Learning from events - experience with an electronic tool supporting the report of events, evaluation, analysis, and the corrective action program

Transcription

1 1 Learning from events - experience with an electronic tool supporting the report of events, evaluation, analysis, and the corrective action program Hans Maimer IEEEHPRCT101 Belziger Str Berlin, Germany Tel./Fax Hans.Maimer@SOL-VE.ch

2 2 Learning from events - experience with an electronic tool supporting the report of events, evaluation, analysis, and the corrective action program 1. Background 2. Concept of SOL-VE OEM 3. Functionality 4. Implementation and Evaluation

3 (0) Background

4 The model of structural aspects of organizational learning shows the central role of a comprehensive data base and a feedback system to relevant groups. 4 Wahlström, B., et al., LearnSafe. Learning organisations for nuclear safety, Otamedia Oy, Espoo (2005).

5 (0) Concept of SOL-VE OEM

6 6 Concept of SOL-VE OEM An effective event administration and processing tool should cover a standardized registration of all types of events (collection of experience), a specific work flow system for the different event types (processing, analysis, reports, decisions) and the administration of corrective actions including the pendency control and evaluation of implemented actions. The developed event and corrective action administration system covers different event types, e.g. reportable and nonreportable events, near misses, audits, external events. For all working steps of event and corrective action handling (administration, analysis, reporting, approval) working groups or responsible persons can be assigned and authorized.

7 7 After registration and classification of an event the event processing serves the working on events within the event administration system. The administration of corrective actions serves adjusting, processing, following up and evaluating of measures.

8 (0) Functionality

9 The event types taken into consideration can be extended on organizational demand e.g. to occupational accidents or regulatory pendencies. 9

10 10 Functionality of SOL-VE OEM Networkable Windows application It supports the cooperation between different analysts and departments. The composition of teams for tasks and partial tasks is variable and changeable. Integrated administration system for the allocation of access and user authorization (specific for each event type). A visualized workflow concept shows the processing status of all events and actions as well as the status of all subtasks depending on responsible person, project group membership or responsible department. The user is able to generate a detailed list of personal pendencies or pendencies of his department including an estimation of the necessary working hours.

11 11 Depending on the event type the various processing tasks and subtasks can be managed in specific windows. processing functions

12 12 Window for in-depth-analysis

13 13 Window for in-depth-analysis (chapter 1)

14 14 The processing tasks of corrective actions can be managed in specific windows. processing functions

15 15 Functionality of SOL-VE OEM The action tracking system is divided into the proposal/approval part integrated in the event handling and the real action tracking part of approved actions at the corrective action side. Both parts are observed regarding exceedings of time limits. Several automatic functions regarding the pendency control, the control of completed action and the evaluation of actions (e.g. visualized expiration of time limits, periodical reports and statistics, electronic mail) are implemented in the software.

16 An attendant software program supports the voluntary reporting of notifications or near misses. 16 Digital notification system (main window).

17 Digital notification system (window 1: My concern) 17

18 18 Functionality of SOL-VE OEM Only the authorized responsible recipients are able to see the incoming messages and to open it. They decide how to deal with the notifications using a standardized risk matrix. The possibilities are to put the message into the notification file (no safety relevance), to transform it into a near miss (small risk) or into an event (higher risk). The sender of a notification can follow up his contribution to organizational learning by a specific access code, up to the report, the identified corrective actions, and the status of the actions.

19 (0) Implementation and Evaluation

20 20 Implementation and Evaluation The application was developed in close cooperation with the users in nuclear power plants. Most of the functions, the automatically generated reports and statistics are designed plant specifically. The software is implemented in several nuclear power plants in Switzerland and Germany since January In two plants it is the official tool for event and corrective action administration, implemented as network version. It can be started by all employees via intranet. In some other plants it is running as a pilot application on single work places. All sensitive data including data dealing with authorization are saved in encrypted form.

21 21 Implementation and Evaluation The experiences show that the method helps in ensuring that the collected information is effective analyzed, integrated in the corrective action program, and subjected to the control of time limits and priorities. The hints for pendent tasks (yellow), for short-term tasks (orange, if the time limit is shorter than two weeks), and for expired terms (red, if the time limit is exceeded) stimulate the finishing and demonstrate the necessary resources. Further the program ensures that the feedback is distributed and easily available for all users. The common use of the method by different departments increases the cooperation of departments related to operating experience management and organizational learning.

22 22 Implementation and Evaluation To gather as much as possible material for learning, incentives like winnings for incoming notification increase the acceptance of the tool. The common access to the anonymizated data as well as to the content and status of actions for all employees of a nuclear power plant raises the commitment. It is important to see that it is not only a tool for the management but also an instrument to ensure the operating experience knowledge and the experience feedback for everybody.

23 23 Number of Notifications (one Plant, N=105) Notifications 2007 (as of August 20th) Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

24 24 Treatment of Notifications (one Plant, N=105) Treatment of notifications (2007, as of August 20th) Notification file (no safety relevance) 15 Nearmisses (NM) 70 Non reportable events (NRE) 8 Reportable events (RE) 2

25 Thank you for your kind attention 25