marilyn peabody 8/27/2009 · - safety priority, direction, expectations and accountability are...
TRANSCRIPT
U N C L A S S I F I E D
U N C L A S S I F I E D
Operated by the Los Alamos National Security, LLC for the DOE/NNSA
LA-UR 09-05018
Integrating Safety Into All of Work at Los Alamos National Laboratory Through Worker
Engagement Utilizing the Worker Safety and Security Teams (WSSTs)
Marilyn Peabody
8/27/2009
U N C L A S S I F I E D
U N C L A S S I F I E D
Operated by the Los Alamos National Security, LLC for the DOE/NNSA
LA-UR 09-05018
Personal Biography – Marilyn C. Peabody, MS
Los Alamos National Laboratory, Safety Program Lead
Invested 20 years educating youngsters in the biological and physical sciences earning Teacher of the Year in1997/98
Have worked at Los Alamos National Laboratory for over 11 years
Worked as Sr. Training Specialist specializing in Radiation Protection and Nuclear Safety Training for six years
Was appointed to the Worker Safety Committee in 2002 and became the Safety Program Coordinator 2004
Became the Safety Program Lead for Stockpile Manufacturing and Support Directorate in 2007
Was voted in by my peers as the 2009 Institutional Worker Safety And Security Team (WSST) Chair working towards being a DOE VPP STAR Site
Hold a Masters in Organizational Management from the University of Phoenix; Bachelors of Science in the Sciences (Biology, Physics and Chemistry) from the University of New Mexico; OSHA Certified
U N C L A S S I F I E D
U N C L A S S I F I E D
Operated by the Los Alamos National Security, LLC for the DOE/NNSA
LA-UR 09-05018
Slide 2
VPP & Integrated Safety Management Systems
ISMS
Define scope
of work
Analyze
hazards
Develop /
implement
controls
Perform
work
Feedback /
improvement
ISMS 8 Guiding Principles
• Worker involvement • Line management responsibility • Clear roles / responsibilities • Competence with responsibility • Balanced priorities • Identify safety standards and requirements • Hazard controls tailored to work • Operations authorization
VPP strengthens ISMS by emphasizing
Employee Involvement and Management Leadership.
ISMS is LANL’s Safety Program
U N C L A S S I F I E D
U N C L A S S I F I E D
Operated by the Los Alamos National Security, LLC for the DOE/NNSA
LA-UR 09-05018
Slide 3
Five VPP Elements
4. Hazard
Prevention
& Control
5. Safety
& Health
Training
1. Management
Commitment
2. Employee
Involvement
3. Worksite
Hazard
Analysis
Voluntary
Protection
Program (VPP)
1. Management Leadership is required
- motivating force and resources
- lead by example and involvement, not by directive
- safety priority, direction, expectations and accountability are clear
2. Worker-driven Safety is the key
- you understand our safety issues
- you know effective solutions for these issues
- worker/management interactions are increased
U N C L A S S I F I E D
U N C L A S S I F I E D
Operated by the Los Alamos National Security, LLC for the DOE/NNSA
LA-UR 09-05018
Worker Safety and Security Teams (WSSTs)
Doormats • Institutional Team
• Primary and Alternate members from all 16 Associate Directorates
• sub-contractors involved
• Co-Sponsored by ESH&Q & Security ADs
• Championed by the Director
• 16 Associate Directorate Teams
• 67 Division Teams
• Each group has at least one
representative on a WSST
U N C L A S S I F I E D
U N C L A S S I F I E D
Operated by the Los Alamos National Security, LLC for the DOE/NNSA
LA-UR 09-05018
Highest categories:
Slips, Trips and Falls
Repetitive Trauma/Ergo
