Presentation produced under contract with:

1. Presentation produced under contract with:

2. Best Practices Implementing Human Performance Improvement (HPI) ISM Workshop – Developing Effective Safety Culture Session D-1 Kim Leffew Larry Supina Richard S. Hartley, Ph.D., P.E. November 28, 2007

3. What We Are Going To Cover • HPI Accomplishments • How HPI Sustains the HRO • HPI+ to Sustain the HRO at Pantex • Future Direction for HPI • Reduce gap between worker – supervisor • HPI Integration into Causal Factors Analysis

4. HPI Accomplishments at Pantex • HPI/BBS Integration with data tracking from error precursors • Using HPI Tools to review weapon system procedures to mitigate error likely steps • HPI designated within the Lessons Learned Program • Supervisors perform HPI review with new employees • Division specific HPI objectives to identify and mitigate LOWs • HPI Coordinators active in improving Critiques, CAMPs, and CFAs • 8 HPI Accident Investigations Completed

5. HPI Accomplishments at Pantex • Maintain HPI 5 Year Plan • EFCOG & INEL Pro-force Benchmarking (adopted in Security) • Co-Chair of EFCOG HPI Task Group • Plant-Wide Training • 19 Sr. Management (2 ½ day HPI classes) • 8 HPI Program Coordinators (40 hour HPI class) • 275 - Managers (8 hour HPI class)/HW/Test • All Workforce (2.5 hours HPI Introduction) - 09/2007 • Continue with Supervisory Training - 09/2008 • 8 HPI Accident Investigators (32 hour class) • HPI Fully Integrated into Causal Factors Analysis and CA/MPs • Trained HPI Coordinators/Cause Analysis/ORPS Personnel

6. No Event High Reliability Theoryof Preventing an Event HRO Attribute #2: Redundancy • Duplication • Overlap Vision, Beliefs, & Values Vision, Beliefs, & Values Mission Goals Policies Processes Programs HRO Attribute #4: Learning Organization HRO Attribute #1: Leadership Safety Objectives HRO Attribute #3: Decentralized, Culture, Continuity • Decentralized decision making • Culture of Reliability • Continuous Operations • Adjust procedures • Simulate events • Lean from Info rich events • Safety held as priority by mgt. • Redundancy, constant training • Clear Operational Goals

7. Event HowOrganizational Accidents Occur Flawed Defenses Different Vision, Beliefs, & Values Vision, Beliefs, & Values Mission Goals Policies Processes Programs Initiating Action LatentOrganizationalWeaknesses Human Errors

8. No Event How HPI Sustains the HRO Proactively Prevents Accidents – Protect Plant from Worker Flawed Defenses Manage Defenses Different Vision, Beliefs, & Values Vision, Beliefs, & Values 2 Md Mission Goals Policies Processes Programs Minimize Initiating Action Re LatentOrganizationalWeaknesses HPI Re + Md = E Re = reduce occurrence of errors Md = manage defenses E = no significant events 1 Human Errors Reduce Human Errors

9. BWXT Pantex HPI + Learning Verification Evaluate and Address Effectiveness as a Learning Organization Evaluate the Gap Between “Work-As Imagined” and “Work-As-Done” The problem is not that different images of work exists Problems arise when organization not sufficiently aware of gap between images Having a gap is not an indication of a dysfunctional organization -- but not knowing about it, and not learning why it exist, is More ignorance about gap, more difficult it is to make effective organizational investments in safety, as you may be investing in the wrong thing Sidney Dekker

10. No Event BWXT Pantex HPI+ (Re + Md) * Wg = E Re = reduce occurrence of errors Md = manage defenses Wg = reduce gap between “work-as-imagined” and “work-as-done E = no significant events HPI+ Practice of Preventing an Event Proactively Preventing Accidents – Protect Plant from Worker Reduce Gap Wg Flawed Defenses Manage Defenses Work-as imagined Work-as-done Closer Vision, Beliefs, & Values Vision, Beliefs, & Values 2 Md Mission Goals Policies Processes Programs Minimize Initiating Action 3 Re Identify & Fix LatentOrganizationalWeaknesses 1 Human Errors Reduce Human Errors

11. HPI Focus for FY08  Reduce WgFocus HPI Resources on Gap Between the Supervisor  Worker 1 • Pre-emptive analyze work to identify: • Error Precursors (Re) • Look at impact of the work process if something goes wrong • Flawed Defenses (Md) • Workers must know barriers to be effective • Barrier Analysis performed to evaluate existing work processes • Latent Organizational Weaknesses (Wg) • Interviews to evaluate gap between “work-as-imagined” vs. “work-as-done” • Corrective Actions to prevent events/accidents • Close loop – track, evaluate corrective actions, reevaluate • ISM Process 2 3

12. Largest Number of Human Performance Errors Occurring Due to Task Demands | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Human Error Precursors (TWIN Analysis) 1 Used with permission from TXU Cause Analysis Handbook, Rev 7, June 28, 2005

13. 2 The Basics of Barrier Analysis (Protect the Plant from the Worker ) Target Threat Defense-in-Depth

14. 2

15. Pre-Emptive HPI Analysis & Corrective Action Tool(Evaluate & Close Gap Between “work-as-imagined” vs. “work-as-done”) 1 2 3 Barrier Analysis TWIN Analysis Gap Reduction

16. Evaluate Effectiveness & Learn Problem Identification Evaluate Corrective Actions Initiated by the Team Investigation Analysis Corrective Actions Lead to An Event OR AND Lessons To Be Learned? Learn Did We Learn? Evaluate

17. 2 Identify Gaps between “work-as-imagined” and “work-as-done” Evaluate Failure to Learn as an Organization HRO Attribute #4 4 Work-as imagined Work-as-done Identify Flawed Defenses HRO Attribute #2 Mission Goals Policies Processes Programs 5 Initiating Action Causal Factors Analysis 1 “What” Happened Event Facts Identify LatentOrganizationalWeaknesses HRO Attribute #1 3 Identify Human Performance Error Precursors HRO Attribute #3 CFA Feedback to HRO Attributes Re-Actively Preventing Accidents – Protect Plant from Worker Event

18. Conclusions • Pre-emptive HPI process to prevent events • HPI sustains HRO • HPI Complements CFA • Tools from CFA used in HPI • Next Phase of HPI: Close Gap between Management and 1st Line Supervision (Wg) • Evaluate the corrective actions and lessons to be learned to prevent future events