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Value of Peer ReviewsLearning from Experience Keith Spooner EHSS&Q Director, Magnox Ltd CQI NucSIG Conference HSE Offices 19 January 2011
Peer Review ‘is a generic term for a process of self-regulation by a profession, or a process of evaluation involving qualified individuals within the relevant field. Peer review methods are employed to maintain standards, improve performance, and provide credibility’ …Wikipedia
Better … “A smart man learns from his experience, but a wise man learns from the experiences of others” … old proverb
Learning from the experience of others International UK WANO (INPO) IAEA Overseas Utilities PBO Activities SLCs Supplier Organisations Societies/Institutes Regulators Industry Other Organisations (Bench-marking) Media driven Other
Response to third party / own event (re-active) • International events (major) • UK events (major) • Industry events (typically major, e.g. fatality, INES 2+) • Company events (significant, wider learning) • Texas City explosion • NIMROD crash • Work at height fatality • Pond event • Road Traffic Accident
Texas City - Response BP shared learning at Nuclear Operations Conference Cascaded to EHSSQ Managers Peer Group by the Texas City EHS Manager CNOO Oversight Programme coincidently established Process Safety Indicators developed, best practice across NDA? WANO TSM specifically requested to review Oversight Programme HoP Nuclear Safety appointed Further learning from the Oil and Gas Industry Risk Management and Process Safety Conference, also Chemical Industry learning from the IChemE conference on Process Safety
Safety Case Design ‘creep’, departure from original design intent Configuration control of modifications Importance and rigour of the challenge function Complacency (Titanic ‘mentality’ - “NIMROD was assumed to be safe”) Organisation Outsourcing: importance and oversight of the Intelligent Customer function Project delivery focus Independence of the challenge function Ageing plant and systems Overall organisational resilience (need to maintain capability) NIMROD - Learning
Treated event as if it happened within our Company MD led telecon with all site and functional lead teams Not accepting leaving of any openings, albeit with barriers, as a general practice Barriers to be secondary not primary means of defence No tolerance of long term temporary covers Stand-downs of sites and functions to cascade MD message Exec out and about around sites ‘walking the talk’ Sites confirmation of compliance with existing arrangements Working at height Lone working Independent compliance checks (Site Inspection activity) Review and enhancement of arrangements Response included in ‘NIMROD vulnerability programme’ Focus for future EHSS&Q reviews Fatality – Work at Height (Non Magnox Event)
Pond Event - Response ‘Management Centre’ established during initial event to promulgate ‘hot’ learning across the business (MxN,MxS) Mandatory Assessment (MA) covering key questions on material condition, design, safety case and maintenance All sites undertook plant walk downs Improvement plans drawn up and actions placed Follow up by CNOOs to confirm close out of actions Key alarm management section now included in Conduct of Ops Standard
RTA – Driving on Company Business • Senior Management ‘Stand Down’ • New Standard produced – independently reviewed by Institute of Advanced Motorists • Emphasis on forward planning and risk assessment • Focus now on reduction in driven miles (Phase 2 ‘enablers’) • Targeted in EHSSQ 3 P Plan Improvement Plan • Implementation audited across organisation • Business now making conscious decisions not to drive • Sharing learning with other organisations
Pro-active approach - better practice • Audits • Bench-marking • Peer Reviews • External • Internal • First, second, third party • Various … • WANO Peer Review / TSMs • IAEA Peer Reviews • SLC Peer Assists • Magnox Peer Reviews / Assists
Bench-marking • Chevron Refinery, Pembroke by Director and HESAC (General EHS, Process Safety) • Olympics Construction Project by Industrial Safety Expert Group (Construction Safety) • RSRL, Harwell by Directors, MXN and MXS (EHS Improvement) • Springfields by Director and Chief Engineer (Maintenance Schedule Management).
WANO Peer Reviews • Annual Plan of support from WANO agreed • Includes TSMs aimed at helping us solve specific problems • Provide peers for WANO Peer Review and TSM programmes across the WANO community • Participate in Seminars W/shops on a wide range of topics • Oldbury hosted WANO HP conference in November • PO&Cs developed by Magnox North to enable WANO to support sites in defuelling phase; trialled at Chapelcross through TSM
WANO Peer Reviews – Key Issues Arising Management Effectiveness – setting and reinforcing standards in the field are areas most commonly identified as weaknesses. This can have an effect on performance in all areas. Key learning for Magnox has been: • Development and deployment of company wide executive sponsored human performance programme • Task observation & coaching programmes being developed • Importance of behavioural safety observation programme • Magnox Leadership programme Peer reviews continue to identify insufficient station actions to address Significant Operating Experience Report recommendations. This lack of action to learn from industry experience can contribute to recurring events in the industry: • All WANO SERs and SOERs are managed through the organisation Mandatory Assessment process. All individual MAs are sponsored by the CNO or EHSSQ Director. Status of MAs form part of the CNOO oversight programme
IAEA Peer Reviews • Long standing involvement in IAEA activities – conferences / seminars / site visits • Magnox sought ‘first’ decommissioning peer review • Joint development of Terms of reference for ‘International Peer Review of Decommissioning Programme and Activities’ • Outline programme agreed next two years • Pilot at Bradwell in 2008 • Scope • Learning • Magnox to support Peer Review in 2011 • On request • Peer review of Magnox site in 2012 • To be confirmed
SLC Peer Assists • Event Reporting (Magnox - other NDA SLCs) • Approaches / inconsistencies • Contractor Management (RSRL - NDA SLCs) • Control and supervision • Source Management (Magnox - NDA SLCs) • Control and storage • Contamination Control (Oldbury - SLCs) • On-going (low level) issues
Magnox Peer Review / Assists Exec-led EHSS&Q Reviews CNO Directed Reviews/Assists (also MAs) EHSS&Q Expert Assists Site (Own) Reviews Peer Checking
What value added? • Has our performance been improved? • What events have we prevented? • Are we better off overall? • Is it worth it? • Should we continue it? • Could we do it better? “Yes” to all !
Future Thoughts • Organisational Learning (Major Events) • Why do we all do it separately? • Need to collaborate more; build on, not re-invent the learning; do it once for the Industry • Use peer reviews / assists to test / help implementation of learning • Audits • What value are we getting after first assessments? • Need to move emphasis from arrangements and process to event follow up and effectiveness of learning