NAVSEA Industrial Activity Safety Summit
May 11 – 13, 2010
Meeting Minutes
Purpose:
To improve safety across the NAVSEA Industrial Activities and drive safety
hazards and mishaps to “As Low as Reasonably Achievable.”
Location:
Washington, DC
Date:
May 11 – 13, 2010.
Enclosures:
(1) Meeting Agenda
(2) Attendance Roster
(3) Bibliography
Action Items:
1. Publish Meeting Minutes and a Plan of Action and Milestones for the NAVSEA
Industrial Activity Safety Summit. Action: SEA 04R (Mr. Brice). Due: May21, 2010.
2. Add Supervisors of Shipbuilding, Conversion, and Repair to the Trouble Report
distribution list. Action: SEA 04XQ (Mr. Mieszczanski). Due: May 21, 2010.
3. Contact the Naval Safety Center to discuss NAVSEA’s intention to complete a Trouble
Report and a critique for a fatality in advance of the SIR. Action: SEA 00L (Ms.
Zivnuska). Due: June 30, 2010.
4. Contact the fleet concerning how NAVSEA can provide input to the JFFM. Action: SEA
04RS (CDR Gelker). Due June 30, 2010.
5. Contact the fleet and the Naval Safety Center concerning addressing ship’s force unsafe
practices not related to ship availability. Action: SEA 04RS (CDR Gelker). Due June
30, 2010.
Key Points
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
The Nuclear Navy’s Industrial Principles permeated the remarks of Troy Mueller (NAVSEA
08R): rising standards of excellence, technical self-sufficiency, facing facts, training, total
responsibility, and capacity to learn from experience.
A keystone principle of the Naval Reactors safety management approach is to “work hard on
small problems today so that you don’t have to deal with big problems later.”
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NAVSEA Industrial Activity Safety Summit
May 11 – 13, 2010
Meeting Minutes
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An underlying theme of many mishaps was that the people involved had either lost or never
acquired the ability to “see” correctly, that is, to proactively identify deficiencies and
precursors of mishaps, to address them, and to reduce the likelihood of mishaps occurring.
The “safety” triangle and hierarchy of problems (number and severity) model the experience
of accident investigators that most incidents and serious problems do not strike like a “bolt
from the blue,” completely unexpected and hard to anticipate. On the contrary, [major
problems or disasters] are typically preceded by a [large] number of [smaller] problems …
that an organization has been tolerating for some time.
By identifying, reducing and aggressively investigating 3rd order deficiencies, organizations
“put pressure” on the triangle and push more problems lower (or prevent them in the first
place) and build a broad population of questioning attitudes and awareness of deficiencies
that will ultimately reduce the likelihood of 1st order incidents.
Working hard on the small problems today through persistent questioning to determine why
things did not go as planned enables members of the organization to remain vigilant and
“see” the deficiencies that exist (Karl Weick calls this “preoccupation with failure” and
“mindfulness”).
[We need] two shifts in mindset: (1) going beyond the minimal requirements of the
regulation (similar to VPP), and (2) to be really serious about something, it has to be
personal, you have to have something meaningful to you at stake.
High Risk Work Permits [used by Naval Reactors at their facilities] … [require] both a
worker and his manager [to sign] that the high-risk work is warranted, that the formal work
procedure has been engineered to provide necessary hazard mitigation to protect workers,
that the workers are adequately trained, that the workers will be briefed before performing
the high-risk work, and that arrangements have been made to provide field surveillance
during the high-risk work.
The High Risk Work Permit forces everyone concerned with the work to acknowledge that
they cannot think of a better way of doing this work (guaranteed to make engineers
uncomfortable), a very important source of “cognitive dissonance” that was a key to
changing their approach
A key lesson learned from the High-Risk Work Permit initiative is to spend more time on
getting organizational buy-in for the approach as opposed to implementing them by … the
“shock and awe” approach… people would have spent less time resisting the changes if they
had understood what [NR] was trying to accomplish earlier.
