Operating Experience Committee

Conference Call Minutes

Tuesday, April 14, 2009

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ACTION: All. Please send May conference call agenda ideas to Jeannie Boyle and be prepared to discuss LL on the next call.

April 14, 2009 Call

Time: 11:00 a.m. - 12:00 p.m. EST

Call-In Number: 301-903-9198 Confirmation 231806

AGENDA

Welcome and Roll Call / Jeannie Boyle
Group Sharing of Recent Lessons Learned / All
Sharing of Lessons Learned from OPEX assessments / All
Planning for the Spring Workshop at WIPP (April 28-30)
1.  Last Minute Registrations (send to Bertha and Jeannie)
2.  Last Minute Questions and Answers / Bertha Cassingham/
Jeannie Boyle
What sites use the LL module of Pegasus/ePegasus? / Jeannie Boyle
Why Can't We Learn From Our Mistakes? / David Langstaff, DOE RL
OPEX Assessment Findings/Opportunities for Improvement (OFIs) to Teresa Cochran and Jeannie / Teresa Cochran
Jeannie Boyle
Task Team Status Updates / Jeannie Boyle
Roundtable / Subjects for Next Call / All

Welcome and Roll Call

# / Name / Site / Org. /
1 / Ammonet, Patti / Pacific Northwest National Laboratory / Battelle Memorial Institute
2 / Ballard, Ed / LSO / Livermore Site Office
3 / Barnes, Rus / PPPO / LATA/Parallax (LPP)
4 / Book, Jackie / PPPO / LATA/Parallax (LPP)
5 / Boyle, Eugenia / DOE HQ / HS-32
6 / Branson, Gary / INL / Battelle Energy Alliance, LLC
7 / Brown, Karen / ORO / Parallax
8 / Brown, Richard / ORP / Bechtel National Inc (BNI)
9 / Brown, Sharon / DOE HQ / HS-32
10 / Cheng, Sam / LASO / Los Alamos Site Office
11 / Chimah, Paul / Service Center / Service Center
12 / Christensen, Rob / PPPO / LATA/Parallax (LPP)
13 / Clarke, Debbie / ORP / Bechtel National Inc (BNI)
14 / Cochran, Teresa J. / Oak Ridge - ORNL / UT-Battelle/ ORNL
15 / Cole, Matt / DOE HQ / SC
16 / Collier, Linda / LANL / Los Alamos National Security
17 / Czincila, Robert / DOE HQ / HS-32
18 / D'Ambrosia, Loretta / NTS / NSTec
19 / Du Bose, Rick / DOE HQ / FE PSO
20 / Eichorst, Jeffery A. / LASO / Los Alamos Site Office
21 / Forshey, Cathy / PPPO / Theta Pro2Serve Mgmt Co
22 / Galbraith, Don / CBFO / CBFO
23 / Gile, Andrea / NTS / NSTec
24 / Gilliam, Susan / Y-12 National Security Complex / Babcock & Wilcox Technical Services (B&W)
25 / Haynes, Rick / PSO / Pantex Site Office
26 / Heard, Marie / Stanford Site Office (SSO) / SSO
27 / Jones, Carla / Y-12 National Security Complex / Babcock & Wilcox Technical Services (B&W)
28 / Langstaff, David / RL / Richland Operations Office
29 / LaPointe, Todd / DOE HQ / CNS
30 / Lauterbach, Paul / NETL / Albany, Fairbanks, Morgantown, Pittsburgh, & Tulsa
31 / Longpre, Dan / PPPO / Theta Pro2Serve Mgmt Co
32 / Lopez-Cardona, Emma / DOE HQ / EM
33 / Lowry, William / NETL / Albany, Fairbanks, Morgantown, Pittsburgh, & Tulsa
34 / Mallison, Tyler / YSO / Y-12 Site Office
35 / Marshall, Ginnie / DOE-HQ / NA-50
36 / McCallister, Russell / PPPO / Portsmouth/Paducah Project Office - Lexington
37 / McCann, Pamela / YMPO / Yucca Mountain Project Office
38 / McVey, Jim / PPPO / Swift & Staley (SST)
39 / Myszka, Larry / West Valley / WVES
40 / Pasko, John / Washington, DC / Defense Nuclear Facilities Safety Board
41 / Payne, Howard / West Valley / WVES
42 / Petts, Mark / DOE HQ / HS-23
43 / Polanish, Carolyn / Brookhaven Site Office / BHSO
44 / Richards, Paula / Oak Ridge / Isotek
45 / Robison, Camille / INL/ AMWTP / BBWI/AMWTF
46 / Roggenkamp, Ken / KSO / Kansas City Site Office
47 / Rozek, Eric / Washington, DC / Defense Nuclear Facilities Safety Board
48 / Schutt Bradley, Joanne / Oak Ridge - ORNL / Bechtel-Jacobs
49 / Searfoss, Glenn / DOE HQ / HS-32
50 / Sheehan, Kathy / ORP / Bechtel National Inc (BNI)
51 / Stanberry, Tom / PPPO / Swift & Staley (SST)
52 / Stein, Darrin / Grand Junction Project Office (Moab) / S&K Aerospace Inc
53 / Sterling, Michael / ORO / Parallax
54 / Stuewe, Bob / LANL / Los Alamos National Security
55 / Tamplain, Jeffrey / SPR / DynMcDermott
56 / Taylor, Karen / Pantex / B&W Pantex
57 / Taylor, Linda / KCP / Honeywell
58 / Thomas, Scott / DOE HQ / EE-3C
59 / Treichel, Lisa / DOE HQ / HS-23
60 / Tripodes, Jim / LLNL / Lawrence Livermore National Security
61 / Whitney, Gerry / RL / Fluor Hanford Inc.

