Personnel Accountability Policy (Rev 3)

Transcription

1 Personnel Accountability Policy (Rev 3) Purpose This policy provides guidance on the issue of personnel accountability at DCPP as it relates to Human Performance Events or Issues. The appropriate performance management tools for bargaining unit and management employees should be consulted when implementing this policy, as applicable. Introduction In the complex environment of a nuclear power plant, human performance errors and mistakes are inevitable. It has been proven in many industries that these events can be reduced by minimizing contributing factors. In that light, it is essential that we review human performance events at a lower level and apply corrective actions in order to prevent more significant occurrences. It is essential that a consistent accountability policy be applied both horizontally and vertically throughout the organization. Similarly, accountability should not merely address the individual directly involved with the performance, but should also be applied to those indirectly involved - those responsible for items such as oversight, planning, process design, performance standards, etc. One of the core traits in our continued success is the ability to honestly recognize and aggressively learn from our errors and mistakes. In order to truly become a learning organization, we must create an environment where the reporting of human performance events is encouraged and individual consequences, both positive and negative, are aligned with individual performance. Accountability3.doc Page 1 of 11 1/23/2001

2 Definitions The following definitions may help in understanding this policy. Accountable: Answering for one s own conduct and obligations, meeting commitments, doing what you say you re going to do. Accountability: Responding in a consistent manner to personal actions or conduct related to behaviors that are known to contribute to human performance errors and mistakes. It is intended to positively reinforce desired behaviors and provide strong motivation for the modification of negative behaviors. Blameless Error: An error in which there was no willful intent to cause the undesired outcome, use unauthorized substances, or violate procedures. A similarly qualified individual in the same situation could have made the same mistake. See the attached Culpability Evaluation Tool (p. 5). Consequences: A result or reaction that logically follows individual performance. Some examples are rewards, recognition, coaching, counseling, or disciplinary action. Once again, consequences are arranged to positively reinforce desired behaviors and provide strong motivation for the modification of negative behaviors. Human Error: An occasion in which a planned sequence of mental or physical activities fails to achieve its intended outcome, and when this failure cannot be attributed to chance. Intentional Act: Intentional behavior in conflict with standards and policies, causing an event through possible malicious intent or gross neglect. Mistake: A failure of the processes involved in the selection of an objective, or in the specification of the means to achieve that objective. Positive Discipline (for bargaining unit employees) and Total Performance Management (for management and A&T employees) are formal programs designed to: provide employees the opportunity to correct deficient performance and build committment to expected performance. Accountability3.doc Page 2 of 11 1/23/2001

3 Responsibilities Directors, managers, and supervisors are encouraged to provide positive recognition for employees and groups whose performance exemplifies accountability. Face-to-face recognition, reward programs, and positive contact slips are effective and should be used to maintain and support exemplary performance. The appropriate use of these methods will help to minimize human error and maximize DCPP performance. Managers should develop examples and non-examples of accountability within the context of the type of work accomplished within the section. These section-specific examples should provide a clear image of the manager s expectations regarding accountability and allow employees to refine their personal definitions of expected performance. In addition, it is management s expectation that all employees will exert positive peer pressure, reinforcing good work and operating practices and bringing them to the attention of their supervisors. Reporting errors and mistakes It is the responsibility of all employees involved in or having knowledge of a human error or mistake to: promptly report the event cooperate in any resulting investigation, and provide input to assist in determining corrective actions. Once aware of an error or mistake, the individual or supervisor shall ensure proper notification and reporting is accomplished, using OM7.ID1, Problem Identification and Resolution-Action Requests. Event Trend Records should be used to document less significant events that do not require Action Requests. Accountability3.doc Page 3 of 11 1/23/2001

4 Investigating events and determining accountability An investigation commensurate with the significance of the event will be performed prior to applying consequences for an event involving human error or mistake to ensure that accountability is accurately established. The Culpability Evaluation Tool (p. 5) should be used as an aid during the investigation. This does not preclude management from making changes in the immediate work assignment of individuals involved during the course of an investigation. Because management and supervisory personnel are accountable for their work group actions, this investigation should include management and supervisory methods. Every effort will be made to include all involved parties in the investigation. A Shop Steward should be included if desired by bargaining unit employees. For situations involving blameless errors where there is no history of unsafe acts, disciplinary action will not be implemented. The results of the investigation should be documented in the same manner as a coaching and counseling session. For other situations, consequences should be arranged to reinforce desired performance and take full advantage of lessons learned. Disciplinary actions may be considered as an option if warranted. Disciplinary actions will be considered if the investigation determines that any of the following has occurred: The event involved an intentional act. The event was caused by malicious intent, gross neglect, or repetitive inattentiveness to duty. The inappropriate action resulted in a threat to personnel or public safety. Any individual intentionally did not report a significant event. Any individual lied or withheld information regarding the event. Any individual knowingly circumvented a procedural requirement. Accountability3.doc Page 4 of 11 1/23/2001