If achieving minimum requirements only is the accepted practice, then normal variability
around the mean due to human performance factors will result in a 50% failure rate (i.e., the
minimum standard is not achieved 50% of the time). As a result, a higher standard of
excellence must be set to achieve a margin to minimum requirements.
DuPont Route to ZERO (Injuries) model … has four levels, depicted as a progression that
characterize the kinds of thinking that lead to improved safety performance. Level 1 is
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NAVSEA Industrial Activity Safety Summit
May 11 – 13, 2010
Meeting Minutes

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Reactive – Survival Of The Fittest. Level 4 is Interdependent – We Are Responsible For the
Safety Of Each Other (what the Navy calls “watch team back up”).
VADM McCOy: “a problem well-defined is half-solved.”
A shipyard can have accident-free days and go right to a pinnacle event because managers
do not fully understand how the work is being accomplished.
it [is] a mistake to focus on process first. Focus on people, their training, and their capability
to do the work first. People who do not think with good engineering discipline write bad self
assessments
The group determined to assign four working groups, one from each shipyard to address one
of the four high-risk areas, to address risk management and worker commitment to safety:
1.
2.
3.
4.
PNSY (Code 950 2730/270), Electrical Safety.
NNSY (Code 970 980/710), Fall Protection.
PSNS&IMF (Code 920/250), Confined Space Entry.
PHNSY&IMF (Code 960 2350/260), Energy Control/Lock Out – Tag Out
(LOTO).
Meeting Minutes
Discussion Topics:
Tuesday, May 11, 2010

Welcome and Opening Remarks (RADM Campbell). RADM Joseph Campbell, Deputy
Commander, Logistics, Maintenance and Industrial Operations (SEA 04), opened the Safety
Summit by welcoming the participants and reviewing his expectations for the meeting. He
discussed his Four S guiding principles with the group – Service, Safety, Success, and
Satisfaction. Service is why we exist (to provide Fleet Readiness), Safety is foremost and
essential to mission success, Success equates to meeting cost, schedule, and quality
standards, and Satisfaction is the cornerstone of employee morale and motivation. RADM
Campbell challenged the group to improve safety dramatically in the Navy’s ship repair and
maintenance business. RADM Campbell participated in the Summit through noon, and
attended the out brief on Thursday morning.

Opening Presentation (Mr. Brice). Mr. James Brice, Assistant Deputy Commander for
Maintenance, Modernization, Environment/Safety (SEA 04R), opened the Safety Summit by
presenting the meeting objectives and deliverables and a review of current safety
performance in the Navy’s ship repair and maintenance business (i.e., Naval Shipyards,
Regional Maintenance Centers, and Supervisors of Shipbuilding, Conversion, and Repair).
He reviewed three recent, serious safety mishaps (fatality at NNSY from an engineer falling
off a roof, the electrocution of a Navy Chief on CVN 76, and an arc flash caused by a Pearl
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NAVSEA Industrial Activity Safety Summit
May 11 – 13, 2010
Meeting Minutes
Harbor electrician that violated electrical safety rules with a non-approved tool working in
the battery well of the USS CHEYENNE). He described Navy leadership concerns in the
wake of these mishaps. Navy leadership concluded that the ship repair and maintenance
business must (1) adopt a risk-based approach to safety by focusing on reducing hazards and
the potential for serious injuries; (2) find and fix safety problems instead of them finding us;
(3) take on a long-range vision of zero injuries; and (4) embrace and adopt proven Navy
safety models (e.g., Nuclear Safety, Radiological Safety, and Crane Safety). He reviewed the
Safety Pyramid (focusing and following up on lower level issues before they lead to bigger
problems) and the As Low As Reasonably Achievable (ALARA) approaches to risk
management. Given that two unrelated fatalities have recently occurred in the Navy’s ship
repair and maintenance business, NAVSEA currently is defining its pinnacle safety event
(i.e., the event that could shut down or seriously impact the business) as a single mishap
involving multiple fatalities. The objective is to push the top of the pyramid (the pinnacle
events) “down” over time by improving standards of work and safety performance so that the
pinnacle event begins a transition to a single fatality, then a serious injury, then a minor
injury, or As Low As Reasonably Achievable. He reviewed DuPont’s Route to Zero model
for human behavior related to accidents and safety, which essentially posits that
organizations become more safe and efficient when they transition from reactive approaches
to safety (only taking actions after an accident) to interdependence among workers, work
teams, and management such that an organization’s safety performance is a matter of pride
for its workforce. Mr Brice also reviewed what he called the Voluntary Protection Program
(VPP)+ concept, taking what is already working with the VPP currently embraced by many
NAVSEA activities and taking some specific steps to improve the relationship between
increased safety, quality performance, and increased worker productivity and efficiency. He
concluded by reviewing the detailed agenda for the Safety Summit and reviewing NAVSEA
leaders’ expectations for the meeting. Refer to Enclosure (1), Meeting Agenda for details.