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U N C L A S S I F I E D
Operated by the Los Alamos National Security, LLC for the DOE/NNSA
LA-UR 09-05018
Addressing Slips, Trips, and Falls
Signs to encourage
workers to use
de-icer
Distributed > 6000
snow/ice cleats to
workers
Winter Campaign
Bags, tags, de-
icer labels and
safety emergency
information
U N C L A S S I F I E D
U N C L A S S I F I E D
Operated by the Los Alamos National Security, LLC for the DOE/NNSA
LA-UR 09-05018 LANL Combined
Slips-Trips-Falls
FY09 vs FY08 thru Feb 09
0
5
10
15
20
25
30
Oct Nov Dec Jan Feb Mar Apr Ma Jun Jul Aug Sep
FY09
FY08
FY09: Oct-Feb Case Count = 57
FY08: Oct-Feb Case Count = 84
32% Reduction
U N C L A S S I F I E D
U N C L A S S I F I E D
Operated by the Los Alamos National Security, LLC for the DOE/NNSA
LA-UR 09-05018
ADSMS Injury Free Career
5.02
4.30 4.35 4.41 4.37 4.28
3.34 3.41
2.28 2.09
1.87
1.64
2.12
2.93
2.58 2.39
2.21 2.18 2.03
1.56 1.59
1.14
0.93
0.70 0.70 0.71
0.00
1.00
2.00
3.00
4.00
5.00
6.00
Rate
per
200000 H
ou
rs/N
um
ber
of
Cases
TRC Cases
DART Cases
TRC 12-Month Rate
DART 12-Month Rate
58%
76%
Target
TRC 1.84
DART 0.50
U N C L A S S I F I E D
U N C L A S S I F I E D
Operated by the Los Alamos National Security, LLC for the DOE/NNSA
LA-UR 09-05018
ATOMICS
ATOMICS is a safety observation process that will
Reinforce safe behaviors,
Identify/eliminate at-risk behaviors/conditions
Is owned by the employees
Managed the managers and supervisors
Promoting and providing positive reinforcement
of individual safe behaviors
U N C L A S S I F I E D
U N C L A S S I F I E D
Operated by the Los Alamos National Security, LLC for the DOE/NNSA
LA-UR 09-05018
ADSMS TRC/DART Rates & ATOMICS Observation Relationship
428366
240
563
1227
1065
1162
12661306
1395
1302
1393
4.30 4.35 4.41 4.374.28
3.343.41
2.28
2.09
1.871.64
2.12
2.582.39
2.212.18
2.03
1.56 1.59
1.14
0.93
0.70 0.70 0.71
0
200
400
600
800
1000
1200
1400
1600
Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09
Ob
se
rva
tio
n C
ou
nt
0.00
0.67
1.33
2.00
2.67
3.33
4.00
4.67
5.33
6.00
6.67
TR
C / D
AR
T R
ate
Observations
TRC Rate
DART Rate
U N C L A S S I F I E D
U N C L A S S I F I E D
Operated by the Los Alamos National Security, LLC for the DOE/NNSA
LA-UR 09-05018
Safety Conversation –
Most Important Part of Safety Observation
Observation Cards
Facility Conditions
Glovebox Work
Observations
Detonator Facility
Good Catch
Office Work
Outdoor Activities
PC Shop Fabrication
Standards and Calibration
Radiation Protection –
Self Monitoring
Cold Lab Activities
Receiving lifting Loading
Vehicle Operator
U N C L A S S I F I E D
U N C L A S S I F I E D
Operated by the Los Alamos National Security, LLC for the DOE/NNSA
LA-UR 09-05018
Pre-Job – HPI “SAFER” Dialogue
The following
SAFER
structure aids
workers in:
Anticipating
Preventing
Catching
Recovering
from error during
a task
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U N C L A S S I F I E D
Operated by the Los Alamos National Security, LLC for the DOE/NNSA
LA-UR 09-05018 Process: Prepare Chemistry Samples/Waistband
Pre-Operational Checklist Activity Completed
by Completion Date
Verify glovebox operating parameters.
O2 □ Gloves □ Windows □
Check interior of glovebox for cleanliness. Clean if
needed.
Verify operator training and qualifications in
accordance with training plan 5700.
Verify M&TE is in calibration and is in proper
operating condition.
Verify tools and fixtures are present and in operating
condition. Verify Traveler is signed off.
