# Presentation: 207128

##  BNL Lessons Learned Workshop 

**Presented by Ed Sierra**
**Laboratory Lessons Learned Coordinator**
**June 27, 2008**
**Quality Management Office**

## Agenda

## Slide 3

## 

Assessment of BSA Contractor Assurance Program

It’s good business practice!  

**Assessment of BSA Contractor Assurance Program**
**It’s good business practice!  **

## What is a Lesson Learned?

**A lesson learned is the knowledge acquired from an ****innovation ****or an ****adverse**** experience that *****causes ******a worker or an organization to improve:***
**a process**
** **
**an activity**
**worker safety**
**efficiency**
**quality  **
**In short, a ****change in behavior**** occurs.**
- _[LL Example:](https://sbms.bnl.gov/sbmsearch/ll/viewLesson.cfm?LessonID=495)_

## Participate in Corporate OPEX Program

Share BNL Developed LLs (DOE Database)
Required for Type A & B Accidents, Signficance Category 1 and R Occurrences
Optional for all other OPEX

Screen DOE Corporate and External OPEX

**Share BNL Developed LLs (DOE Database)**
**Required for Type A & B Accidents, Signficance Category 1 and R Occurrences**
**Optional for all other OPEX**
**Screen DOE Corporate and External OPEX**

**DOE Order 210.2 DOE Corporate Operating Experience Program**

**Notes:**
Key Messages:
The Department has collected, and continues to collect, wealth of information that we are not fully utilizing.  This information IS Not always readily available, easy to use, access, or analyze.

This need is experienced throughout the DOE hierarchy.  Many reasons explain why this is the case. Lack of ready access,  Lack of sufficient database and analysis skills, Complexity of the data, Fragmentation of information, etc 

EH Corporate Vision:
Reinvigorating technical competency- 
Promoting technical inquisitiveness by DOE and contractor staff
Learning from experience---Continuous Improvement, And 
Field Orientation and Assistance----Recognizing that Success is accomplishing the mission safely and reliably

These are all important lessons that we had to re-learn among other things after the Columbia tragedy and the Davis-Besse incident.  

## Distribute applicable OPEX to Personnel for review, analysis, internalization and corrective action implementation

Designate an Operating Experience Program Coordinator – who will be a member of the Operating Experience Committee

Implement Required Actions of Corporate OPEX Documents (e.g., SORs, SAs, SBs, etc.) and Formally respond as required

Trend Contractor Operating Events for Lesson Learned from Recurring Issues

Establish Metrics 

**Designate an Operating Experience Program Coordinator – who will be a member of the Operating Experience Committee**
**Implement Required Actions of Corporate OPEX Documents (e.g., SORs, SAs, SBs, etc.) and Formally respond as required**
**Trend Contractor Operating Events for Lesson Learned from Recurring Issues**
**Establish Metrics **

**DOE Order 210.2 DOE Corporate Operating Experience Program**

**Notes:**
Key Messages:
The Department has collected, and continues to collect, wealth of information that we are not fully utilizing.  This information IS Not always readily available, easy to use, access, or analyze.

This need is experienced throughout the DOE hierarchy.  Many reasons explain why this is the case. Lack of ready access,  Lack of sufficient database and analysis skills, Complexity of the data, Fragmentation of information, etc 

EH Corporate Vision:
Reinvigorating technical competency- 
Promoting technical inquisitiveness by DOE and contractor staff
Learning from experience---Continuous Improvement, And 
Field Orientation and Assistance----Recognizing that Success is accomplishing the mission safely and reliably

These are all important lessons that we had to re-learn among other things after the Columbia tragedy and the Davis-Besse incident.  

