the cycle of performance getting back on the path to excellence warning flags/precursors palo verde:...
TRANSCRIPT
![Page 1: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/1.jpg)
The Cycle of Performance
Getting Back on the Path to Excellence Warning Flags/Precursors
The Cycle of Performance
Getting Back on the Path to Excellence Warning Flags/Precursors
Palo Verde: A Case Study
Frederic LakeCorrective Action Program Manager
Palo Verde: A Case Study
Frederic LakeCorrective Action Program Manager
![Page 2: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/2.jpg)
![Page 3: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/3.jpg)
8
7
6
5
4
3
2
1 9
Potential Stages of Power PlantsPotential Stages of Power Plants
A B C D E
![Page 4: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/4.jpg)
Coming off a Long Period of Strong PerformanceComing off a Long Period of Strong Performance
• Attributes– Mature Culture– Stable Operations– Performance indicators “Green”– Positive recognition by industry (INPO, Peers)
• Attributes– Mature Culture– Stable Operations– Performance indicators “Green”– Positive recognition by industry (INPO, Peers)
![Page 5: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/5.jpg)
Coming off a Long Period of Strong PerformanceComing off a Long Period of Strong Performance
• Behaviors– Overconfidence– Believing your own press– Arrogance– Withdrawal– Managers not reinforcing behaviors to set
high standards– Managers distracted (external changes,
regulatory, major projects)
• Behaviors– Overconfidence– Believing your own press– Arrogance– Withdrawal– Managers not reinforcing behaviors to set
high standards– Managers distracted (external changes,
regulatory, major projects)
![Page 6: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/6.jpg)
Unaware CultureUnaware Culture
• Some members may challenge current behaviors but face denial from other members
• CAP owners may be dealing with poor behaviors
• Strength of the Culture:– Length of time– Stability of membership– Emotional intensity of past experiences
• Some members may challenge current behaviors but face denial from other members
• CAP owners may be dealing with poor behaviors
• Strength of the Culture:– Length of time– Stability of membership– Emotional intensity of past experiences
![Page 7: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/7.jpg)
Palo Verde…..Early 2000’sPalo Verde…..Early 2000’s
• Plant running well• PV recognized as excellent by INPO • The place where people come to
benchmark• Insular Staff
• Plant running well• PV recognized as excellent by INPO • The place where people come to
benchmark• Insular Staff
![Page 8: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/8.jpg)
Mounting Problems…..Mounting Problems…..
• 2004 – 2006:– NRC Substantive Cross-Cutting Issues (SCCI) in
Human Performance and PI&R– Decreasing Equipment Reliability– Increased Forced Loss Rate– Decreasing Regulatory Confidence
• 2007– INPO Evaluation: significant weaknesses in several
areas– NRC ROP Column 4
• 2004 – 2006:– NRC Substantive Cross-Cutting Issues (SCCI) in
Human Performance and PI&R– Decreasing Equipment Reliability– Increased Forced Loss Rate– Decreasing Regulatory Confidence
• 2007– INPO Evaluation: significant weaknesses in several
areas– NRC ROP Column 4
![Page 9: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/9.jpg)
What Problems? What Problems?
• Attributes– Increasing emergent issues/equipment
failures/Forced Outages– Poor CAP Behaviors/Accountability– Efforts to Turn Performance Overly focused
on process/procedure changes
![Page 10: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/10.jpg)
Efforts to Turn Performance Not SuccessfulEfforts to Turn Performance Not Successful• Using old solutions • Cause Analysis fails
to correct underlying problems
• Using old solutions • Cause Analysis fails
to correct underlying problems
The problems that exist today cannot be solved by the same level of thinking that created them.
…Albert Einstein
![Page 11: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/11.jpg)
What Problems? What Problems?
• Behaviors– Event significance not recognized– Signs of performance decline rationalized– Teamwork declines; groups become isolated– Training is minimized – Reluctance to challenge each other
• Behaviors– Event significance not recognized– Signs of performance decline rationalized– Teamwork declines; groups become isolated– Training is minimized – Reluctance to challenge each other
![Page 12: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/12.jpg)
Who me?Who me?