Mr. Brice challenged attendees to develop creative ways to achieve a culture change and get
everyone’s commitment to safety. Refer to Enclosure (2), Attendance Roster.

Safety Principles (Mr. Mueller). Mr. Troy Mueller, Naval Reactors (SEA 08R), explained the
safety principles employed by SEA 08 to manage safety in the five joint DON/DOE facilities
supporting the U.S. Naval Nuclear Propulsion Program (i.e., Knolls, Kesselring, Bettis, etc.).
[Soule note: the Nuclear Navy’s Industrial Principles permeate these remarks. Briefly, they
are: rising standards of excellence, technical self-sufficiency, facing facts, training, total
responsibility, and capacity to learn from experience. For more information, see enclosure
(4)] A keystone principle of the Naval Reactors safety management approach is “to work
hard on small problems today so that you don’t have to deal with big problems later.” Mr.
Mueller’s experience is also informed through participating in a number of mishap
investigations, including collisions and groundings of submarines and mishandling of nuclear
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May 11 – 13, 2010
Meeting Minutes
weapons. An underlying theme to these mishaps was that the people involved had either lost
or never acquired the ability to “see” correctly, that is, to proactively identify deficiencies
and precursors of mishaps, to address them, and to reduce the likelihood of mishaps
occurring. By way of setting context, Mr. Mueller reviewed how SEA 08 uses the safety
pyramid in the nuclear propulsion radiological exposure controls (Figure 1. Safety Pyramid).
Overexposure to radiation is what the Radiological Controls group at Naval Reactors defines
as their pinnacle event. The Safety Pyramid is subdivided by three horizontal lines parallel to
the base of the triangle. Level 1 problems, what NAVSEA 08 calls “incidents” are in the top
section of the triangle with Levels 2 through 4 below that. Naval Reactors requires that Level
1 problems get reported to the Director Of Navy Nuclear Power in writing. These reports get
a lot of review and will, by the nature of the interaction with Naval Reactors before and after
they are sent, require the engagement of an organization’s senior leadership to understand the
problems and be accountable for corrective action (thus driving future improvement because
of their engagement with the details). SEA 08 has defined 17 items that constitute a
prioritized list of Level 1 incidents, with overexposure being number one. SEA 08 has
modified the criteria for incidents over time as organizations have improved to ensure the
standard is consistently improving. This approach to improving the standard minimizes the
tendency for organizations to become complacent about their performance and ensures there
is a steady flow of problems for organizations to work. Level 2 problems are near misses
(i.e., nearly incidents) that should be prosecuted by an organization the same way they would
a Level 1 problem without the requirement to send a report to NAVSEA. Mr. Mueller
characterized near misses as “gifts” because they provide the organization an opportunity to
learn from them without causing any damage or injuries. The facilities define what
constitutes a near miss. The facilities conduct critiques or appropriate level of fact finding on
all Level 1 and 2 items. Level 3 and 4 deficiencies are deviations from standards that did not
cause a significant event to occur. However, a trend in or series of lower level deficiencies
can constitute a near miss and should be evaluated for a critique to learn lessons to arrest the
trend. The triangle and hierarchy of problems (number and severity) model the experience of
accident investigators that most incidents and serious problems do not strike like a “bolt from
the blue,” completely unexpected and hard to anticipate. On the contrary, 1st order problems
are typically preceded by a number of 2nd order problems and an even larger number of 3rd
