DOE OSTI2012
Evaluating operational incidents can provide a window into the drivers most critical to establishing and maintaining a strong safety culture, thereby minimizing the potential project risk associated with safety incidents. By examining U.S. Department of Energy (DOE) versus U.S. Army drivers in terms of regulatory and contract requirements, programs implemented to address the requirements, and example case studies of operational events, a view of the elements most critical to making a positive influence on safety culture is presented. Four case studies are used in this evaluation; two from DOE and two from U.S. Army experiences. Although the standards guiding operations at these facilities are different, there are many similarities in the level of hazards, as well as the causes and the potential consequences of the events presented. Two of the incidents examined, one from a DOE operation and the other from a U.S. Army facility, resulted in workers receiving chemical burns. The remaining two incidents are similar in that significant conduct of operations failures occurred resulting in high-level radioactive waste (in the case of the DOE facility) or chemical agent (in the case of the Army facility) being transferred outside of engineering controls. A review of the investigation reports for all four events indicates the primary causes to be failures in work planning leading to ineffective hazard evaluation and control, lack of procedure adherence, and most importantly, lack of management oversight to effectively reinforce expectations for safe work planning and execution. DOE and Army safety programs are similar, and although there are some differences in contractual requirements, the expectations for safe performance are essentially the same. This analysis concludes that instilling a positive safety culture comes down to management leadership and engagement to (1) cultivate an environment that values a questioning attitude and (2) continually reinforce expectations for the appropriate level of rigor in work planning and procedure adherence. A review of the root causes and key contributing causes to the events indicate: - Three of the four root cause analyses cite lack of management engagement (oversight, involvement, ability to recognize issues, etc.) as a root cause to the events. - Two of the four root cause analyses cite work planning failures as a root cause to the events and all cause analyses reflect work planning failures as contributing factors to the events. - All events with the exception of the Tuba City plant shutdown indicate procedure noncompliance as a key contributor; in the case of Tuba City the procedure issues were primarily related to a lack of procedures, or a lack of sufficiently detailed procedures. - All events included discussion or suggestion of a lack of a questioning attitude, either on the part of management/supervision, work planners, or workers. This analysis suggests that the most critical drivers to safety culture are: - Management engagement, - Effective work planning and procedures, and - Procedure adherence with a questioning attitude to ensure procedural problems are identified and fixed. In high-hazard operational environments the importance of robust work planning processes and procedure adherence cannot be overstated. However, having the processes by themselves is not enough. Management must actively engage in expectation setting and ensure work planning that meets expectations for hazard analysis and control, develop a culture that encourages incident reporting and a questioning attitude, and routinely observe work performance to reinforce expectations for adherence to procedures/work control documents. In conclusion, the most critical driver to achieving a workforce culture that supports safe and effective project performance can be summarized as follows: 'Management engagement to continually reinforce expectations for work planning processes and procedure adherence in an environment that cultivates a questioning attitude'. (authors)
12 MANAGEMENT OF RADIOACTIVE AND NON-RADIOACTIVE W↗