5 Culpability Evaluation Tool Introduction This tool is intended primarily for the use of supervisors as an aid to determine the culpability level of an individual in response to events or near misses caused by human error. When used in conjunction with the DCPP Accountability Policy, this tool will assist the organization in applying equitable and consistent consequences across all departments and work groups. This tool does not replace current, approved policy documents or practices (Positive Discipline Guidelines, Total Performance Management Process, etc.). Instead, the intent is that it be used within the framework of these existing practices. A common understanding of the blameless error (p. 2) concept is essential in ensuring consistent application of this tool. Applicability This tool becomes applicable when a Human Performance event or issue reaches the threshold for an Action Request to be generated. What does culpability mean? Culpability is a rather archaic term most commonly associated with the legal ramifications of being guilty or meriting condemnation or blame. For our purposes, culpable is a weaker form of guilty, used to connote some malfeasance or error of ignorance, omission, or negligence. Another way to look at it may be that the degree of culpability is roughly equivalent to the amount of personal responsibility one would expect to accept for an act (behavior). This should not detract from the fact that we are all personally responsible for each of our actions. There are sometimes mitigating circumstances or factors that should be understood to ensure that just actions are taken in response to human error. Accountability3.doc Page 5 of 11 1/23/2001

6 Why a tool like this? Accountability is a double-edged sword. On the one side we have the discipline aspect. The other includes the performance improvement aspect. In the long run, performance improvement is the name of the game. As performance improves, fewer and fewer errors will be committed. This in turn reduces the frequency and severity of adverse consequences (known as events). Consistent accountability is sometimes difficult to sustain. Although it sometimes escapes us, the organization is responsible for ensuring a just culture exists if workers are expected to take personal responsibility for their actions. Responsible adults, more often than not, demand equitable accountability and will respond favorably as long as the rules, process and consequences are clearly understood up front. How to use the flowchart (p. 11) The following sections provide some general guidance on the thought process to be used during an evaluation of an error. It is intended that the supervisor and employee work through the flowchart together while striving for consensus on each of the decision points. If a disagreement occurs, the great benefit of this process is that there will be a dialog during which each side will listen the other s point of view. A Shop Steward should be included if desired by bargaining unit employees. In most accidents or events there are likely to be a number of different unsafe acts, or errors. It is intended that the flowchart be applied separately to each one of them. The supervisor and employee should agree on the specific error being evaluated. It is important to accurately define each error before trying to apply this aid. If you try to evaluate a problem like, Worker A removed the wrong valve from the system without breaking it down into smaller discrete errors, you most likely will miss something. There are many errors that could lead to an event like the one above and each one must be evaluated on its own merits. During the evaluation, more errors may be discovered that require additional attention. Also, during the evaluation it is important to understand the type of error (rule, skill or knowledge-based) you are dealing with. This will help you determine what types of corrective measures are required. During the evaluation, you must establish the conditions the worker was under at the time of the error. Real time, real place, etc. Avoid hindsight, however difficult it may be. Accountability3.doc Page 6 of 11 1/23/2001

7 Is there an FFD issue? Fitness For Duty (FFD) issues can include substance use, fatigue, mental or emotional stress, etc. Be sure to consult appropriate procedures as required. For the purposes of this evaluation, we follow the FFD program procedures and process as required. First line supervisors are expected to understand the FFD program requirements and their responsibilities for the program. Several resources are available to supervisors to assist them when evaluating FFD issues; 1. FFD Program supervisor (Bill Ryan) x 3329; on call 24 hours a daycontact Security Watch Commander x 3330; 2. Your human resources advisor; 3. EAP program counselor; 4. peers, and 5. management. Were the actions intended? Initially the key question relates to intention. If both the actions and consequences were intended, we are out of the error realm and into the arena of intentional acts. These acts are possibly sabotage, malevolent damage, willful violation, etc. If the actions were not as intended (I meant to push Button A, but somehow pushed Button B ), then we are probably dealing with a mental slip or lapse. These generally are skill-based errors. Were the consequences as intended? If the actions were as intended, but the consequences were not, then the error was most likely a mistake or violation (not willful). These are rule and knowledge-based errors. If the answer to this question is NO, then proceed to the next section. If YES, you are probably not dealing with an error at all (intentional act) and should consult your management. Were reasonable expectations knowingly violated? Reasonable expectations consist of guidance communicated through procedures, policies, work practices, verbally, or just plain common sense. Once again, it is necessary to establish the intent of the individual being evaluated. If it is established that the individual was aware of the expectations, but consciously elected not to conform to those expectations, then the answer would be YES. If the answer is YES, proceed to the next section. If NO, proceed to the substitution test section. (p. 9) Intent will come into play later. Accountability3.doc Page 7 of 11 1/23/2001

