British Occupational Hygiene Society · British Occupational Hygiene Society . LA-UR-17-22603 . Michael Brandt, ... • Leadership Lessons ... March 2016 thru February 2017

Operated by Los Alamos National Security, LLC for the U.S. Department of Energy's NNSA

British Occupational Hygiene Society

LA-UR-17-22603

Michael Brandt, Dr.PH, CIH, PMP Associate Director for

Environment, Safety, and Health Day 3

April 27 Session 14a 13:40-14:25

OH 2017 Conference Harrogate, UK

April 24-27, 2017

“Operational Leadership” – Sustaining Improved Environmental, Safety, and Health Performance

2

Agenda: • Introduction to Los Alamos National

Laboratory – Role / Mission / Location / People

• Event Learning • Problem Statement – 3 Common

Causes • Problem Solution – Operational

Leadership • Data analysis/Metrics • Operational Leadership Actions • Healthy Safety Culture • Summary and Conclusion • Leadership Lessons • Questions

Introduction to Los Alamos National Laboratory

Role

Mission

Location

People

Los Alamos National Laboratory | 3

The role of Los Alamos in global security


• Kansas City Plant

• Lawrence Livermore National Laboratory

• Los Alamos National Laboratory

• Nevada National Security Site

• Pantex Plant

• Sandia National Laboratories

• Savannah River Site

• Y-12 National Security Complex

Nuclear Security Enterprise

- 1/17 - 1/8

Role


Mission Los Alamos delivers science and technology to protect our nation and promote world stability

The world remains a dangerous place….LANL‘s mission is to reduce the dangers inherent to a complex global society

As the nation’s premier national-security science laboratory, we certify the safety, security, and effectiveness of the nation’s nuclear deterrent

- 4 of 7 weapons systems

We deliver national-security mission solutions to NNSA, DoD, and IC

- Our science and imagination saves lives by solving complex problems others can’t

We rely on high-performance computing, leading-edge experimental facilities, and the world’s brightest minds to accomplish our mission


LANL Site: • Roughly the size of Paris • 40 square miles • 1,230 bldgs (42 yr av age)

• 13 nuclear facilities • 268 mi of roads • 34 mi electrical lines • 63 mi gas lines • 1 power plant

Annual Budget = $2.5B

Location

Unique Characteristics: • 37 historical buildings • >2,000 archeological sites

• 4 endangered species • 8 Pueblos • 3 Counties • Multiple mesas


37% Ops/ Business 21% R&D 11%

Engineering

6% IT 14% Student/ Post-Doc

8% Crafts 3% Pro-Force

People

11,000 Employees:

• 39% live in Los Alamos - remaining commute

• 46 average employee age

• 67% male / 33% female

• 44% minorities

• 66% hold university degrees - 28% undergraduate - 17% Master’s - 21% PhD

Two significant events have shaped

our improvement efforts


Nitrate salt event at the WIPP site in February 2014 – eroded public trust that we can safely execute our National security mission

Event 1 description

Panel 7 Room 7 Los Alamos National Laboratory | 9


Event 1 details

Nitrate salt event at WIPP – Largely a result of an unhealthy safety culture

3 general causes contributing to event

Management Responsibility

and Engagement

Risk Management Process and Controls Commensurate with

Hazards

Worker Involvement


Arc-flash event May 2015 – the impacts got personal Event 2

description


Event 2 details Arc-flash event – Largely a result of human performance

3 general causes contributing to event

Risk Management Process and Controls Commensurate with

Hazards

Management Responsibility and Engagement

Worker Involvement


1. Worker involvement in work planning is inconsistent/incomplete Workers shift to: • Be personally responsible for performing work safely

• Raise safety concerns

• Anticipate error-likely situations and take action

2. Line management not always engaged in work planning and execution Line managers shift to: • Be responsible and accountable for operational outcomes

– be present in the field • Anticipate and prevent events using hazard controls

• Encourage workers to question/pause work as necessary

3. Risk management process/controls not followed/executed Risk management process shifts to: • Anticipate what “must go right” to perform work safely

• Identify and evaluate hazards

• Tailor controls to work being performed

Event learning consistently yields three common themes Events problem statement


Risk Management Processes

Problem solution Enable these positive behaviors

Make conditions conducive to these components

Focus on 3 of the 8 guiding

principles of ISM and VPP


How do you check, balance, and course correct your management decisions and safety actions? and How can you focus your efforts to achieve the largest return?

An expert is someone who has succeeded in making decisions and judgements simply through knowing what to pay attention to and what to ignore . . . . . . . .Edward de Bono

Risk management process

Anticipate and prevent

potential risks

Analyze, integrate,

and prioritize actions

Manage and monitor

responses


Continuous improvement pays off – but do we accept positive trending and stop investigating?