## What are the Lessons Learned Coordinator Responsibilities? 

**Organization’s point of contact**
**  **
**Inform organization staff**
** **
**Apply Lessons Learned information to their programs, projects, or activities**
**Generate and disseminate Lessons Learned**
** **
**Report on Lessons Learned status for organization as a part of the organization’s Self Assessment program**

## Title of the Lesson LearnedMust Get The Reader’s Attention

**Make it short . . . but tell the whole story;**
**Make the reader sense that this is something they **_**need**_** and **_**want**_** to know.**
**Be specific to the incident or the situation, avoid using generic phrases;**
**The Title is what is displayed in the subscription service e-mail notice and in references to the LL document.**

## Tips for Writing a Lesson Learned Document

**Use the readers language**
**Don’t use technical language if not necessary;**
**Don’t use slang inappropriate for written documents;**
**Don’t assume your reader knows all your acronyms.**
**Speaks directly to the reader in an informal, conversational style.**
** **
**An emphasis on explaining and interpreting causal analysis results rather than on methodology. **

## Lessons Published 3rd Qtr FY 08

**Beware:  A Safety Analysis Cannot be Viewed as a Static Historical Document (BNL)**
**Team Review of Management Concern Related to the Acquisition of Equipment**
**Minor Fire in Non-NRTL Listed HEPA Filter and Fan Assembly (BNL)**
**Closed-Top Funnels are Compliant and Safe (BNL)**
**Material Handling Events at Hanford**
**Loss of Breathing Air - Importance of Three-Way Communication**
**Do You Conduct Screening for Hypersensitivity (Allergic) Reactions When Planning Field Work? (BNL)**
_**In Review Process **_
**Include an Instructional Designer when Embarking on a new Training Initiative (BNL)**
**A top heavy, five drawer, lateral filing cabinet tips over and injures a worker (BNL)**

## Is the Lesson Learned Program Effective?

**   ****The system can be measured for value only on the basis of the **_**prevention benefits**_** it provides to BNL.**

##  Lesson Learned Metrics 

**No. of internal LL submissions/distributions**
**No. of external LL submissions/distributions**
**LL Sources reviewed**
**Most viewed  Lessons**
**Timeliness of distribution of internal and external LL**
**User data (unique user, user searches, user organization)**
**Feedback –** (**applicability, corrective actions, procedure revision, training revisions, etc.)**
**Data stream trending for LL**
**Work Control (pre- and post-job LL)**
**LL origin (Occurrences, operating experience, assessments, critiques, etc.)**

**“****Bean **
**counting”**

- KPIs

## Lesson Learned Feedback Prompt!

**Prompt/capture feedback of published LL Communications**
**Will adopt**
**Distributed for Information**
**Not applicable**
**Previously adopted**
**Reading for Interest only**
**Under investigation**

## 2nd Qtr FY 08 LL Feedback

## 2nd Qtr FY 08 Lesson Learned Feedback

## Slide 17

## A Sampling of BNL Lesson Learned Feedback

**This is the first lessons learned notice I received.  If you were involved in adding me to the distribution list, I appreciate it.  This will prove to be helpful.  Thanks!**
**This appears to be an excellent use of web media to convey/inform employees of pertinent safety information**
** **
**Not very illuminating!**
**I have incorporated this Lesson Learned into a Work Instruction for removing combustible materials from the HFBR (Building 750).**
** **
**I try to get the big picture from lessons learned and incorporate any ideas, knowledge, and improvements into my work/life.**
**  ** ** **
**This Lessons Learned is a jewel. As a sea going oceanographer that put big moorings in the ocean, I have given an "awareness" sermon a hundred times to those that helped me on deck.**

## A Sampling of BNL Lesson Learned Feedback

**I find reading Lessons Learned helps me with my work planning to maybe stop future failure.    **
**The Lessons Learned format is clear and "inviting" information well-presented. Photographs added to understanding. **
**Good info, most of what was discussed was deployed during the RSB and CFN Construction review. I like the idea of the on-site nurse station that can be used for the NSLS II project.**
**This reinforces the critical importance of every driver being aware of their surroundings. You never know when someone's life will depend on it.**
**I'm trapped here. Every time I launch my web browser I get this feedback page**

