1Bechtel National Inc.

Hazardous Energy Work Control

Presented September 13, 2006DOE Integrated Safety Management Best Practices Workshop

Mike LewisConstruction

Bechtel National, Inc.Hanford Waste Treatment and Immobilization Plant

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Hazardous Energy Work Control – A Life Critical Process

Important elements of working safely

– Work Planning – consistent, thorough, with worker involvement

– Work Control – clear roles and responsibilities and stop work authority

– Work Authorization – management and supervision engagement for hazardous energy work

– A trusting environment where people will ask questions and provide feedback

These are a great fit into our new Nuclear Safety & Quality Culture

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The Old Way of Controlling Hazardous Energy Work

Multiple areas each implementing requirements as they deemed applicable – often reliant upon a single individual’s decision for applicability of LOTO and Hazardous Work Permits

No high level involvement in determining need for and authorization of hazardous energy work control

Multiple LOTO Tagging Authorities in different areas running the LOTO program a little different in each area

A mixture of processes and tools that were not always used consistently

Organization quick to find fault with participants when events occurred, but mostly failed to recognize the organizational weaknesses that led to the events

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Awareness of an Adverse Trend

Eight hazardous energy incidents at WTP in 2005 No obvious commonality between incidents Corrective Action Report issued – Seven compensatory actions:

– Management Suspension of Work – Suspended all LOTO work

– Investigate incidents with help from Building Trades

– Unions interview incident participants

– Investigate assured grounding features for buried cables

– Management interview incident participants

– Safety Assurance to investigate LOTO violation

– Develop interim work control process for hazardous energy

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Investigations and Assessments

Root Cause Analysis

– 14 recommendations fed into RITS program

Work Control Assessment

– 22 recommendations fed into RITS program (not all related to hazardous energy)

Human Performance Investigation

– 3 recommendations mostly focusing on workplace culture and organizational weaknesses

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Key Recommendations from Investigations

Fix the organizational weaknesses! Build defense in depth into the work control process Provide rumble strips to keep people within the parity zone Improve and integrate hazard analysis into the work control process Increase worker involvement in work planning Provide consistent supervision and management involvement in work

planning, authorization and execution Incorporate knowledge based testing into hazardous energy

work training Centralize hazardous energy work planning

7SAW2

2005 2006

Electrical Incident -

ORPS

LOTO Incident not in ORPS

Reduced Fee for Chilled Workforce

Safety Rally

Management Suspension of Work

DOE Electrical Safety Month

DOE $10,000 Electrical Safety Challenge

Site Wide PSP Update for Electrical

DecAugJan Feb Mar Apr May Jun Jul Sep Oct Nov DecAugJan Feb Mar Apr May Jun Jul Sep Oct Nov

CAR Issued 10 Actions

Safety Standown Hazardous

Energy

Safety Rally

Reduced Fee for Nuclear Safety

Culture

DOE Safety Reminder Letter

from James Rispoli

DOE Electrical PPE Letter from Roy Schepens

DOE Initiate DNFSB Commitment 23

Work Control Assessment

Two Mechanical Incidents - ORPS

Seven Electrical Incidents - ORPS

ORPS Closure Submitted

ORPS Closure Rejected

DOE Letter RCA to be Re-evaluated

• Incident Investigations• Need for RCA• LOTO Improvements• Work Control

Oversight

HPI TrainingHPI Assessment of

ORPS Reports

BNI Request HPI Assessment

Work Control Center for Life Critical Processes• Lockout / Tagout• Configuration Management• Excavation Permits• Hot Work Permits• Hazardous Work Permits

Effective Assessment

DOE

Six Sigma Designed Metrics

Nuclear Safety Culture Rally

Perform RCA

Establish CUG Interim Work Control

Actions Complete

Twenty Recommendations

• Work Package Quality

• Hazard Analysis• Planning and

Scheduling• Management

Expectations

2007

Jan

• DOE/Contractor Relationship

• Working Outside Controls

• Work Place Culture

Self Assessments

Corporate ES&H Assessment

Electrical Safety Assessment

Annual LOTO Surveillance

DOE ORP Electrical Safety Assessment

Corporate ES&H Assessment

Mgt. Assessment of Electrical Work

Processes

Two Electrical Incidents - ORPS

Key

&

US DOE Actions

& BNI Actions

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Construction Utilities Group Established

