Debbie Jenkins Director, Performance Analysis and Quality, ORNL - PowerPoint Presentation

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Debbie JenkinsDirector, Performance Analysis and Quality, ORNL

Challenges to Conducting a Good Investigation: A National Laboratory Perspective

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Accident Investigation Workshop, Oak Ridge National LaboratorySlide2

Battelle Memorial Institute has chartered “Communities of Practice” to promote

continuous improvementA formal cross-cutting effort designed to help establish laboratory operations' standards and expected levels of performance for management systemsEach COP’s expectations includeIdentifying, documenting, and sharing of best practicesStrengthening capability development and stewardshipEnsuring deployment of expertise to meet internal needs

The Integrated Performance Management COP has the

responsibility for event investigation processes Slide3

Formal Investigations are performed for serious events/issues

Examples of serious events have includedSerious injury caused by 1500 lb. falling magnetGun accidently discharged during training classRadiological release and employee exposuresOur serious events are not mass casualty events that are sometimes seen in the commercial industryFrom FY2013 – FY2016, Battelle Laboratories have conducted approx. 120 investigations

The vast majority of our investigations are

conducted internally

Apparent Cause Analysis

Investigations &

Root Cause Analysis

No Causal RequiredSlide4

The process for investigation and analysisSlide5

Rarely do we see an event caused by one thing, usually it’s a combination of factors

March1580 lb chamber tipped over onto employee, resulting in fractures and lacerations (surgery required)

2014

Inadequate safety culture in work groups and supervisors

Inexperienced supervision and salvage handlers

Led to 41 corrective actions over 4 years

11 Contributing Causes

Ineffective application of work processes and tools

Work plan did not address full range of hazards

Hazard Information not utilized

Work plan not briefed to temporarily assigned workers

Training including OJT not adequate to understand risks associated with unstable loads

Supervision not adequately engaged in resource assignment, planning & oversight

Inspections/Walk-

thrus

did not identify potential hazards

Ops Experience & Lessons Learned not effective

Requirements for Riggers not adequately communicate

Conduct of auction/sales is fast-paced

Presence of wheels on scattering change led to incorrect perception of riskSlide6

Our investigation process is rigorous and self-critical

However, there are some common challenges:Multiple causal factors can lessen the importance of the critical issues to addressOverwhelming list of corrective actions can result from these types of investigationsYou can fall into the trap of treating all identified causes equally Considerable resource challenge result that could detract from the important criteria or causesCorrective actions can take up to months and years to closeAre we diluting the impact of our improvement actions by trying to fix everything? Slide7

Improving operational reliability

and safety performance

Promote steps that supervisors and managers

can take to manage administrative burden

and improve reinforcing worker behaviors

Streamline activities and time needed

for supervisors to prepare workers

for daily activities

Increase supervisor coaching and reduce efforts to capture and trend observations

Reduce the number of low-value corrective actions assigned to an

issue (some issues are best handled by managers coaching individuals or reinforcing accountability)

INPO found that allowing supervisors to spend more time coaching staff is required to improve human performance

“A disproportionate number of human resources are focused on the administrative aspects of the corrective action program (CAP) process, and extensive causal analysis…As a result, these administrative aspects detract supervisors and managers from being in the field coaching workers and preventing problems.” Slide8

We are asking ourselves some key questions about our investigation processes

Are we losing focus on the most important issues in an effort to find every possible contributing causes?Are we using the best techniques to isolate the true root cause of an event?Are we hindering organizational learning by overwhelming our staff with corrective actions?Does volume of cause and corrective actions equate to a good investigation?Is our investigation process perpetuating a lack of focus on the most significant aspects of preventing recurrence?Slide9