## Point to Ponder

**The more we stress only what we can measure, the more we need to remember that not everything that is measurable matters, and not everything that matters is measurable.”**
**                                                  ****- Elliot Eisner **

## Lesson Learned Infrastructure

- _[https://sbms.bnl.gov/](https://sbms.bnl.gov/)_

## Slide 22

## Slide 23

## Color blocks help identify work flow status

## Slide 25

##                 Recent Modifications/Path Forward

**Recruit new LL Coordinators**
**Conduct/document an evaluation of the effectiveness of actions implemented from LL**
**Revise subject areas to include steps that prompt the search for, and the application of LL**
**Revise Laboratory-wide safety committee charter(s) to include responsibility to review value-added LL for possible improvements to institutional policies, procedures, work practices, training, and assessment activities**
**Modify the “will adopt” LL feedback mechanism to capture the action(s) that will be taken in response to the Lesson.**
**Revise the Lessons Learned (LL) subject area to require a formal response from Organizational LL Coordinators regarding evaluation/utilization of LL ** ** ** ** ** ** ** ** **

##                      What are Traps, Triggers and Tools? 

**Traps**
- Conditions or situations that people may fall into without recognizing it and cause and error, event or incident
**Triggers**
- observable **actions** or **reactions**,
- a recognized thought or individual **perception **
- or a “**gut-feeling**” that something isn’t right.
**Tools**
- Methods used to recognize and avoid traps and prevent errors, events and incidents

**Demands of **
**Task **
**Work Environment**
**Individual Factors **

**Notes:**
TIGER TRAP STORY

## Performance Modes

**Key Words****	****	****   ****	****Error**
**	****	****	****    ****	**** ****Rate**

_***SKILL-BASED***_ -- stored **patterns** 		**HABIT**
- of pre-programmed actions.		Familiar (> 50 times)	1 per
- Acting out of habit without 		**Not Thinking**		1000
- conscious thoughts.

_***RULE-BASED***_ -- rules accumulated	There is a rule,
- via experience and training. 		and **I KNOW** there	1 per
- Can be WRITTEN or VERBAL		is a rule			100

_***KNOWLEDGE-BASED***_ -- using		**You don’t Know**		**1 in 2**
- analytical processes and stored knowledge. 		**what**		     **to**
- Has NOTHING to do with how smart	**You don’t know!!!!!**	**1 in 10 !!!!**
- you are! You are uncertain how to proceed.

- This **PERSON** on this **TASK** at this **TIME**

**Notes:**
Rasmussen and Jenson created the General Error Modeling System (GEMS) in the 1970s to describe the mental models people use to perform tasks. Are related to specific tasks – not activities

Draw chart on paper – have them draw on a page too.

You might ask what is a performance mode anyway?
The three performance modes were are going to review are really just the mental models that one uses to complete a given task.  We are not going to talk about the technical aspects of these modes.  
What we are going to focus on is “this person” at “this task” and “at this time”.  A very important point to remember is that a group, can not be in a performance mode.  In fact, each individual within the group can be in a different mode within a group on the same task.  
Let’s look at an example, a pitcher who winds up an throws a baseball is probably in a skills-based mode, so is the batter, but the umpire is most likely functioning in a rule-based mode trying to determine if the pitch is a ball or a strike.  If the team at bat is down by 10 runs, the coach is probably in the knowledge-based mode trying to figure out how to close the gap.  But, they are all part of the same team-trying to accomplish the same outcome.
A good work-related example would be where you have a highly experienced employee and a new employee working on a task that is routine within the department.  The seasoned employee is likely to be in one performance mode, for example skill-based, while the new employee is likely to be in a knowledge-based performance mode.  And as a result, the error traps and error rates are likely to be different for both.   