To help address organizational weaknesses relating to hazardous energy work, Construction Management established the Construction Utilities Group (CUG)

CUG scope:

– Develop a new work process for hazardous energy work control

– Provide work planning and authorization

– Establish hazard controls

– Configuration management and system status

– Design/modifications of construction utilities and facilities

– Manage the beneficial use of permanent facilities

– Primary interface with maintenance group for systems and facilities maintenance

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Previously Existing Tools Improved Upon

Planning (P), Control (C), Authorization (A)

– Job Hazard Analysis (JHA) process (P & C)

– Electrical arc flash calculations (P & C)

– Safe to work instructions (zero energy checks) (P, C,& A)

– LOTO Permits – identification of boundaries (P, C,& A)

– Pre-job Briefings (P & C)

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New Tools and Processes Summary

Planning (P) Control (C), Authorization (A) New Hazardous Energy Packages (P, C, & A) Integration of previously existing tools into new packages Web accessible database for package processing (P) New configuration management approach (P & C) System Status boards (P) New approach to training (A) LOTO Independence from Construction (Defense in Depth)

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New Hazardous Energy Packages

Consistent format for Hazardous Energy Packages Formal management authorization and supervision release to

work for each package Standardized control points for ‘safe to work checks’ Hazard Identification Checklist with defense in depth Integration of existing tools into overall process Standard feedback mechanism – (trusting environment)

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New Hazardous Energy Packages

14 sections for every package Typically 10-12 sections applicable, those that are non-applicable are

positively identified as such Involvement of Craft, Supervision, Safety, Field Engineering, and

Management in every package LOTO Tagging Authority involvement for all LOTO packages New packages provide planning, authorization, control and

feedback in line with expectations for conduct of operations

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Typical Hazardous Energy

Package

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AUTHORIZATION

Front Sheet

Positive identification of applicable sections

Work Authorization and release – (defense in depth)

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PLANNING

Section 1

Work Scope DescriptionFour formats typically used depending upon type and complexity of work

Standard format under development (using CUG database)

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PLANNING

Section 2

Drawing ListMostly for permanent plant work

“Construction Viewer” print outs normally used

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PLANNING & CONTROL

Section 3

Work InstructionsStandard format under development (using CUG database)

Key work steps, safety steps and mandatory sequencing identified

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FEEDBACK

Section 4

Inspection ReportsThe section mostly applicable to permanent plant work (minority of packages)

Various forms used according to types of inspection

Other procedures drive type of forms to be used

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PLANNING

Section 5

Work Area DrawingsAny legible identification of the work area

Typically a marked up site plan or building plan

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PLANNING & CONTROL

Section 6

Hazard ID ChecklistTying in existing work processes to the package

Engaging the right SMEs

Dual verification (defense in depth)

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PLANNING & CONTROL

Section 7

JHA (s)JHA procedure integrated in package

Forms driven by JHA procedure

New Hazardous Energy Work Control process ensures worker involvement in JHA development

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PLANNING, CONTROL & AUTHORIZATION

Section 8

LOTO Permit ApplicationLOTO procedure integrated in package

Forms driven by LOTO procedure

Workers often consulted on boundary options

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PLANNING & CONTROL

Section 9

Arc Flash CalcDeveloped and signed by Electrical Engineers

Identified boundaries and PPE

Similar labels will eventually be placed on the actual equipment

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PLANNING & CONTROL

Section 10

Electrical Zero Energy CheckStep by step instructions

Developed and signed by Electrical Engineer

STOP WORK hold point – (rumble strip)

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PLANNING & CONTROL

Section 10

Non-Electrical Zero Energy CheckStep by step instructions

Developed and signed by Field Engineer

STOP WORK hold point – (rumble strip)

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PLANNING, CONTROL & AUTHORIZATION

