Brookhaven Science Associates Accelerator Safety Workshop Human Performance Initiative at Collider-Accelerator Department, Brookhaven National Laboratory

Brookhaven Science Associates

Accelerator Safety WorkshopAccelerator Safety Workshop

Human Performance Initiative at Collider-Accelerator Department, Brookhaven National Laboratory

E. Lessard

August 7-9, 2007

2Brookhaven Science

Associates

Accelerator Safety Workshop

August 7-9, 2007

OutlineOutline

C-AD Facilities and Hazards Summary of Requirements Safety Management Model Performance Indicators Human Performance Summary

3Brookhaven Science

Associates


August 7-9, 2007

Summary of C-AD Facility Characteristics

Summary of C-AD Facility Characteristics

120 Buildings 7 Accelerators 3 Major Experimental Areas 6.2 Miles Of Vacuum Pipe 24 Miles Of Cable Tray 1000s Of Electro-magnets / Power Supplies 10s Of Compressors For Cryogenics Systems 62 Electrical Substations 1000s Of Electrical Distribution Circuits 15 Cooling Towers In Service 52 Cooling Systems In Service 1.2 Million Ft2 Of Office And Laboratory Space 1000 Acres Of Land 1200 Users 380 FTE Direct Staff 40 FTE Allocated Staff

4Brookhaven Science

Associates


August 7-9, 2007

Summary of Environmental Aspects

Summary of Environmental Aspects

Regulated Industrial Waste Hazardous Waste Mixed Waste Radioactive Waste Atmospheric Discharges Liquid Discharges Storage / Use Of Chemicals Or Radioactive

Material Soil Activation Power And Water Consumption Sensitive / Endangered Species And Sensitive

Habitats

5Brookhaven Science

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August 7-9, 2007

Summary of Radiological HazardsSummary of Radiological Hazards

Low-level Contamination Residual-radiation Levels At Collimators and Beam

Dumps Tritium Production In Helium Gas And Cooling

Water Radioactive Waste Radioactive Atmospheric Discharges Radioactive Liquid Effluents Storage / Use Of Radioactive Material Soil Activation Residual-radiation From Activated Materials Very High In-beam Radiation Levels Sky-shine

6Brookhaven Science

Associates


August 7-9, 2007

Summary of OSH HazardsSummary of OSH Hazards

Non-ionizing Radiation (Lasers, RF, UV) Magnetic Fields Working With Hazardous Or Toxic Materials Exposure To Electrical Energy Oxygen Deficiency Confined Spaces Being Struck By An Object; Cranes; Lifting

Devices Falls; Vacuum; Pressure Contact With Temperature Extremes

7Brookhaven Science

Associates


August 7-9, 2007

Applicable Safety RequirementsApplicable Safety Requirements

DOE Orders and Federal Regulations• DOE Order 5480.19, Conduct of Operations• DOE Order 420.2B, Accelerator Safety• DOE Order 420.1A, Facility Safety, §§ 4.2 and

4.4• DOE Order 414.1C, Quality Assurance• 10CFR835, Radiation Worker Protection• 10CFR851, Occupational Worker Protection

BNL SBMS Subject Areas• 98 Subject Areas Contain ESH Requirements

Voluntary Management Systems• OSH Management System, OHSAS 18001• Environmental Management System, ISO

14001• Human Performance Initiative, INPO

8Brookhaven Science

Associates


August 7-9, 2007

Safety Management Model at C-AD

Safety Management Model at C-AD

3 Root Factors• Management Commitment• Line Responsibility For

Injuries • Worker Involvement

Desired Outcomes • Safe Equipment And

Facilities• Safe-aware People • Excellent Injury Record• …

3 Driver Factors • Clear Rules• Competent Safety

Specialists• Comprehensive Safety

Systems

Values (Integrity, Concern for Others, Concern for Environment)

9Brookhaven Science

Associates


August 7-9, 2007

Some ESHRequirement

Sets

Safety Management Factors:

Comprehensive Safety System(Driver Factor)

Worker Involvement(Root Factor)

Management Commitment(Root Factor)

Integrated Safety

Management (ISM)*

DOE Manual 5 Core Functions 7 Guiding Principles

Worker Safety and

Health10CFR851*

National and Consensus Standards

Worker Rights and Responsibilities

Management Responsibilities

Safety ManagementSystem**

OHSAS 18001 Job Risk Assessments Management Review

EnvironmentalManagement

System**ISO 14001 Process Assessments Management Review

Human Performance**

***

Fisher Improvement Technologies

Self-Check Tool Step-By-Step Tool Stop When Unsure Tool

Work Observation Program SMART Model for Procedures Just Culture for Deviations

*DOE Mandated Requirements **Voluntary Requirements ***Improves Operations and ESH Performance

ESH Rules Versus Safety Model

10Brookhaven Science

Associates


August 7-9, 2007

Audits – Where Do They Fit?Audits – Where Do They Fit?

