Value of Peer Reviews
Learning from Experience
Keith Spooner
EHSS&Q Director, Magnox Ltd
CQI NucSIG Conference
HSE Offices 19 January 2011
EHSS&Q
Peer Review
‘is a generic term for a process of self-regulation by a
profession, or a process of evaluation involving qualified
individuals within the relevant field. Peer review
methods are employed to maintain standards, improve
performance, and provide credibility’
…Wikipedia
EHSS&Q
Better …
“A smart man learns from his experience, but a wise man
learns from the experiences of others”
… old proverb
EHSS&Q
Learning from the experience of others
International
UK
WANO (INPO)
IAEA
Overseas Utilities
PBO Activities
SLCs
Supplier Organisations
Societies/Institutes
Regulators
Media driven
Other Organisations
(Bench-marking)
EHSS&Q
Industry
Other
Response to third party / own event (re-active)
• International events (major)
• UK events (major)
• Industry events (typically
major, e.g. fatality, INES 2+)
• Company events (significant,
wider learning)
EHSS&Q
 Texas City explosion
 NIMROD crash
 Work at height fatality
 Pond event
 Road Traffic Accident
Texas City - Response
• BP shared learning at Nuclear Operations Conference
• Cascaded to EHSSQ Managers Peer Group by the Texas City EHS
Manager
• CNOO Oversight Programme coincidently established
• Process Safety Indicators developed, best practice across NDA?
• WANO TSM specifically requested to review Oversight Programme
• HoP Nuclear Safety appointed
• Further learning from the Oil and Gas Industry Risk Management
and Process Safety Conference, also Chemical Industry learning
from the IChemE conference on Process Safety
EHSS&Q
NIMROD - Learning
• Safety Case
– Design ‘creep’, departure
from original design intent
– Configuration control of
modifications
– Importance and rigour of
the challenge function
– Complacency (Titanic
‘mentality’ - “NIMROD
was assumed to be safe”)
EHSS&Q
• Organisation
– Outsourcing: importance and
oversight of the Intelligent
Customer function
– Project delivery focus
– Independence of the challenge
function
– Ageing plant and systems
– Overall organisational
resilience (need to maintain
capability)
Fatality – Work at Height (Non Magnox Event)
•
•
Treated event as if it happened within our Company
MD led telecon with all site and functional lead teams
–
–
–
•
Stand-downs of sites and functions to cascade MD message
–
•
Exec out and about around sites ‘walking the talk’
Sites confirmation of compliance with existing arrangements
–
–
•
•
•
•
Not accepting leaving of any openings, albeit with barriers, as a general practice
Barriers to be secondary not primary means of defence
No tolerance of long term temporary covers
Working at height
Lone working
Independent compliance checks (Site Inspection activity)
Review and enhancement of arrangements
Response included in ‘NIMROD vulnerability programme’
Focus for future EHSS&Q reviews
EHSS&Q
Pond Event - Response
• ‘Management Centre’ established during initial event to promulgate
‘hot’ learning across the business (MxN,MxS)
• Mandatory Assessment (MA) covering key questions on material
condition, design, safety case and maintenance
• All sites undertook plant walk downs
• Improvement plans drawn up and actions placed
• Follow up by CNOOs to confirm close out of actions
• Key alarm management section now included in Conduct of Ops
Standard
EHSS&Q
RTA – Driving on Company Business
• Senior Management ‘Stand Down’
• New Standard produced – independently reviewed by Institute of
Advanced Motorists
• Emphasis on forward planning and risk assessment
• Focus now on reduction in driven miles (Phase 2 ‘enablers’)
• Targeted in EHSSQ 3 P Plan Improvement Plan
• Implementation audited across organisation
• Business now making conscious decisions not to drive
• Sharing learning with other organisations
EHSS&Q
Pro-active approach - better practice
• Audits
• Bench-marking
• Peer Reviews
• External
• Internal
EHSS&Q
o First, second, third party
o Various …
o
o
o
o
WANO Peer Review / TSMs
IAEA Peer Reviews
SLC Peer Assists
Magnox Peer Reviews /
Assists
Bench-marking
• Chevron Refinery, Pembroke by Director and HESAC
(General EHS, Process Safety)
• Olympics Construction Project by Industrial Safety Expert
Group (Construction Safety)
• RSRL, Harwell by Directors, MXN and MXS (EHS
Improvement)
• Springfields by Director and Chief Engineer (Maintenance
Schedule Management).
EHSS&Q
WANO Peer Reviews
•
•
•
•
•
•
Annual Plan of support from
WANO agreed
Includes TSMs aimed at helping
us solve specific problems
Provide peers for WANO Peer
Review and TSM programmes
across the WANO community
Participate in Seminars W/shops
on a wide range of topics
Oldbury hosted WANO HP
conference in November
PO&Cs developed by Magnox
North to enable WANO to
support sites in defuelling
phase; trialled at Chapelcross
through TSM
EHSS&Q
Wylfa
July 2011
Peer Review
Oldbury
Mar 2011
Maintenance - TSM
Oct/ Nov
2011
Plant Status &
Configuration Control
–TSM
Feb 2011
Control & Supervision TSM
Traws
WANO Peer Reviews – Key Issues Arising
Management Effectiveness – setting
and reinforcing standards in the field are
areas most commonly identified as
weaknesses. This can have an effect
on performance in all areas. Key
learning for Magnox has been:
•Development and deployment of
company wide executive sponsored
human performance programme
•Task observation & coaching
programmes being developed
•Importance of behavioural safety
observation programme
•Magnox Leadership programme
EHSS&Q
Peer reviews continue to identify
insufficient station actions to address
Significant Operating Experience Report
recommendations. This lack of action to
learn from industry experience can
contribute to recurring events in the
industry:
•All WANO SERs and SOERs are
managed through the organisation
Mandatory Assessment process. All
individual MAs are sponsored by the CNO
or EHSSQ Director. Status of MAs form
part of the CNOO oversight programme
IAEA Peer Reviews
•
•
•
•
Long standing involvement in
IAEA activities – conferences /
seminars / site visits
Magnox sought ‘first’
decommissioning peer review
Joint development of Terms of
reference for ‘International
Peer Review of
Decommissioning Programme
and Activities’
Outline programme agreed
next two years
•
Pilot at Bradwell in 2008
– Scope
– Learning
•
Magnox to support Peer Review
in 2011
– On request
•
Peer review of Magnox site in
2012
– To be confirmed
EHSS&Q
SLC Peer Assists
• Event Reporting (Magnox - other NDA SLCs)
– Approaches / inconsistencies
• Contractor Management (RSRL - NDA SLCs)
– Control and supervision
• Source Management (Magnox - NDA SLCs)
– Control and storage
• Contamination Control (Oldbury - SLCs)
– On-going (low level) issues
EHSS&Q
Magnox Peer Review / Assists
Exec-led EHSS&Q Reviews
CNO Directed Reviews/Assists (also MAs)
EHSS&Q Expert Assists
Site (Own) Reviews
Peer Checking
EHSS&Q
What value added?
•
•
•
•
•
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Has our performance been improved?
What events have we prevented?
Are we better off overall?
Is it worth it?
Should we continue it?
Could we do it better?
“Yes” to all !
EHSS&Q
Future Thoughts
• Organisational Learning (Major Events)
– Why do we all do it separately?
– Need to collaborate more; build on, not re-invent the
learning; do it once for the Industry
– Use peer reviews / assists to test / help implementation of
learning
• Audits
– What value are we getting after first assessments?
– Need to move emphasis from arrangements and process to
event follow up and effectiveness of learning
EHSS&Q