Section 11

Hazardous Work PermitHazardous Work Permit procedure integrated in package

Forms driven by Hazardous Work Permit procedure

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PLANNING, CONTROL& FEEDBACK

Section 12

Pre-Job BriefingPre-determined applicable topics

All job associated crew will attend

Sign in sheet provided

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CONTROL & AUTHORIZATION

Section 13

Training RequirementsSpecific safety training needs for package

Identify the crew

Verify the training

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FEEDBACK

Section 14

Work Closure and FeedbackClose out the work

Identify punch list items

Provide feedback (continuation sheets provided in each package)

In a just culture we hope to identify errors and error precursors before we have events

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When Needed, Further Sections can be Added

Examples:

– Confined Space Permit

– Excavation Permit

– MSDS Sheets

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Electricians in Proper PPE for Zero Energy Check

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Web Accessible Database

Web accessible database to request and process hazardous energy packages

– Streamlined process that provides consistent format

– Auto population of data between sections in the package

– Ability to stay electronic until final need to print

– Ability to run a variety of reports for process management

PLANNING TOOL – Removing/Reducing Barriers for Timely Production

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Configuration Management

Identified the need to improve accuracy of configuration management to enable safe work planning

Temporary installations will be used for several more years, accurate as-built P&IDs, Single Lines and Panel Schedules essential

Field labeling to match drawings greatly improved Configuration management improvements more in line with

expectations for conduct of operations

PLANNING & CONTROL

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Construction Power Distribution Rack

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Standardized Orange and Black ID Labels

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Configuration Management – System Status Boards

System Status boards for electrical and piping systems introduced

– Started with pin boards and have since introduced color coded system status images on large LCD screens

– System status more in line with expectations for conduct of operations

– Colored dots indicate valve/breaker positions, LOTO and Defective equipment.

PLANNING

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LCD Partial Screen Shot

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LCD Partial Screen Shot

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New Approach to Training

Everyone at site needs basic training to know when to use a Hazardous Energy Package

More detailed training for those that will prepare and work under a hazardous energy package

Two training modules developed and both include a written knowledge-based test

All training is classroom delivered Procedure reading, alone, is not deemed adequate Training rolling out to direct hire, subcontractors and service reps

QUALIFIED PERSONNEL

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LOTO Independence

LOTO group separated from Construction LOTO group reports to Project Director LOTO completely independent from Construction

production pressures LOTO staffed by experienced Startup personnel familiar with

LOTO in an operating plant environment

DEFENSE IN DEPTH

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Subcontractors and Service Reps

Clear recognition that subcontractors and service reps do not have sufficiently robust programs for hazardous energy work control

Flowdown of procedure requirements to subcontractors and service reps greatly improved

Subcontractors and service reps included in new training

Compensatory Action Service reps performing service work escorted and screened to

ensure work process compliance

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Managing the Process

Key metrics to monitor effectiveness during Implementation Phase

– Safety – hazardous energy incidents/near misses

– Quality* – inspection success / rejections

– Timeliness* – meeting the customer need dates

– Effectiveness* – reporting of errors not resulting in events (feedback section of hazardous energy packages)

* Tracked in CUG database

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Hazardous Energy Incident Metrics

15* 9 **

0 0

Type of Report Nov 2001 to Oct 2005

Oct 2005 to July 2006

Corrective Action Report

ORPS Reports

CAIRS Safety Reports

3 (< 1 per year)

6 (8 per year)

* 14 events with hazard exposure, 1 with no hazard exposure

** 3 events with hazard exposure, 6 with no hazard exposure

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Conclusion

There are more CARs for hazardous energy in the past nine months than the previous four years, but these recent CARs are mostly without safety consequences – people have the courage to speak up

The recent ORPS reports are mostly management concerns and administrative violations – we are not afraid to share a critical look at ourselves

The improved “Just” culture is encouraging people to identify and address errors before events occur, there is less fear of blame, and more confidence in contributing to a safe work process

Recent instances of stop work authority being used for hazardous energy activities demonstrates the questioning attitude we are striving for

A Trusting Culture is Emerging

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Conclusion (continued)

We need to continue to manage hazardous energy work with a conduct of operations approach

We have significantly improved PLANNING, CONTROLS, AUTHORIZATION & FEEDBACK

Craft are typically an under-utilized resource for work planning – get them involved!

People will make mistakes, don’t automatically blame them. Look for and eliminate or mitigate our organizational weaknesses and strengthen our defenses

Developing a Strong Conduct of Operations