You are in the skill-based performance mode when you are doing a task that typically are routine, repetitive, habitual.   These tasks normally require low or no conscious thought and become a habit after they are repeated 50-100 times.  Skill-based errors usually involve tasks with less than 7-15 steps.  A good example would be operating the remote control for your television or turning on the lights in your home.
Slips are associated with a lack of attention and include: Intrusions, Omissions, Reversals, Mis-ordering or timing errors.  
Lapses on the other hand represent memory short-falls, and can be characterized as Omitting planned items,  Place-losing or  Forgetting intentions.
Together, slips and lapses have an error rate of once in every 1,000 attempts.
How many of you have more than one TV at home?  Are all the remotes the same?  How about your lights switches, have you ever flipped on the wrong light when the switches are side by side?

In rule based mode an individual or work group has the knowledge, skills and experience, knows the rules and procedures and either takes a short-cut, misapplies a rule or procedure or the rule or procedure is WRONG for the situation.
It is important to remember that not all rules are written-some are implied.
Is it okay to proceed through a red-light at an traffic intersection?
What if you are making a right-turn after stopping?
What if you are directed to do so by a uniformed officer directing traffic?
What if you are driving and ambulance or fire truck?
What if you live California-I hear it’s a okay if you honk first......just kidding on that one!
Rule-based mistakes have an error rate of 1 in 100 attempts.
You see why it is important to remember...the performance mode as it relates to 
This person
This task
This time

You will know you are in knowledge based mode, when you find yourself scratching your head like this (DEMONSTRATE) during problem-solving.  
...”I wonder... and Do you recall” should be signals that they are in the knowledge-based mode.  
These errors occur when the individual or the sum of the work group as a whole DOES NOT HAVE the knowledge, skills and experience or a rule or procedure that applies DOES NOT EXIST, or is UNAWARE of the rule or procedure. In short the individual in this mode....DOES NOT KNOW-what he/she does not know.
How many of you have ever tried to repair a home appliance, a boat motor or a vehicle and found out by trial and error that you replaced five parts or components before you really identified the problem? (Give/solicit an example)  What was your error rate?  Why did it happen?  
For most of us, we either didn’t have the knowledge, skills and experience or we DID NOT KNOW-what WE DID not know!  
With an error rate of 1 in 2 to 10 attempts in greatly reinforces the need to control risk in these types of situations.

## Why is this important for people to understand?

- Helps them keep from “**proceeding in the face of uncertainty**” which causes many accidents and injuries
- Makes them aware of the **probable failure rate** of a task or action
- Helps them apply the right **TOOL** to prevent an error, accident or injury

**Notes:**

story about using the right tool for the right job - and abandoning tools when the tool is right but the USE is wrong.
Understanding the three performance modes, the error traps and the tools to reduce the potential for error have three takeaways for you.
First, it reduces the risk of your having to work the face of uncertainty.
Second, it should make you aware of probable failure rate you are likely to encounter in each mode. 
And finally will help you to apply the right error prevention tool to the situation or task at hand.

## Which Performance Mode Would You Rather Be in?

**Notes:**
Instructor Notes:

Based on the descriptions of the three performance modes, which one would you rather be in?
Do you see how your performance mode can impact the likelihood of producing an error?

## Top 10 Error Traps...

- High work load
- Time pressure
- Poor communications
- Vague or poor work guidance
- Overconfidence in work and/or abilities
- Infrequent or first time performing a task (new-to-job)
- Distractions
- First working day following time off > 4 days
- The end of a shift or work cycle

**Top 10 Error Traps...**

**Notes:**
Instructor Notes:
Ask people to raise their hand for each of the error traps they see in a given day. Remind them if this is just a list – they wont deal with them.

These all look and feel the same to us...
Stress
High work load
Time pressure

These all put us in KB performance mode...

Poor communications
Vague or poor work guidance
Overconfidence in work and/or abilities
First time performing a task

It is worth noting that the “traps”  of stress, high work load and time pressure work together to become “individual” drivers for end of shift  or work cycle errors.