Verify the current WI and data forms are presents.
This checklist is a guide provided to assist the PIC in conducting pre-job briefs. .
Work activity authorized and approved.
Work is scheduled on POD.
Copy of work instruction/DOP/ or IWD for the job available
Conducted review of all task/steps and or phases or the work activity
Asked work team “how can we make a mistake at this point?”
Ask work team “what is the worst thing that can go wrong?”
Discussed with work team who can stop work?
Discussed response to alarms or emergencies?
Verified that all members of work team have necessary equipment, materials, and PPE?
Discussed with work team what a successful outcome will be for this work activity?
All work team members agreed to tasks/steps, hazards, and controls, and committed to
follow them.
RLM, PIC and workers signed Pre-Job Briefing?
Other (specify)
HPI Error Precursors influencing Job Context and Behaviors
Task Demands Individual Capabilities
1. Time pressure (In a hurry) 17. Unfamiliarity with task (1st time)
2. High Workload (memory requirements) 18. Lack of knowledge (mental model)
3. Simultaneous, multiple tasks 19. New technique not used before
4. Repetitive actions, monotonous 20. Imprecise communication habits
5. Irrecoverable acts 21. Lack of proficiency / inexperience
6. Interpretation requirements 22. Indistinct problem-solving skills
7. Unclear goals, roles & responsibilities 23. “Hazardous” attitude for critical task
8. Lack of or unclear standards 24. Illness / Fatigue
Work Environments Human Nature 9. Distractions / Interruptions 25. Stress (limits attention)
10. Changes / Departures from routine 26. Habit patterns
11. Confusing displays or controls 27. Assumptions (inaccurate mental picture)
12. Workarounds / Out-of-Service instruments 28. Complacency / Overconfidence
13. Hidden system response 29. Mindset (“tuned” to see)
14. Unexpected equipment conditions 30. Inaccurate risk perception (Pollyanna)
15. Lack of alternative indication 31. Mental shortcuts (biases)
16. Personality conflicts 32. Limited short-term memory
Indeterminable
33. Error precursors are indeterminable
√ FINAL CHECK & REVIEW BEFORE CONDUCTED WORK ACTIVITY
Summarize critical steps:
Anticipate error-likely situations:
Foresee consequences:
Evaluate controls:
Review operating experience:
U N C L A S S I F I E D
U N C L A S S I F I E D
Operated by the Los Alamos National Security, LLC for the DOE/NNSA
LA-UR 09-05018
Safety Communication
• FLM Monday morning
Safety Stand-ups
• News Room Monitors
• ADSMS Email News
• Porcelain News
• SMS Broadcast of
Observations Newsletter
• Plan of the Day / Morning
Standup Meeting
• Operations Center
• Posters Campaigns
Anonymous Avenue
for communicating concern
- No Surprises Program
Top 5 Continuous Improvement Projects
Using Lean Six Sigma
Boards/Committees:
Operations Board
First Line Manager Board
Radiation Protection Board
Training Board
Glovebox Glove Improvement Committee
Data Analysis Safety Team Management
Review Board
FLMs Gone Wild- Walk Downs
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U N C L A S S I F I E D
Operated by the Los Alamos National Security, LLC for the DOE/NNSA
LA-UR 09-05018
Work our Safety Improvement Plans (SIP) – ATOMICS Observations – Peer to Peer Conversations
– Ergo Injury Prevention in Gloveboxes and Administrative Work
– Slip, Trip and Falls Preventions – Fall and Winter Campaign
– Prevention of Glovebox Glove Failures and Breaches
– Struck by and Against Prevention- Keep up your Housekeeping
– Rad Protection – Practice ALARA
Focus for the Future
U N C L A S S I F I E D
U N C L A S S I F I E D
Operated by the Los Alamos National Security, LLC for the DOE/NNSA
LA-UR 09-05018
Think Safety! Live Safely!
Key to success is
Worker Involvement & willingness
to change their attitudes
towards safety,
security &
environment!