Root Cause Analysis for Safety Culture and Performance Improvement

Facilitator: Dr. William Corcoran

Description:

This full-day workshop will present a plain English approach based on ordinary logic and modern quality principles. Participants will leave able to apply the learning in their next day at work.

Safety Culture and Performance Improvement material will be consistent with recent INPO and NRC practices.

Participants will have the option to bring their own investigation reports to work in the group. They can be redacted reports from their own organization or reports downloaded from the internet.

We will be using a spectacular video from the U.S. Chemical Safety Board as a case study.

All materials will be provided electronically by e-mail. After you register notify the instructor by e-mail at firebird.one@alum.mit.edu so you can be sent the materials in advance of the conference

Change Management and Organizational Alignment Working Session

Focus Area: TBA

Facilitator: Gilmore Crosby

Time: Monday A.M. Session

Description:

Participants will apply industry specific and universal change management theory and methods to an analysis of their own organizational human performance initiatives. They will devise strategies based on their analysis. In addition, they will be invited to assess and devise strategies towards maximizing the ongoing effectiveness of their role within the organization.

Human Error Root Cause Analysis

Facilitator: Dr. Tyrone S. Tonkinson

Time: Monday A.M. Session

Description:

Are you experiencing repeat events? Want to learn how to get the most learning from active human errors? This workshop is designed for the intermediate or advanced level Root Cause Analysis practitioner. Several techniques will be explored specifically designed for probing events involving human error. The workshop will include a workbook, interview sheets, explanation of techniques, review of case-studies, and practical exercises. The seminar is based on over 25 years of experience and thousands of investigations, and will include review of:
• Human nature
• What motivates workers (why they do what they do)
• Understanding the relationship between reinforcement and behavior
• Behavior-based corrective actions
• Report writing

A Risk-Based Approach to Managing Human Performance

Facilitator: Tony Muschara

Time: Monday P.M. Session

Description:

Objectives:
1. Defining and managing human error risk during work
2. Clarifying the purpose of a human performance risk management process
3. Developing a risk-based human performance management strategy
4. Integrating human performance into operations instead of developing a human performance program
5. Reducing error at critical steps and risk-important actions using the Work Execution Process – a systems approach to managing risk in human performance
6. Managing defenses using failure modes and effects analysis (FMEA) and the error-management hierarchy (eliminate, prevent, catch, detect, and mitigate) to develop controls and barriers
7. Improving the strength of safety culture through a mindful preoccupation with failure—chronic sense of uneasiness
8. Defining management’s role in reducing drift and accumulation
9. Creating a change management plan for integrating a risk-based approach to human performance into current operations.

This course prepares supervisors and managers to develop an approach to human performance that is integrated into current operations without necessarily developing a full-blown program. The approach identifies risk-important human touchpoints with sensitive equipment, products, services, and other assets that must be controlled to ensure safety and reliability. Critical steps and risk-important actions and how they are controlled will be discussed. The course will conclude with a description of management’s role in optimizing the real safety margin in human performance, especially in establishing a strong safety culture by creating a mindful preoccupation with failure. Finally, the course provides insights on how to rollout critical steps to an organization with no previous experience with critical steps.

Practical Applications of High Reliability

Facilitator: Dr. Richard S. Hartley

Time: Monday P.M. Session

Description:

Dr. Richard Hartley, who developed the HRO Guide (http://bookstore.gpo.gov/collections/hrho.jsp), along with Gary Pool and Kim Leffew, will provide this 4 hour professional development seminar on applying High Reliability. The seminar provides a quick introduction to the 4 HRO Practices but focuses on HRO Practice #2 “Reduce System Variability.” To do this, a logical framework focused on breaking the chain between the threat (human error) and the plant hazard to avoid a consequential event is presented. The framework is called Break-the-Chain (BTC) Framework and consist of 6 simple to remember and implement steps. This is not a theoretical class but, a hands-on experience that gets the audience engaged in steps to make any operation highly reliable. The class will be guided through the application of the BTC framework then will be provided a worksheet that they can take back to their organization to try in their workplace. Attendees can send the worksheet to the instructors for feedback and improvement.

NOTE: You can receive 0.4 CEU credits for the 4 hour HRO seminar through West Texas A&M University. The cost of the university administrative fee is $10 with checks made payable to West Texas A&M University.