 12
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

wet chemistry
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

w 56 readiness assessment pantex
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

west valley demonstration project
West Valley Demonstration Project
  • Not Performance-Based
  • DOE Oversight - inadequate
  • Poor DOE understanding of ORR process

12T 12 L 9M May 2005 Revision

f canyon
F-Canyon
  • “Dream Team”
  • Phased startup
  • Linking database
  • Corrective Action Team

12T 12 L 9M May 2005 Revision

y 12 receipt storage shipment
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

srs tcon
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

y 12 bldg 9212 reduction process
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

tru supernate process at oak ridge
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

slide31
AHCF
  • Facility Hazard Category questionable
  • Repeat Findings from MSA
  • Facility procedures showed hasty revisions with missing steps

12T 12 L 9M May 2005 Revision

slide32
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

slide33
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