order problems that an organization has been tolerating for some time. In almost every case
of an organizational accident like the loss of a Space Shuttle, the organization was tolerating
and not correcting many 3rd order deficiencies. By identifying, reducing and aggressively
investigating 3rd order deficiencies, organizations “put pressure” on the triangle and push
more problems lower (or prevent them in the first place) and build a broad population of
questioning attitudes and awareness of deficiencies that will ultimately reduce the likelihood
of 1st order incidents. In this way, organizations can look closely at how they accomplish
work and attempt to design processes to make second and first order problems exceedingly
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May 11 – 13, 2010
Meeting Minutes
Severity
unlikely. The standard of performance is the
same every day. Over time, there may be some
variance in the number of critiques and
problems experienced, but this tends to flatten
(depicted as a sine wave in Figure 1) when these
concepts are consistently practiced. This
proactive approach of working hard on the small
problems today through persistent questioning
to determine why things did not go as planned
enables members of the organization to remain
vigilant and “see” the deficiencies that exist
Number of Uncorrected Deficiencies
(Karl Weick calls this “preoccupation with
failure”). This proactive approach also is a form
Figure 1. Safety Pyramid
of continuous improvement (i.e., number of
occurrences and severity of incidents, problems, and deficiencies shrinks). Everyone can
share in Troy Mueller’s philosophy that “I reserve the right to be smarter tomorrow than I am
today.” [Soule – this means one should continually try to improve one’s knowledge and learn
from experience/others to be better tomorrow than today.] For more information on these
High Reliability Organization practices, consult “Managing the Unexpected,” Weick and
Sutcliff, “Managing the Risks of Organizational Accidents,” Reason, and “Managing
Maintenance Error,” Reason and Hobbs.
Level 1
Level 2
Level 3

Lessons Learned (Mr. Mueller). Mr. Mueller reviewed lessons learned from SEA 08’s
experience with Environment, Safety, and Health (ESH) oversight of the joint DON/DOE
facilities. In the facilities, ESH inspections are combined with Radiological Control
(RADCON) inspections since Mr. Mueller is responsible for both. Mr. Mueller discussed the
differences between ESH and RADCON standards. In either case, the worker is exposed to
hazards; the objective is to keep the worker safe and never take unnecessary risk. Safety has
overtaken RADCON in terms of his current focus. SEA 08 conducted a safety summit of the
DOE facilities and accomplished two objectives: (1) Definition of pinnacle event (i.e., What
kind of problem could occur for which you would turn your badge (i.e., resign)?). (2)
Definition of 1st order incident reporting criteria (i.e., fatality, injuries, near misses) for safety
problems. The facilities set the pinnacle event to multiple fatalities initially, then
subsequently changed the pinnacle event to a single fatality. The facilities identified 17 types
of incidents requiring a critique. Prior to implementing this proactive approach, the facilities
reported 10 to 15 incident reports a year. After adopting the new standards, each site issued
15 incident reports in two months, with many incidents identified by government
representatives at the sites instead of the organization identifying them on their own.
Underlying this approach are two shifts in mindset: (1) going beyond the minimal
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NAVSEA Industrial Activity Safety Summit
May 11 – 13, 2010
Meeting Minutes
requirements of the regulation (similar to VPP), and (2) to be really serious about something,
it has to be personal, you have to have something meaningful to you (like your job) at stake.
to improve your performance.

