Improving Risk Reduction and Cost Effectiveness
I see from the agenda that the topic of my keynote speech is to be “Improving Risk Reduction and Cost Effectiveness”. But this is a Facility Representative meeting, so I am going to approach this topic from the standpoint of the FR’s relationship to cost effectiveness and risk reduction.
Let me first address cost effectiveness. I can address that quite simply. Cost effectiveness is no accident. No occurrence. No mistake. Errors are costly; and errors leading to accidents often disastrously so. Bhopal, Kursk, recent train collisions, all examples of accidents which could have been prevented. How would the balance sheet look if these accidents had never happened? Would the cost effectiveness have been improved? I think so. That’s the global view. Safe operation is cost-effective when compared to the alternative. This is what ISMS – the Integrated Safety Management System – proves. By living the principles put forth in ISMS contractors can do work safely – and therefore efficiently.
And what about designing and operating plants so far within the envelope that nothing bad can ever happen. Problem is, nothing good can either. Over conservatism saps resources and creates inefficiencies that are almost impossible to overcome.
But operating reasonably close to the safety envelope requires deliberate careful operations that are carried out by trained, responsible workers using appropriate procedures. Workers who, despite management’s faith in them, are closely watched, monitored, and coached. Here’s where the FR comes in.
I was around when the first facility reps were “commissioned” at SRS and I have watched the concept as it has evolved and spread throughout the complex. I can tell you that the facility representative program is still a work in progress, is continuing to evolve, and is more than ever critical to the success of the Department. The facility reps have been at the forefront of revolutionary changes in the relationship between DOE and its contractors.
In general, before the creation of the facility reps, let’s call it BFR for short, contractor operations were very much a black box. DOE and its predecessors really knew only what the contractors told them regarding day-to-day operations in the plant. Denied accurate knowledge of root causes of seemingly minor incidents, the government was not able to foresee trends that were omens of major incidents. Installation of the facility reps in plant provided the government with a trained set of eyes that served to provide an independent and critical view of activities in the plant. This presence not only had the effect of providing direct insight, but also encouraged the contractor to be more forthright in reporting activities and incidents. Trends can now be observed and analyzed, and the risk of a major incident reduced. Perhaps the presence of a fully competent and independent observer could have prevented the tragedy at the HCN facility at Bhopal, India, or the loss of the Kursk, or any of the numerous accidents we read about. Quite often degradation in systems – and I include human performance as a system – is so gradual that those closest do not notice the change until it is to late. A trained independent observer is more likely to recognize and call to the attention of the operators performance trending away from the ideal. It is essential that this presence be continued and in some cases strengthened if we are to continue to build the kind of safety record we must have. I say must have because it is our safety record that most affects the public attitude toward DOE and its operations. Without public trust we will never be able to carry out our programs- programs that are vital to national defense, protect and restore the environment, and keep our neighbors safe from harm
In 1962 Admiral Rickover sent a letter to his NR Representatives in the field. His purpose in writing this letter was to reinforce and reiterate his expectations for their performance. In closing the Admiral stated that “To achieve the status of a true NR representative requires the acquisition of God-like qualities; but you can try”. It is my belief that the presence of a fully competent and effective FR in a facility is the most effective agent for risk reduction that the government can have.
So we must continue. I think it may be well to review some of the God-like qualities necessary for a successful Facility Rep and for the FR program.
First and foremost you must be trained to competency in your facilities, their processes, authorization basis, and the fundamental sciences and academic disciplines underlying all of these. This is both a tall order and a never-ending process. Yet without this, you will not be able to speak with the confidence and authority to be effective in your work. With it you will earn, albeit sometimes grudgingly, the respect of the contractor people you work with on a daily basis. You will earn also the trust of your own management, trust that will gain their support and understanding, as you become more God-like in driving change. So train, study, learn; remain current in the technologies and documentation for your facilities.
Understand the facility’s history; be aware loss of corporate knowledge can lead to disaster. Loss of corporate knowledge can occur over a relatively short period. Some years ago a serious accident occurred at Hanford when an ion-exchange column exploded, seriously contaminating one worker. Investigation showed that the column had been loaded with americium just prior to what turned out to be an extended strike by plant workers. By the time the workers returned the column had dried out. The fact that the column had been loaded had been forgotten during the strike. Because its loaded condition was forgotten, the column had not been properly maintained, and the accident occurred.
Trust your training. Don’t fall into the trap of believing an action must be proper simply because it was performed by an experienced operator with confidence. If it seems wrong, it probably is wrong. Question it.
Be confident in what you know, and aware of what you don’t know. Never be afraid to ask for help from subject matter experts when needed. You can not, however God-like you may be, be expected to know everything. But you are expected to know when to ask!
Knowledge is, in fact, power, and the first of our God-like qualities.