1.12

0.13

0

1

2

3

4

Jun-

06

Feb-

07

Oct

-07

Jun-

08

Feb-

09

Oct

-09

Jun-

10

Feb-

11

Oct

-11

Jun-

12

Feb-

13

Oct

-13

Jun-

14

Feb-

15

Oct

-15

Jun-

16

Feb-

17

Rat

e pe

r 200

000

hour

s

LANS TRC and DART Rolling 12-month Rates thru February 17

(excludes subcontractors)

TRC 12 Month Rolling DART 12 Month Rolling

3.37

1.07 These numbers

represent PEOPLE

Not when worker safety is at stake – but where to focus efforts?

Lab-wide safety performance

30%

51%

65%

74%

83% 88%

91% 93%

96% 97% 98% 99% 100%

0%

20%

40%

60%

80%

100%

0

20

40

60

80

100

120

140

Stru

ck A

gain

st/B

y

Slip

/Trip

/Fal

l

Cont

act w

ith B

io/C

hem

/Haz

/Tox

icSu

bsta

nce Li

ft/P

ush/

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Repe

titiv

e M

otio

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eTr

aum

a

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ht In

, On,

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r Bet

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n

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ntar

y M

otio

ns

Bite

/stin

g

Mot

or V

ehic

le A

ccid

ent

Cont

act w

ith E

lect

rical

Cur

rent

Fore

ign

Mat

ter i

n Ey

es

Tem

pera

ture

Ext

rem

es

Trai

ning

/Qua

lific

atio

n

Noi

se E

xpos

ure

Cumulative Frequency

Num

ber o

f Inj

urie

s LANL Recordable/Non-Recordable Injury by Source - March 2016 thru February 2017

Non-Rec Rec


Lab-wide injury source data

Five common sources account for >80% of site injuries – indicating where to

focus our ESH resources to eliminate these sources and improve performance

Sounds logical, but how do we explain the

serious electrical event?

30%

39%

47%

54%

61%

68%

74%

79%

84% 87%

90% 92%

94% 96% 97% 98% 99% 99% 100%

0%

20%

40%

60%

80%

100%

0

20

40

60

80

100

120

140

ADPM

ADES

H

ADBI

ADM

ASER

ADCL

ES

ADPS

M

ADEP

S

ADW

ADN

HHO

ADE

PADC

AP

ADTI

R

ADTS

C

DIR

ADX

PADS

TE

ADEM

NO

N-L

AB

PADG

S

PADO

PS


Num

ber o

f Inj

urie

s LANL Recordable/Non-Recordable by Organization - March 2016 thru February 2017

Non-Rec Rec


Lab org injury data

The arc-flash involved skill-of-craft workers in the construction and maintenance organization. These

workers sustain ~30% of total injuries across the site.


23%

43%

60%

68%

73%

78% 82%

87% 91%

94% 96% 98% 99% 100%

0%

20%

40%

60%

80%

100%

0

5

10

15

20

25

30LA

BORE

R

PIPE

FIT

TER

ELEC

TRIC

IAN

SHEE

T M

ETAL

WO

RKER

CARP

ENTE

R

IRO

NW

ORK

ER

OPE

RATI

NG

ENGI

NEE

R

PAIN

TER

TEAM

STER

MAI

NTE

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CE

SUPE

RIN

TEN

DEN

T

SE P

ROFE

SSIO

NAL

ASBE

STO

S W

ORK

ER

ROO

FER


Num

ber o

f Inj

urie

s Craft Injuries by Worker Type - March 2016 thru February 2017

Non-Rec Rec

Construction and maintenance org injury source data by skill-of-craft

17% of construction and maintenance injuries are to electricians


What is the electrical safety worker exposure risk?

Let’s examine the electrical event data for insight

75K Work Evolutions

24K 1K Entries 1.2K Compliance Inspections

760 Excavation Permits 360 IWDs for R&D Electrical Work 1,840 IWDs for Facility Electrical Work

data reported per year

Electrical safety risk identification

1.5K Energized Electrical Workers

Los Alamos National Laboratory|22

73

64

60

46

0

10

20

30

40

50

60

70

80

2013 2014 2015 2016

Num

ber o

f Inc

iden

ts

Calendar Year

All Electrical Incidents

Electrical safety metric demonstrates a negative slope of decreasing events over time

Lagging indicator

Despite the decline of electrical safety incidents over the last four years – we still had the serious arc-flash injury and a couple of near misses