By their nature, observational audits suffer serious handicaps

They are subjective, both in judgments made by observers and in input shared by those observed

What they see is colored by their experience and what they say is largely based on opinion

To the auditor, past performance could have just been good luck


Associates


August 7-9, 2007

Past PerformancePast Performance

What does it mean?


Associates


August 7-9, 2007

Performance, Backward-Looking Indicators

Performance, Backward-Looking Indicators

2004 2005 2006 10-1-06to

6-30-07

Collective Dose (person-rem) 5.3 1.4 0.95 0.55

Skin and Clothing Contaminations

0 0 0 0

Internal Contaminations 0 0 0 0

Hazardous Materials Overexposures

0 0 0 0

Annual DART Rate (# / 100 FTEs) 1.7 0.29 0.30 0.33

Number of Injury Cases 7 1 1 1

Annual Recordable Rate (# / 100 FTEs)

2.9 1.2 1.5 1.0

Number of Injury Cases 12 4 5 3

First Aid Cases Excluding Athletic Injury

5 1 1 4

Occurrences 7 3 2 1


Associates


August 7-9, 2007

Injury Performance – Long TermInjury Performance – Long Term

Injury/Illness Rates(# per 100 FTE)

0

1

2

3

4

5

6

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

DART

TRC


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August 7-9, 2007

Injuries In FY 2007Injuries In FY 2007

Recordable Cases• Bookshelf fell, caused laceration of forehead, DART• Cut hand on sharp edge of waste can, antibiotics given• Dirt from air conditioner floated into eye, antibiotics

given

First Aid• Bruise from walking into stanchion• Stood up and hit head on metal tank• Cut finger on metal shelf• Cut finger on tie wrap


Associates


August 7-9, 2007

Occurrence Performance – Long TermOccurrence Performance – Long Term

0

2

4

6

8

10

12

1990 1995 2000 2005 2010

Number of Reportable Occurrences per Year


Associates


August 7-9, 2007

Occurrences In FY 2007Occurrences In FY 2007

2007• Coffee-Room Microwave Oven Fire Causes Building

Evacuation


Associates


August 7-9, 2007

Radiological Performance – Long Term

Radiological Performance – Long Term

Annual Collective Dose, person-rem per year

0

10

20

30

40

50

60

70

80

90

1997 1999 2001 2003 2005 2007

RHIC Operations Starts

HEP Operations Ends

Collective Dose, person-rem

0

100

200

300

400

500

600

700

1960 1970 1980 1990 2000 2010

Year

Pers

on-r

em


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August 7-9, 2007

Backward-Looking IndicatorsBackward-Looking Indicators

C-AD Injury Performance Indicators Are In The Noise

C-AD Technical Performance Indicators Are Declining:• OSHA Deficiencies• Occurrences and Environmental Non-Compliances• Radiation Exposure

Backward-Looking Indicators Do Not Measure:• Organizational Deficiencies• Failure To Maintain And Modernize Critical Equipment• Operations Pressures• Cost-cutting In Maintenance, Training, Personnel• Management Commitment• Worker Involvement• Line Accountability For Injuries


Associates


August 7-9, 2007

Performance, Forward-Looking Indicators

Performance, Forward-Looking Indicators

Growth In ESSH Practices

05

10152025

Jan-87 Jun-92 Dec-97 Jun-03 Nov-08

Number of ESSH Committees

Number of ESSH Practices

EXAMPLE PRACTICES:•Safety Meetings•WOSH Committee•Disciplinary Rules•Work Planning•Safety Surveys/Feedback•Self-Assessment•Manager Work Observations•Management Review•3rd Party Registrations•Security Committee•Annual Objectives and Targets•Human Performance Training•Error-Prevention Tools•User Training•Guest Agreements•…


Associates


August 7-9, 2007

Human Performance Initiative at C-AD

Human Performance Initiative at C-AD

C-AD managers and supervisors trained on fundamentals • Some discussion of specific human performance (HU)

practices • 8 Hour Course

Workers trained in HU practices• We chose practices associated with:

– Worker planned work– Design of equipment – Event reporting

• 12 Hour Course• Well Received – Supervisors want to start an HU team

Annual re-training is planned• 2 to 4 Hours

BNL likely to go forward and train whole lab in HU in September


Associates


August 7-9, 2007

You cannot engineer out the human element

Need a systems approach

Purpose: Minimize the frequency and severity of events

Benefit: Improves performance in all areas, not just safety

Events

Understanding Human Performance Improvement


Associates


August 7-9, 2007

80% fuel-damaging accidents due to human error Three out of four significant events due to human

error Greatest contributor to costs 70% of causes due to weaknesses in organization