Knowledge alone will not carry the day without your physical presence in the facility. This, I know, is becoming increasingly difficult as demands on your time grow and grow. Without your physical presence, though, you will be forced to rely on contractor reports to assess the health of your facility. You can not be effective if you must rely on contractor reports to tell you what is wrong. Now, don’t get me wrong here- you absolutely want the contractor to identify and correct their own problems. The operative opinion however, is yours. So I encourage you to fight like dogs for your time in the facility. Push back when competing tasks are thrown your way. Remember (and remind others) of your primary reason for being. If you are not there you can not see the step missed, the valve closed in error, the safeties wired down. You are powerless to influence the course of events. Physical presence is most certainly a God-like quality, and perhaps the most difficult to attain, but it is essential.
The third of our God-like qualities is thoroughness. See, hear everything. When observing an operator at the controls do not become so engrossed that you miss a critical conversation or act nearby. Observe with understanding of the actions involved. Know what results are expected and what is “normal”. Observe actions and reactions. If you see an action or condition that is dangerous do not hesitate to call it to the contractor’s attention. Immediately. Would a careful, uninvolved observer have provided the eye at the periscope that could have prevented USS Greenville from colliding with the Japanese fishing vessel? Would an observer not feeling pressure to launch have observed and recognized the implications of the degradation of the o-ring seals on the solid rocket boosters that ultimately led to loss of Challenger? We will never know, but the prospect is certainly intriguing, isn’t it?
Never accept unsatisfactory conditions just because “it’s always been like that”. The drip from a torpedo may lead to loss of the ship. The “broken” gauge may be telling the truth. Do not fail to observe and question the substandard.
Be thorough and rigorous in your follow-up. Was the runaway reaction a known phenomena or was it new and unexpected? Is research being done? Was the failure mode known or does it require further analysis to set limits and expectations? Has the contractor assigned proper scientific expertise to the problem? Do they have a plan? Remember the red-oil explosion a few years ago at the Russian processing plant at a place called Tomsk? Well, several similar explosions had occurred previously both in the U.S. and abroad. But until Tomsk research after each event was fairly specific to the event and did not fully explore all possible conditions, which could lead to the accident. It was not thorough. Research after Tomsk, performed by experts at several sites according to a detailed plan, has been more complete than ever before, and all will benefit from it.
Next on our list, and I say our list by the way, because your managers, supervisors, and critics are likely to have ideas of their own, is communicate. Remember that this is a two way street. You must hear and analyze what others say while conveying to them your issues, ideas, and thoughts.
Report everything. You will, I think, find that your management will draw the line to separate the wheat from the chaff. Until they do, though, report everything. Communicate with the contractor. Give him them benefit of your observations. Ensure they understand your concerns and the basis for them. Your opinions are essential to their operation of the facility and they should be grateful for them.
Another and important aspect of communication is sharing. Share your experience on a timely basis with other facility reps at your site, and with your peers at other sites. Observe the contractor to see that they also are sharing experiences in timely fashion with other shifts and with other plants. If they are not then you must drive them to do so. See that they are actively seeking information on and benefiting from experiences at other sites. A leading theory on the cause of Scorpion’s loss is that a faulty torpedo caused a fire and explosion. Such torpedo failures had been noted in the past, yet there is no evidence Scorpion had been informed. Would sharing have helped?
Communicate with your DOE peers in programs, planning, support, and engineering. They have important information about activities, plans, schedules, issues and so forth that you may need to carry out your job. They need your observations to factor into their planning and their analysis of the contractor’s performance.
Good communication is a definite God-like quality.
In achieving your status of holder of all God-like qualities, you must remember your place and function. You are there to be a critical observer of the contractor’s performance. You are not there to pick on the contractor, or to nit-pick the performance of their operators. Understanding this is a major distinction between the savvy facility rep and all of the others.
You are not there to be an advocate for the contractor. They can speak for themselves, and often you may find that their actions speak louder than words.
It is not your role to defend the contractor to your management, and to do so is a fatal sin in the field of God-like qualities.
You are not there to substitute your judgement for your superiors. You are rather there to provide your superiors with the information they need to make an informed judgement of their own.
Unless you have been specifically directed to do so, do not interpret directions from your superiors to the contractor. If such a situation occurs, refer the contractor to the appropriate organizational contact. God-like though you may be, you may not know all the issues considered when the direction is issued.
Guard against becoming too “chummy”, as Admiral Rickover put it, with the contractor. Maintain a respectful arm-length relationship. You are looking for their respect, not their friendship.
Maintaining your proper place is the last of our God-like qualities.
So to Re-Cap:
· train to and maintain the competencies necessary to your job;
· maximize your time in the facilities;
· be thorough;
· communicate to gain and give critical information; and,
· maintain your proper place as a full status facility rep replete with all necessary God-like qualities.
I challenge you to embrace these qualities as you go about your duties. Never forget that you are the Department’s eyes and ears. You are on the front lines, in the trenches, on the watchtower, the final line of defense in the Department’s efforts to conduct safe and efficient operations. You are indeed the vanguard of risk reduction.
What about a more narrow issue. The cost effectiveness of the FR Program. Well ladies and gentlemen, that’s easy. Simply achieve full attainment of the God-like qualities and you will be at your most effective.