Arc- flash event

and

RLUOB near-misses


92 13 20

305

41 33

255

13 2 44 36 75 145

14

1616

86 36 58 11 1 7

144 27 0

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Jan

13

Apr

13

Jul 1

3

Oct

13

Jan

14

Apr

14

Jul 1

4

Oct

14

Jan

15

Apr

15

Jul 1

5

Oct

15

Jan

16

Apr

16

Jul 1

6

Mon

thly

ESI

Nor

mal

ized

to

LAN

L To

tal W

ork

Hou

rs

Electrical Severity Index (ESI) From 0 to 310,000

0-30 = no risk to worker 31-1749 = medium risk

>1750 = high concern and risk Monthly ESIRolling 12 Month AVG

4379

The DOE complex-wide Electrical Severity Measurement tool categorizes only one incident of significant concern

Ergo desk cord

AET power strip

Forklift hits 13.8 kV wires

277 V shock NEC violation R&D work

no LOTO

RLUOB 77 V shock

and 480 live work

Substation Arc-flash

Pharos - R&D conduit

cut during D&D -

moderate exposure w/

no injury

Lagging indicator

So, are the root causes associated with low risk and high risk events different?


Why do TRC/DART rates continue to decline while electrical events continue to trend upward?

0

2

4

6

8

10

12

Jun 06 Jun 07 Jun 08 Jun 09 Jun 10 Jun 11 Jun 12 Jun 13 Jun 14 Jun 15 Jun 16

Num

ber o

f ele

ctric

al e

vent

s

Electrical Events vs. LANL TRC/DART Rates Electrical Incidents Reported Rolling TRC Rolling DART Linear (Electrical Incidents Reported)

Leading indicator

Management and worker corrective action is warranted


2013 2014 2015 2016

Number of incidents receiving a more concerning rank of 3, 4, 5 per calendar year Concern Ranking from 0 to 5 (0 = least / 5 = most)

4 total

7 total

ten 3’s

three 3’s

six 3’s

two 3’s

two 4’s

one 5 one 4

Subjective measure of all elements contributing to an electrical incident - work control, human error, significant equipment failure, etc.

6 total

11 total

two 4’s

one 4

serious concerns declining to zero in

2016

Systematic data review revealed that the occurrence of major events requires: 1. A high risk condition must exist 2. Hazard controls must fail 3. These two factors go unchecked

Pharos

Arc-flash

RLUOB

480 live work

R&D no

LOTO

Forklift

NEC violation

Emerging negative trend

mid-level concerns

on the rise in 2016

So what are we doing about

this new insight and leading indicators?


Healthy Culture

Integrated Safety

Management (ISM)

Human Performance Improvement

(HPI)

Voluntary Protection Program

(VPP)

Work Planning

Institutional Risk

Management - Metrics - MOVs

Safety Leadership Workshop

(SAFE)

More than 60 Health and

Safety Programs

Operational Leadership Campaign


Including electrical safety

https://images.lanl.gov/AllImages/2343.jpg

Worker perception of safety culture – 2016 survey results trend upward


– More than 2,000 survey responses • growing levels of trust within organizations • increased comfort with raising issues/pausing work • increased perception of mistakes as learning opportunities • strong manager and employee commitment • strong organizational emphasis on injury prevention

– Opportunities for growth • Strengthen role of employee worker safety teams to address the most

challenging issues that confront the Laboratory • Raise worker knowledge about Safety and Security Improvement Plans • Effectively communicate improvement initiatives, worker safety team

activities, and recognition of successful work

Healthy safety culture


LANL is continuously improving as a learning organization Summary and Conclusion

1. Adapt and course correct as managers and employees –Continue to use metrics to focus improvements –Understand and apply lessons learned from event causal analysis –Identify predictive indicators and apply knowledge obtained from

• near-miss events • emerging data trends

2. Recognize that the construction and maintenance workforce is a population at high-risk

–High volume of work activities –Inherent risk associated with type of work

• sources of high energy and plant construction –Unusual and non-routine work being performed

3. Ensure that existing risk management processes and tools are being fully implemented

–Use mistakes as opportunities to learn

Success will be realized when we respond urgently to pre-cursors (both positive and negative) and act deliberately to prevent events

Las Conchas Fire 2011

Nitrate Salt Event at WIPP 2014

Arc-Flash 2015 Tc-99 Exposure Event 2012


Lessons in Leadership


Operational Leadership commitment is expressed all the way back to the founding of the Los Alamos mission

“Each employee can do more to protect

himself and his fellow workers than all

the rules in the world, and it is of

utmost importance that each of us feel

at all times, the responsibility of

safeguarding himself and others.”

. . . J.R. Oppenheimer 1945

LANL’s proud legacy

Documents

British Occupational Hygiene Society · British Occupational Hygiene Society . LA-UR-17-22603 . Michael Brandt, ... • Leadership Lessons ... March 2016 thru February 2017