• Attributes– Problems persist– Increasing backlogs – Sub-optimizing– Rapid decline in performance indicators -
station is measuring against themselves– Ineffective Evaluations
![Page 13: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/13.jpg)
Who me?Who me?• Behaviors
– Finger pointing; low accountability– Poor CAP support:
• “loopholes”• Poor closures & resolution• CAP vs. “real work”
– Declining CARB performance• Poor support• High use of alternates• Driving down level of participation
• Behaviors– Finger pointing; low accountability– Poor CAP support:
• “loopholes”• Poor closures & resolution• CAP vs. “real work”
– Declining CARB performance• Poor support• High use of alternates• Driving down level of participation
![Page 14: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/14.jpg)
Interim MeasuresInterim Measures
• Metrics showing magnitude of backlogs
• Outside cause analysis expertise • Team established to determine scope
and magnitude of issues• Comparison of station performance to
the industry (Epiphany)
• Metrics showing magnitude of backlogs
• Outside cause analysis expertise • Team established to determine scope
and magnitude of issues• Comparison of station performance to
the industry (Epiphany)
![Page 15: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/15.jpg)
CommunicationCommunication
• Message:– Unless we change something bad will happen– Objective is sustained performance; not just
getting out of trouble
• Weekly alignment meetings• Executive level CAP message• Safety message• Relentless repetition……….
• Message:– Unless we change something bad will happen– Objective is sustained performance; not just
getting out of trouble
• Weekly alignment meetings• Executive level CAP message• Safety message• Relentless repetition……….
![Page 16: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/16.jpg)
Stop the BleedingStop the Bleeding
• Direct and targeted actions to break the culture patterns and stop the declining performance:– Problem definition & triage– Causal analysis to determine underlying
drivers and actions– Training using outside expertise in the
essential functions of CAP, including causal analysis and CARB
– Refining metrics and reinforcing accountability for CAP
• Direct and targeted actions to break the culture patterns and stop the declining performance:– Problem definition & triage– Causal analysis to determine underlying
drivers and actions– Training using outside expertise in the
essential functions of CAP, including causal analysis and CARB
– Refining metrics and reinforcing accountability for CAP
![Page 17: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/17.jpg)
Safety NetsSafety Nets
• Increased oversight• Closure Review Boards for actions
important to the recovery• 100% CAP Closure Reviews• Increased management control of
CAP administrative functions
• Increased oversight• Closure Review Boards for actions
important to the recovery• 100% CAP Closure Reviews• Increased management control of
CAP administrative functions
![Page 18: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/18.jpg)
BehaviorsBehaviors
• Directive Management from Executive Leadership and CAP Program Owner
• Focus on Specific CAP Behaviors:– Identification of Issues– Causal Analysis Quality– Quality Completion of Corrective Actions
• Training to close skills and knowledge gaps and to improve performance
• Directive Management from Executive Leadership and CAP Program Owner
• Focus on Specific CAP Behaviors:– Identification of Issues– Causal Analysis Quality– Quality Completion of Corrective Actions
• Training to close skills and knowledge gaps and to improve performance
![Page 19: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/19.jpg)
Evaluate GapsEvaluate Gaps
• Team devoted to analyses of performance
• Results grouped into Fundamental Overall Problem Areas:– Causal analysis performed for each area– Outside expertise – Actions formed the basis for the Site
Integrated Improvement Plan (SIIP), and the NRC Confirmatory Action Letter (CAL)
• Team devoted to analyses of performance
• Results grouped into Fundamental Overall Problem Areas:– Causal analysis performed for each area– Outside expertise – Actions formed the basis for the Site
Integrated Improvement Plan (SIIP), and the NRC Confirmatory Action Letter (CAL)
![Page 20: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/20.jpg)
1. Organizational Effectiveness2. Operational Focus3. Emergency Preparedness 4. Engineering Programs 5. Design Control / Configuration Management6. Engineering Technical Rigor7. Equipment Reliability 8. Industrial Safety 9. Problem Identification & Resolution10. Procedures / Work Instructions11. Managing Plant Work Loads12. Training & Qualification13. EDG K-1 Relay (White Finding)14. RAS Event (Yellow Finding)
1. Organizational Effectiveness2. Operational Focus3. Emergency Preparedness 4. Engineering Programs 5. Design Control / Configuration Management6. Engineering Technical Rigor7. Equipment Reliability 8. Industrial Safety 9. Problem Identification & Resolution10. Procedures / Work Instructions11. Managing Plant Work Loads12. Training & Qualification13. EDG K-1 Relay (White Finding)14. RAS Event (Yellow Finding)