Commercial Nuclear Experience

Commercial Nuclear Experience


Associates


August 7-9, 2007

Significant Events at Commercial Nuclear Plants, US Annual Industry Averages

Significant Events at Commercial Nuclear Plants, US Annual Industry Averages

2.38

1.66

0.85 0.880.77

0.460.28

0.08 0.04 0.03

0.30 0.300.21

0.1 0.07

0.0

0.5

1.0

1.5

2.0

2.5

3.0

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Sig

nifi

can

t Eve

nts

pe

r U

nit

Data Source:

U.S. Nuclear Regulatory

Commission

(Core Damage Potential)


Associates


August 7-9, 2007

Definition of human error: an action (behavior) that unintentionally departs from an expected

behavior

Active Error

(leading to latent weakness)

Latent Error


Associates


August 7-9, 2007

More About Errors (Failures)More About Errors (Failures)

Active Errors• Tend to be variable errors (slips, lapses,

mistakes)• Consequences often immediate• Focus mainly sharp-end of the tool

Latent Errors• Tends to be a consistent error• Consequences lie dormant – act in the future• Focus mainly on 3 root-factors and 3 drivers

– Poor design, unworkable procedures, unworkable schedules, gaps in supervision, shortfalls in training, inadequate tools or equipment at work site, clumsy automation


Associates


August 7-9, 2007

Human Performance as a System

Human Performance as a System

Guiding Principles

Organizational values influence individual behavior– Small organization values always trump big organization values

Performance is based on reinforcement and self-motivation– Managers must foster a culture that values prevention of errors– Supervisors must promote teamwork to eliminate error-likely

situations– Individuals must want to improve personal capabilities

People are fallible – The best make mistakes

Error-likely situations are predictable and preventable– Only if you recognize them

Events can be avoided by knowing causes and applying lessons learned

– Human error is a consequence and not a cause


Associates


August 7-9, 2007

Strategic ApproachStrategic Approach

Anticipate and prevent active error at the job-site

Identify and eliminate latent organizational weaknesses


Associates


August 7-9, 2007

Examples of Error-Reduction Practices

Examples of Error-Reduction Practices

Practices aimed at preventing active errors:

•Place Keeping•Peer Checking•Co-Worker Coaching•‘Am I Ready’ Checklist


Associates


August 7-9, 2007

Performance ModesPerformance Modes

Mode Key Words Known Error Rate When Not Using Error Reduction Practices

Skill Based Habit; < 7 to 15 Steps; Low or No Conscious Thought

1:1000

Rule Based There Is a Rule And I Know There Is a Rule

1:100 - 1:1000(Memory - Written Procedure)

Lack-of-Knowledge Based

You Don’t Know What You Don’t Know

1:2 - 1:10


Associates


August 7-9, 2007

Performance ModesPerformance Modes


Associates


August 7-9, 2007

Management Practices for Error Reduction

Management Practices for Error Reduction

Practices aimed at preventing latent errors:• Set standards, expectations and requirements

that are tied to the mission and to values• Communicate standards to personnel through

training and procedures• Observe work against the standards

Failure to perform the practice in the above sequence can result in major failures


Associates


August 7-9, 2007

HU’s SMART Model for Procedures

HU’s SMART Model for Procedures

Specific – level of detail is specific enough so individual can understand both the action and the reason for the action

Measurable – Desired outcome should be clearly described such that it can be seen or the physical outcome is obvious

Action Oriented – When describing actions or behaviors use active voice (shoulds and shalls are passive voice)

Realistic – Individual must be capable of completing the task

Time Specific – Actions need to have a specific time for completion


Associates


August 7-9, 2007

HU and Safety Management System

HU and Safety Management System

HU addresses:• Organizational Deficiencies

– Failure To Maintain And Modernize Critical Equipment

– Operations Pressures– Cost-cutting In Maintenance, Training, Personnel

• Management Commitment• Worker Involvement• Line Accountability For Injuries


Associates


August 7-9, 2007

SummarySummary C-AD Has Large Facilities With Complex Hazards

• Potential For Organizational Accidents With Multiple Causes ESSH Performance Is Approaching Excellence

• Safety Systems Are Comprehensive (Rules, Training, Safety Experts)

• Users / Workers Perform Work To The Same Safety Standards• Workers / Managers Involved In Safety Program Development• Line Held Accountable For Performance• Managers And Supervisors Are Committed To Excellence In ESSH• The Number Of ESSH Practices Is Increasing

– Organizations Rated World Class In Safety Have 25 To 40 Practices • Human Performance Practices Are Being Implemented Currently• Events/Injuries Declining Toward Zero

Documents

Brookhaven Science Associates Accelerator Safety Workshop Human Performance Initiative at Collider-Accelerator Department, Brookhaven National Laboratory