Pre-Conference Courses
All courses presented on Monday, June 18th, 2012
Integrated Approach to Trending
Facilitator: Alex Torres, Washington, Contractor Assurance, River Protection Solutions, LLC
Time: Monday All Day (Starts @ 8 AM)
Description:
As a continuance to the 2009 HPRCT "Integrated Approach to Trending" and 2011 "The Cause and Effect Relationship with Cause Trending" presentations the Trending Analysis Course will provide hands on training on trending analysis methods using actual data from corrective action and observation databases. The training will include the following topics and practical exercises:- • Trending expectation for problem resolution as defined by NRC, INPO, and DOE
- • Application of trend and cause codes
- • Data gathering techniques
- • Use of data sources such as Corrective Action Program (events/problems/causes), Observation Program, NRC identified issues/findings/violations, contamination logs, and injury reports, DOE occurrence report, DOE surveillance Findings, and PAAA Noncompliance Tracking reports.
- • Cross-Cutting and Cross-Organizational analysis
- • Observation trending
- • Use of Pareto Charts
- • Use of descriptive statistics
- • Control Charts and Performance Indicator trending
- • Trend code evaluations
- • Cause code evaluation
- • Significance/risk based trend analysis
- • Integrated analysis techniques
- • Trending in support of common cause evaluations
- • Trend results communication
Local Rationality - A Systematic and Systemic Approach to Understanding the Causes of Human Failures
Facilitator: Tony Muschara, President, Muschara Error Management Consulting, LLC
Time: Monday All Day (Starts @ 8 AM)
Description:
People do things that make sense to them at the time. Otherwise, they don't do them. That is the
essence of local rationality. But, organizations continue to struggle with the systematic identification
and resolution of the causes of human performance events. Many cause analysts do not fundamentally
understand the systemic nature of human performance, which is characterized by recurring
explanations of failure with failure, such as "failure to follow procedure" or "inattention to detail." This
course provides a set of principles and methods that augment traditional cause analysis techniques. This one-day course will give the attendee a systematic and systemic approach to better understand why an
individual "did" what he/she did, instead of focusing on what the person "did not" do. It is very difficult
to understand why someone did not do something. By understanding why someone did what he/she
did, the analyst can more reliably and consistently identify the systemic and organizational factors that
led to an event. This course has four segments:
• Origins of Human Performance Events
• Local Rationality
• Human Performance Technology
• Culpability Assessment
Enhancing Organizational Performance Through Human Risk Management
Facilitator: John Schaeffer, Williams Industrial Services Group, LLC
Time: Monday All Day (Starts @ 8 AM)
Description:
We can't solve problems by using the same kind of thinking we used when we created them. Albert Einstein- Tired of a large number of human errors?
- Do you know why they are occurring?
- Is your investigation rate stable and near zero? It should be!
- Does your organization have procedure adherence problems? The solution will surprise you!
- Does your organization have hidden compliance problems? Are you sure?
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In this Seminar, You will learn a methodology that has been successfully used to solve organizational problems in multiple, sophisticated industries. Although the average approaches commonly used are intended to provide solutions, we will explore why they are actually part of the problem. You will be provided proven solutions for each organizational level. We will focus on utilizing performance metrics and typical Quality Assurance processes such as QA investigations, document control, and auditing as vehicles to implement solutions.
The Presentation will cover:
- Impact of organizational culture on performance and compliance
- Framework for optimal performance and compliance
- Why common QA corrective actions are really common mistakes
- How to identify corrective actions that will impact performance
- How to set employees up for success
- Techniques that front line workers can use to be successful
- Common procedure usage problems along with proven solutions
- Executive and regulatory paradigms that inadvertently cause negative
performance - How commonly used metrics drive poor performance and increase risk
- How to prevent success from causing future failure
- Participants will perform case studies to enhance apply the methodology to real life events!
Who will benefit from attending?
- Senior leadership
- Supervisors and managers
- Front line workers
- Ideally, all organizational levels should attend because every level has a role in the solution.
Past results from implementation of the methodology:
- 60% to 95% greater reduction in total site event rates from year to year
- 50% to 75% reduction in human error related events
- 60% to 80% reduction in SOP related events
- Reduced significant safety related events from fifty/year to zero within 12 months.
An Alternative to Root Cause Analysis
Facilitator: Bob Nelms, President, Failsafe Network, Inc.
Time: Monday All Day (Starts @ 8 AM)
Description:
Morning: "Theory"
IntroductionsWhat is Latent Cause Analysis? Note: it is not what you think.
Latent Cause Analysis (LCA) is an endeavor whose goal is to "change people." It uses "things that go wrong" as an opportunity for the involved people to answer "what is it about the way I am that contributed to this event, and what am I going to do about it." LCA addresses personal accountability head-on, without resorting to blame and punishment, by requiring them to look into a mirror instead of blaming other people and things.
A Strategy for Inculcating a "Latent Cause Mentality" within an Organization
Things that go wrong are the only phenomena of life capable of prying us out of the grooves of our faulty thinking, as long as we are willing to look at ourselves instead of pointing our fingers at other people and things. A strategy will be presented that taps into the fact that things go wrong at all levels of an organization – small, medium, and large things.
Afternoon: "Application"
The Essentials of the Latent Cause Analysis Method- • An absolute dependence on the 3 PS of evidence (People, Physical, and Paper)
- • The necessity making sure the involved people are confronted with the evidence
- • Ending the inquiry by insisting that the involved people answer: "What is it about the way I am that contributed to this incident, and what am I going to do about it?"
Applying the Essentials to a Low-Consequence Event: A Role Play
Summary and Sharing