Cause Analysis Cause Analysis
![Page 21: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/21.jpg)
Palo Verde Leadership ModelPalo Verde Leadership Model
We SAFELY and efficiently generate electricity
for the long term
![Page 22: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/22.jpg)
Turning the Tide Turning the Tide
• Attributes– High volume of identification, causal analysis, and
reliance on compensatory measures– Station begins to recognize that problem identification
and resolution is a behavior; not simply a process– Metrics drive performance– Consistent message to the organization on staying
the course
![Page 23: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/23.jpg)
Turning the Tide Turning the Tide
• Behaviors– Leaders start to align around:
• Need to improve• Improvement goals• Operational focus
– Leaders working down a level and exhibit a directive leadership style
– WeBe – some workers take a “wait and see” attitude (we’ll be here when you’re gone)
• Behaviors– Leaders start to align around:
• Need to improve• Improvement goals• Operational focus
– Leaders working down a level and exhibit a directive leadership style
– WeBe – some workers take a “wait and see” attitude (we’ll be here when you’re gone)
![Page 24: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/24.jpg)
Closing the GapsClosing the Gaps
• Attributes– Overall plant performance improving– Fewer major equipment issues– Performance indicators continue to show
improvement– High CAP backlog of conditions and actions,
many of which may be no longer necessary
![Page 25: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/25.jpg)
Closing the GapsClosing the Gaps
• Behaviors– Using experience, self-assessment, and
benchmarking to improve major processes – Leaders focus on improving accountability
which allows for compensatory measures to be replaced by long-term processes
– Improved coordination between departments– Some pockets of resistance; however, the
gap between high performers and low performers is widening and becoming more evident
• Behaviors– Using experience, self-assessment, and
benchmarking to improve major processes – Leaders focus on improving accountability
which allows for compensatory measures to be replaced by long-term processes
– Improved coordination between departments– Some pockets of resistance; however, the
gap between high performers and low performers is widening and becoming more evident
![Page 26: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/26.jpg)
The Plateau………..The Plateau………..
• Symptoms:– If you think this is bad…you should have seen
it before• Actions:
– Focus on 3-5 year plans not just the immediate improvement plans
– Communication and awareness– Overtly looking for signs of the plateau &
continuous challenging
• Symptoms:– If you think this is bad…you should have seen
it before• Actions:
– Focus on 3-5 year plans not just the immediate improvement plans
– Communication and awareness– Overtly looking for signs of the plateau &
continuous challenging
![Page 27: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/27.jpg)
Demonstrating Performance Improvement Demonstrating Performance Improvement
• Attributes– Plant operating reliably– Problems identified early and low level
trending, analysis, and other performance improvement tools are used
– Improved metrics that compare to industry– Involvement with the industry
![Page 28: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/28.jpg)
Demonstrating Performance Improvement Demonstrating Performance Improvement
• Behaviors– Highly accountable organization– Supervisors consistently reinforce
expectations– Equipment failures are considered
organizational failures– We find and fix our problems
• Behaviors– Highly accountable organization– Supervisors consistently reinforce
expectations– Equipment failures are considered
organizational failures– We find and fix our problems
![Page 29: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/29.jpg)
A B C D E
8
7
6
5
4
3
2
1 9
Potential Stages of Power PlantsPotential Stages of Power Plants
![Page 30: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/30.jpg)
Common Warning Flags & FactorsCommon Warning Flags & Factors
• Overconfidence• Isolationism• Production Priorities
– Safety is assumed and not explicitly emphasized
– Significance of issues underplayed• Operations and Engineering:
– Poor application of fundamentals– Erosion of design margins
• Poor Change Management• Defensive Leaders• Poor Self-Critical Behaviors
• Overconfidence• Isolationism• Production Priorities
– Safety is assumed and not explicitly emphasized
– Significance of issues underplayed• Operations and Engineering:
– Poor application of fundamentals– Erosion of design margins
• Poor Change Management• Defensive Leaders• Poor Self-Critical Behaviors
![Page 31: The Cycle of Performance Getting Back on the Path to Excellence Warning Flags/Precursors Palo Verde: A Case Study Frederic Lake Corrective Action Program](https://reader036.vdocument.in/reader036/viewer/2022062511/55148f84550346ea6e8b510a/html5/thumbnails/31.jpg)
Life is 10% what happens to you and
90% how you CHOOSE
to react to it!
Life is 10% what happens to you and
90% how you CHOOSE
to react to it!