GROUP SHARING OF RECENT LESSONS LEARNED

Lesson 1: Jim McVey (Paducah) – A worker received a shock when he touched a trailer-mounted generator. The investigation determined that the generator had not been bonded and grounded. Everyone should check to ensure that portable generators are bonded and grounded.

Lesson 2: Gerry Whitney (Fluor Hanford Inc.) – A worker wore coveralls over an OptimAir® PAPR blower. When he bent over, it squeezed the PAPR blower unit, which stopped working. Everyone is cautioned not to wear coveralls over this type of PAPR. Fluor Hanford contacted the vendor, and the vendor is looking into modifying the blower unit to strengthen it.

Lesson 3: Darrin Stein (Grand Junction Project Office - MOAB) – During pre-use checks of a recently received gantry crane, the person performing the inspection noticed that the vertical lift chain had an unusual engraving rather than the standard marking he was accustomed to seeing. The receipt inspection had approved the crane for use, but they decided to double-check on the lift chain anyway. MOAB determined that the chain met all the applicable standards, and the vendor was able to provide a chain certificate for it. The chain was manufactured in Italy, which is why the engraved markings were not familiar.

SHARING OF LESSONS LEARNED FROM OPEX ASSESSMENTS

1.  Bob Stuewe (LANL) –NNSA recently performed a contractor assurance system review at the site. The assessment team reviewed the OPEX Program in detail at the facility level. Although there were no findings, the team identified an opportunity for improvement with regard to better deployment and integration of the site- and facility-level lessons learned into work planning and training at the facility level. The assessment team also focused on the training and qualifications of the people developing the lessons learned.

ACTION: All. Consider discussing at the workshop ways to improve lessons learned sharing and use.

2.  Jim McVey (Paducah) – An ISM/EMS audit was performed at the site last month. NQA-1 was a big issue. It is not clear which parts of NQA-1 and which version of it applies to sites like Paducah. Even though the version of NQA1 to be used is spelled out in the contract, the auditors expected a different version to be in use, which caused some difficulties. In addition, the auditors were very difficult to satisfy. Jim recommended that everyone required to implement NQA-1 carefully review their approach to and implementation of the standard.

Howard Payne (West Valley) noted that Headquarters EM issued a memorandum in 2008 on quality assurance programs. It is based on the 2004 version of NQA-1. Most of the larger sites received direction to implement NQA-1-2004 by providing a gap analysis and implementation plan, with the expectation that implementation would be completed by the end of June 2009. The expectation is that all EM sites will be implemented by the fall of 2009. However, the memo does recognize that some sites have a compelling reason not to implement the 2004 version (i.e., agreements with regulators).