Stress is an error precursor that is present at some level in almost all of us almost all the time. Work always places a variety of demands on each of us. 
There is the task related tension or stress that can be viewed as the mental demand, physical demand, that most of us have for doing well.  It is well documented that stress increases when someone is new-to-the job.  This is true for managers, engineers, supervisors, craft and production workers.  While task and new to the job frustration and effort are associated with increases in error. Stress is often broader than the task.  
It can be found within the work group, the organization and the personal–life outside of work.  When people are unhappy, performance errors have been well documented in almost all occupations. We all have a variety of interpersonal needs that exist in the workplace and at home. In addition to work, individuals often become stressed and frustrated in their marriage, with their finances, over chronic illness in their families and with their children.  
We can all become mentally distracted when fundamental human needs are blocked. Among these are the needs to be included and consulted on important decisions, to be allowed appropriate autonomy and influence over both our jobs and our personal lives.  Such things not only lead to personal satisfaction but also to fewer errors.

Another contributor to human error is the extensive workload that is periodically placed upon an individual. Our inability to cope effectively with multiple sources of information and responsibility clearly contributes to accidents. 
High workload is not typically caused by a single task, but by situations in which multiple tasks must be performed or managed simultaneously.
Fatigue, especially when it involves mobile equipment, work around machinery, working at heights or with electricity can  have catastrophic consequences. 
How many times have you tried to balance too many commitments in your own personal life?  The yard needs mowed, the kids are asking for help with a school project, your spouse’s mother needs to go to the doctor, a community organization calls for you to volunteer on a project.  Now add it the additional commitments of a full-time job and its easy to see how it can become pretty overwhelming at times.

Time pressure is a precursor to people taking short-cuts.  Like our cartoon illustrates: people make more rule-based mistakes and overlook potential at risk situations when the pressure to get the job done is highest.  In these situations, we often just don’t to stop and think before we act.  Short breaks, adequate to meet their needs particularly as the task complexity increases, the situation changes or the environmental conditions worsen - such as when working in extreme hot or cold environments, can help. 

People at all levels of the workforce need and provide a wide variety of information.  Communication is the means for moving information throughout an organization,  Creating a climate that fosters open, direct and a timely flow of ‘relevant” information is a challenge for each of us.
There is a general tendency to “fill in” information when it doesn’t exist, and then act in a manner consistent with that information. If the information is not complete, ask for more.  If feedback is needed, provide it. If information is confusing, ask for clarification. 
This cartoon reminds us that both the receiver and the sender share responsibility for ensuring mutual understanding of the meaning of the message. Filters exist that can cause variability in the information we receive from others.  Some examples include:
physical noise
Interruptions
poor handwriting
ambiguity in the message 

vague or poor work guidance requires us to make decisions with little or no guidance for making it.  
Ever told someone something and they forgot to do it?  Ever forgotten a safety precaution or step while completing a task?  Sometimes this occurs because we were taught once – but we must remember now or it was stated earlier – and we must remember it now.  
Another problem can be found in hidden in Notes, Cautions, Warnings, Precautions within a procedure?  They generally sound like this...CAUTION-Metal banding may be sharp and could cause serious hand and finger injuries.  Wouldn’t it be a lot better to say “Put on your gloves as banding is sharp and can cut hands and fingers.”  Gloves should be the pre-requisite for handling banding not the afterthought.

TELL POWERFUL STORY HERE

Overconfidence was involved in over 70% of one company’s fatalities over a 5 year period.

