# Presentation: 486655

##  BNL Lessons Learned (LL) Workshop “Raising the Bar”

**Presented by Ed Sierra**
**Laboratory Lessons Learned Coordinator**
**May 15, 2007**
**Quality Management Office**

## Agenda

**Point to Ponder**
**Purpose**
**LL Program History at BNL**
**Program Effectiveness **
**Tips for Writing LL Documents**
**Lessons Published 4****th**** Qtr FY 06**
**Customer Feedback**
**LL Infrastructure**
**Path Forward**
**A safety LL**
**  **

## Why this Workshop?

**To prompt feedback, evaluate, and improve BNL’s Lessons Learned Program**

## 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

## BNL Lessons Learned (LL) Program The History 	

**Nov. 1998:  ****	****Issue & Decision Paper approved**
**Feb. 1999: ****	****Full-time Lab LLC hired**
**Mar. 1999:  ****	****Initial Program Elements Finalized**
**Mar. 2000:  ****	****SBMS Components Finalized**
**Jan. 2001:  ****	****Lab LLC, Part-time position**
**Mar. 2001:  ****	****LL Incentive Program**
**July 2005:  ****	****Web-based LL Document **
**June 2006:  ****	****Free LL Subscription to all!**
**April 2007:  ****	****Initiation of LL Workshops**

## 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**
** **
**activity**
**to work safer**
**more efficiently**
**or with higher quality.  **
**In short, a ****change in behavior**** occurs.**

## Effectiveness

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

## Why Document Lessons Learned?

**“****Those who cannot remember the past are condemned to repeat it.” **
**                                  ****- George Santayana** ** (1863 – 1952) **

## Tips for Writing a LL 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. **

## 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.**

## Lessons Published 2nd Qtr FY 07

**Characterize Legacy Issues in Your Spaces**
**Round Sling Inspection** **  **
**Knowledgeable Personnel Should Not Be Substituted for Procedures**
**Non-NRTL Listed Power Strips Pose Shock and Fire Hazard**
**Evaluate Hazards When Introducing New Equipment**
**Painter's Spackling Knife Contacts Abandoned Live Wiring ****(BNL)**
**-----------------------------Pending Final Review--------------------------------------**
**Don’t Let Your Guard Down When Preparing Facilities for D&D ****(BNL)**
**Safe Handling of Failed (Open Circuit State) Capacitor ****(BNL)**
**Electrical Multi-Tap Power Boxes found with Defective Bus-bar Rivets and Loose Bus-bar Screws ****(BNL)**** ****      **

## LL Feedback Prompt!

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

## 1st Qtr FY 07 LL Feedback

## 1st Qtr FY 07 LL Feedback

## Slide 15

## A Sampling of BNL LL 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 **
**Will adopt at Magnet Division.  Revise Subject Area.**
**I have incorporated this Lesson Learned into a Work Instruction for removing combustible materials from the HFBR (Building 750). This work will be performed under Work Permit #D&D-WP317-001 and is very fitting for the job. Thanks**
**I try to get the big picture from lessons learned and incorporate any ideas, knowledge, and improvements into my work/life.  ** ** **
**I'm trapped here. Every time I launch my web browser I get this feedback page **
** **

## LL Infrastructure

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

## Slide 18

## Slide 19

## Slide 20

## Color blocks help identify work flow status

## CAT Electronic Entries

**03/13 – SM, Smoldering debris near Cooling Tower #4 by B912A, SCBNL**
**03/14 – SM, Right index finger injury at Production Services**
**03/15 – SM, Violation of BGRR RAD Admin Control**
**03/15 – SM, Plumber Injures Tooth, SCBNL**
**03/19 – MD, B-197 evacuation due to fire alarm, SCBNL**
**03/21 – MD, Unidentified substance at Chemistry Building determined to be harmless**
**03/22 – MD, Fire Alarm (false alarm) at Building 479 Central Fabrication Services**
**03/22 – MD, Minor finger laceration at Central Fabrication**
**03/28 – AL, Radiological Continuous Air Monitor alarm triggered by a cell phone**  ** **
**04/05 – KK, Warehouse Employee Injures Back **
**04/11 – PB, Instrumentation & Calibration Facility Operational Safety Limit Exceeded**
**04/13 – PB, Legacy grenade with no active explosive component located**
**04/15 – PB, Firefighter fractures foot while physical training, SC3**
**04/16 – KK, 1⁄2 gal oil spill from air compressor at STAR**
**04/17 – KK, Rad Worker Receives Splinter in Radiological Area**
**04/26 – RK, F-18 finger contamination at PET**
**05/01 – AP, Contamination in HFBR fuel vault**
**05/02 – AP, Minor brush fire in Front of building 911**
**05/03 – AP, Minor fire in ventilation system at NSLS**
** **
** **
-  **   **
-  ** **
**  **

## CAT Electronic Entries

**05/05 – AP, Cigarette butt results in smoldering mulch bed near B-735**
**05/09 – SM, Impairment of Water Supply to Bldgs 815 and 817**
**05/10 – SM, Power Supplies for Booster to AGS trip**
**05/10 – SM, Discovery of Disconnected O2 Sensor in B535 during Lab Calibration Audit** **         **
** **
** **
-  **   **
-  ** **
**  **

## Path ForwardSeeking Best in Class!

**Auto deliver LL during work planning**
**Implement SBMS functionality enabling integration of Lessons Learned with Work Planning & Control**
**Initiate bi-annual LL Coordinators workshop to prompt feedback, evaluate, and improve BNL’s LL Program**
**What else can we do to be the best!**

## Lesson to Ponder

- 	**Myth:****  You can’t make significant changes until you get buy-in from everybody.**
**	****In fact, the wait for buy-in can be interminable because leaders fail to acknowledge the truth that behavior precedes belief.  In other words, the cycle of organizational improvement is not “vision, buy-in, and action” but rather “vision, action, buy-in, and more action.”  The buy-in does not occur until employees first see the results of their actions.     ****	****	****	****	****	****  **
**                                                                           ****- Dr. Douglas B. Reeves**
**	****	****	****	****	****                       “****The Learning Leader” 2006**

## Heaven Can Wait!