Note: Dae Chung, EM-60, issued a memo on January 8, 2009, entitled “Revision of the Office of Environmental Management Corporate Performance Metrics System for Quality Assurance Programs.” The metrics system in the memo includes NQA-1-2004. A copy of the memo is attached.

PLANNING FOR SPRING WORKSHOP

Don Galbraith (Carlsbad) reminded everyone that Carlsbad is a small town, and the drivers there don’t always pay attention to proper protocol at four-way stops or traffic lights. Please pay closer attention to other drivers than you normally would. Drivers there have been known to ignore stop signs (perform a rolling stop, act as if the stop sign is a yield sign, or not stop at all). In other words, drive defensively.

Approximately 40 people are currently registered to attend the workshop. Jeannie Boyle reviewed the agenda for the workshop and confirmed it with the various presenters.

ACTION: Jeannie Boyle. Since Steve Chalk cannot attend the workshop, Jeannie will confirm the name of someone else on the CRADs task team to make the presentation.

ACTION: All. If you have not already done so, please e-mail or fax your workshop registration form to Jeannie Boyle. (Fax: 301-903-8403). Please do this even if you have submitted the form to Bertha Cassingham.

ACTION: All. If you are a late registrant for the workshop, please be aware that Bertha Cassingham has been having trouble with her fax machine and has provided an alternate fax number. (Alternate Fax: 575-234-6003).

USE OF PEGASUS OR ePEGASUS

Jeannie Boyle recently saw a demonstration of ePegasus. She queried the group to find out if anyone is using the lessons learned module in Pegasus or ePegasus. As it turns out, ePegasus is just beginning to be rolled out. It will only be provided to DOE HQ and DOE Operations and Site Offices. Contractors will still use their own lessons learned systems.

WHY CAN’T WE LEARN FROM OUR MISTAKES?

David Langstaff is now the OPEX Coordinator for Richland. David wrote Why Can’t We Learn From Our Mistakes, Learn the Lesson – Tell the Story in 2005, and he provided some background and a brief discussion of the paper. DOE had two fatalities in 2004, one at Savannah River and the other at Hanford. Headquarters responded with intense attention to how requirements are flowed down from contracts. From the information they gathered, they determined that four areas needed additional attention. One area was EM’s ability to learn from its mistakes. As part of the analysis, EM spot-checked event reports and learned that symptoms were often being identified as root causes. The number of questionable root causes meant the sites were probably not correcting the real issues. The analysis also found a number of recurring events. It became clear that the need to identify the root cause for a major event (usually more than one root cause) determines whether the issue will be effectively corrected.

We know that we should be able to learn from experience, our own and others, and not repeat mistakes. The premise of this paper is that telling the story well is the key to making people receptive and able to learn from it. The lessons learned from mistakes are not well communicated. This may be because they are not captured during the investigation. The lessons learned in the DOE Headquarters Lessons Learned Database are snapshots of events and often include photographs. These make good operating experience lessons learned so that people will be aware of them and take action. But, these lessons may not reveal the root causes of the event.

Communication is a key factor in lessons learned. Whatever you can do to improve communication will strengthen the system. Incidents must be communicated to the organization and to management in a timely manner. Everyone must understand the incident so that effective action can be taken. We get caught between the need to quickly communicate the event to others and the need to fully analyze it so that we don’t send out incorrect information.

Often, causal factors are not identified during the incident/event investigation. Some causal factors are ignored because it is assumed that they did not have an impact. Weak barriers are not identified because they are not considered relevant to the event. What is left out of an investigation can tell a lot about an organization and its safety culture. We need to pay attention to the small, everyday failures. They are often the key to avoiding the big, catastrophic failures. This need to pay attention to the small problems was identified during the Columbia Shuttle Review Board. So many little things come together to lead to the disaster.

David pointed to The Tipping Point, which talks about small things adding up as you move along until the conditions are right and one small action is all it takes to move past the tipping point. Then, everything bad happens at once. That is another reason why accident/incident investigations can be a big opportunity. It takes a lot of attention to detail to get the true picture of the accident. But, taking the time to do it right provides additional information about the root causes and the actions it will take to correct them.

The causal factors that are (and are not) identified are important in seeing the organization. An organization’s problems are the result of how it does business. How and why something was allowed to happen can be determined by looking at how the organization does business. If the real root causes are not identified, things will get better after the corrective actions are taken, but it will only last for a while.