8 Were reasonable expectations available, workable, etc. The availability, workability, and accuracy of reasonable expectations is an important concept. Once again, this must be evaluated from the perspective of the immediate user. Gaining an understanding of the worker s perception on this matter is important. If it is established that the reasonable expectations were readily available, workable, intelligible and correct, then the answer would be YES. If it is established or suspected that non-compliance has become more or less automatic (as happens in the case of routine short-cuts) you should question the accuracy of the expectations. Violations generally involve a conscious decision on the part of the individual to bend or break the rules. However, while the actions are deliberate, the potential bad consequences are not, in contrast to sabotage, etc. If in establishing the intent (or motive) of the violation it can be argued that the individual was attempting to achieve the proper desired outcome but the situation at hand rendered the expectations unsuitable, then the answer will most likely be NO to this question. If the answer to this question is YES, then there was a possible reckless violation. If the answer was NO or cannot be established, then the error or violation may have been system induced. System induced violation? If it is determined that the violation may have been system induced, proceed to the substitution test section. You must also consider another error or violation at this point. The expectation to stop and seek additional guidance in situations like these (unworkable procedures) is generally understood by all workers at DCPP. Failure to adhere to this and other expectations of this nature should be evaluated as separate acts. Accountability3.doc Page 8 of 11 1/23/2001

9 Substitution test This is probably the most critical, and difficult evaluation to conduct. To evaluate this question we need to perform the following mental test. Substitute the individual concerned with someone else coming from the same domain of activity, possessing comparable qualifications and experience. Then ask the following question, In the light of how events unfolded and were perceived by those involved in real time, is it likely that this new individual would have behaved any differently? If the answer is probably not, then apportioning blame has no material role to play other than possibly to obscure potential systemic deficiencies and blame one of the victims. One method of conducting the substitution test is to ask the individual s peers, Given the circumstances that prevailed at the time, could you be sure that you would not have committed the same or similar unsafe act (error). If the answer again is probably not, then blame is inappropriate. The answer to the substitution test is YES. If the answer to the substitution test is YES, then the error is most likely blameless and you should proceed to the section addressing whether or not the individual has a history of unsafe acts (p. 10). If the substitution test is not passed, proceed along the NO path and evaluate the next section. Deficiencies in training, selection or experience? If it is established that there were no deficiencies in the individual s training, selection or experience, then a possible negligent error must be considered. In other words, should this task have been assigned to this person in the first place? If there are questions about the person s training, qualification or selection for the task, then there is a good likelihood that the unsafe act was a largely system induced error. Accountability3.doc Page 9 of 11 1/23/2001

10 History of unsafe acts? People vary widely and consistently in their liability to everyday slips and lapses. Some individuals are considerably more absentminded than others. For the purpose of determining a history, one would only consider the documented events involving this individual in the previous six months. If the person in question has a history of unsafe acts or errors, it does not necessarily bear upon the culpability of the error committed on this particular occasion. However it probably indicates the necessity for corrective training or other intervention to reinforce desired performance and take full advantage of lessons learned. Absentmindedness has nothing to do with ability or intelligence, but it is not a particularly helpful trait in a nuclear worker. Someone who continually commits errors along these lines would obviously require some individual assistance in overcoming these tendencies. The emphasis here is on improving this individual s performance in their current position or considering other career options that they may be more suited to. Discipline should not be an automatic response. It should only be implemented after carefully considering all options, and in response to a specific problem. Summary It is not desirable to default to the blameless error mode continually. Even though many experts claim a great majority of unsafe acts in high tech environments fall in this category since the system or organization induces most of the errors, there are strong arguments in favor of disciplining the few who commit egregious unsafe acts. In most organizations, the people in the front line know very well who the cowboys and habitual rule benders are. Seeing them get away with it on a daily basis does little for morale or the credibility of the disciplinary process. Fair and consistent application of an accountability model serves to reinforce where the boundaries of acceptable behavior lie. Accountability3.doc Page 10 of 11 1/23/2001

11 Culpability Evaluation Flowchart Were the actions as intended? Knowingly violating reasonable expectations? Pass substitution test? History of unsafe acts? Were the consequences as intended? Were reasonable expectations available, workable, intelligible and correct? Deficiencies in training & selection or experience? Intentional Act (t an Error) te: If a "Fitness for Duty" issue arises during the evaluation, consult the OM14 series procedures for additional guidance. Possible reckless violation System induced violation Diminishing culpability Possible negligent error System induced error Corrective training or other intervention may be warranted Blameless error Accountability3.doc Page 11 of 11 1/23/2001