Overconfidence Talk about verbal triggers

remain alert to the problem of over-confidence...even for the simplest and most routine tasks. It is most common when we work within a task that is normally predictable, reliable and safe.  “Don’t worry, I know what I am doing.”   is right behind... “Hey watch this?” as a signal your about to witness an event!
It’s definitely a potential symptom of overconfidence.  Such error traps exist because we believe that past experiences will normally repeat themselves in current circumstances. Personal signs that overconfidence are setting in are feeling smug, satisfied, invulnerable, and not worrying about the possibility of something going wrong. 
How many of you have heard the word “complacency” used in a similar context?  How do you feel when someone says you are complacent? 
Complacent means: Contented to a fault; self-satisfied and unconcerned - Overconfident means: Overly certain, excessive confidence in oneself; assured success
As you can see complacent implies an emotional state; content, satisfied and unconcerned.   Overconfidence is an observable product of the routine, repetitive, habitual (e.g. being in the skill-based mode) or past success such that one takes a short-cut, misapplies a rule or procedure (e.g. rule-based mode) or doesn’t know what he/she doesn’t know. 
Complacency is subjective and tends to imply that one doesn’t care about the task at hand. High-performers can be overconfident but not complacent.  There is a difference. 

employees new to a job are twelve times more likely to suffer a total recordable injury than their peers who are experienced in the task or job.  
Clearly, the fact that employees new to the job just don’t know what they don’t know creates an error trap that can become a maze of traps when the situation is compounded by stress, time pressure, poor or vague communication...you get the picture.

Distractions split the mind – working with half a brain.
Cell phone use when driving is the equivalent of  .11 BAC

Distractions occur when we are overly involved in demands from outside factors that interfere with our ability to complete this task and this time. 
As humans we all need suffer physical and mental distractions that may interfere with our work.   
What are some of the distractions you’ve experienced when trying to complete at task at home?  
What about those you’ve observed at work?

Excessive overtime is a known precursor to human error. The Alcoa Foundation and Yale studies have shown injury rates for 16 consecutive work hours are 4x higher than injury rates for initial 8 consecutive hours. 
In addition, a significant increase (27%) in recordable injury risk exists for working more than 64 hours in seven days. As a result, companies moved to limit overtime to 16 hours in a day and 64 hours in a week.  
These steps are consistent with many other industries or professions.  As you probably know, truck drivers, pilots and flight attendants all have caps on hours of work.  Recently, there have also been several studies that link the performance of nurses (error rates) to fatigue and excessive hours. The most recent published work indicates an 85% increase in error rate due to fatigue.
When we know we are working in the more risky hours of the shift for example hours 13 to 16 or the last hour of the shift we need to be more alert for error traps and watching out for others who may be in a similar circumstance.  Finally, we should try to recognize error traps related to personal state or condition in ourselves and others so we can avoid them.

The final error trap occurs when we return to work following four (4) or more consecutive days away from the job.  
How many of you have found yourself less that at your best following a long holiday week end or a weeks vacation?  Why is that?
Gotten out of the routine (skill-based mode which is normally safer).
May be fatigued having driven all night to get home to go to work-bad planning and scheduling.
High workload at home and perhaps at work-yard needs mowed, bills to pay, another member ...

## Time Pressure, Stress & High Workload

**All feel the same to us**
- Feels like frustration
- Muscles tighten
- Deep breathing
- Multiple minor errors
- Sweating
**We cannot distinguish between them**

## Poor Communications, Vague Guidance, First Time or Infrequent task or Overconfidence

**All put the person in Knowledge–Based (KB) mode**
**Poor communications** (Verbal) – The part of the communication left out is the part the receiver is in KB mode on and the quality of communication is the primary responsibility of the sender
**Vague Guidance** (Written) – The parts that are vague or missing keep the user in KB mode
**First Time / Infrequent Task** – The parts of the task that they have never done or don’t remember are KB mode
**Overconfidence **– Shrouds our ability to see when we enter KB mode

## Distractions, >4 Days off, End of or Extended Shift

**Distractions – Split the shared resources the brain needs – its like working with half a brain!**
**>4 days off – Our brains disengage and we need time to re-engage**
**End of shift or extended shift – Fatigue or distractions become additional problems**

## Heaven Can Wait!