High Risk Work Permits (Mr. Mueller). Mr. Mueller discussed the High Risk Work Permit
recently introduced at SEA08 facilities. SEA 08 and the DON/DOE facilities defined what
constituted high-risk work and a permitting process to perform high-risk work. Prior to
implementing a High Risk Work Permit, many facilities managers were unaware of high-risk
work being conducted in their facilities on a weekly basis. Appropriate engineering
involvement was also absent in the High Risk work. The High Risk Work Permit corrected
this condition by requiring both a worker and his manager’s signature authorization to
perform the work. In signing the permit, the two affirm that the high-risk work is warranted,
that the formal work procedure has been engineered to provide necessary hazard mitigation
to protect workers, that the workers are adequately trained, that the workers will be briefed
before performing the high-risk work, and that arrangements have been made to provide field
surveillance during the high-risk work. The High Risk Work Permit also requires the
engineer preparing the work procedure, the engineer’s supervisor, the safety organization,
and the manager responsible for performing the high-risk work to sign a statement
concurring with the work procedures developed to perform the high-risk work, including the
hazard mitigation strategy to perform the work safely. The High Risk Work Permit includes
a job briefing sign-off sheet for the workers performing the work. In essence, the High Risk
Work Permit forces everyone concerned with the work to acknowledge that they cannot think
of a better way of doing this work (guaranteed to make engineers uncomfortable). The
process challenges the engineers and their managers to engineer the hazards out of high risk
work to the maximum extent practicable (Soule – engineers hate to have to say that they
cannot think of a better way to engineer work, a very important source of “cognitive
dissonance” that was a key to changing their approach). In the first year of implementation,
the facilities issued lots of High-Risk Work Permits. After three years, the facilities now
issue one-tenth of the number previously issued. The managers changed their mindset to
approaching the work and now engineer the work more safety and efficiently. Improved
safety leads to improved worker efficiency and morale. A member of the audience asked for
the return on investment from implementing improved engineering controls. Mr. Weishar
(Naval Reactors) related an example of a facility installing scaffolding around a component.
The scaffolding eliminated the need for the workers to wear fall protection equipment and
required less time and fewer workers to complete the job (i.e., better planning and execution,
improved efficiency). The return on investment also comes through the number of manyears saved from reduction of injuries and days away from work and the expenses associated
with processing medical claims. Mr. Mueller said that a key lesson learned from the HighRisk Work Permit initiative is to spend more time on getting organizational buy-in for the
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May 11 – 13, 2010
Meeting Minutes
Mean
Excellence
Margin to
Failure
Standards
approach as opposed to implementing them by
management fiat (what he called the “shock and
awe” approach). He believes that people would
have spent less time resisting the changes if they
had understood what he was trying to
accomplish earlier.
Minimum
Requirements

As Low As Reasonably Achievable (Mr.
Mueller). Mr. Mueller elaborated on the
ALARA concept. In radiological protection, a
key objective is to keep the risk to workers of
People
cancer from radiation to a level lower than risks
Figure 2. Margin to Failure
encountered in everyday life (like driving a car
or smoking). Workers generally accept the risk out of a patriotic duty they feel from service
to their country. There is a benefit to our country from workers accepting this risk. SEA 08
has an unwritten contract with the workers to not expose them to unnecessary radiation.
Unnecessary, wasted exposure is unacceptable. The correlation to safety is the concept of
wasted risk. Mr. Mueller encouraged the group to look at safety risk differently than they
have in the past (“it’s a cost of doing business), and to attack it differently. He encouraged
the group to work on lower-level problems as a means of preventing higher-level incidents
from occurring (Figure 1. Safety Pyramid). In the wake of the recent NNSY fatality, SEA 08
looked at safety during its most recently scheduled audit. SEA 08 auditors saw lots of safety
risk at NNSY. As one example of wasted risk, six workers (with equipment) were found to
be working on light-duty scaffolding, rated for only three workers. Another example was a
lack of painted walkways with no place to walk. Dodging fork trucks driven by operators
talking on cell phones (as Mr. Mueller had to do) is wasted risk. Wasted risk equals
unnecessary risk. A key question is, “What are the best criteria for ALARA in safety?” The
group addressed this question over the course of the summit meeting.

Minimum Requirements Mentality (Mr. Mueller). Mr. Mueller addressed the need to exceed
minimum requirements in safety so as to create a margin for failure to compensate for human
performance factors (Figure 2. Margin to Failure). If achieving minimum requirements only
is the accepted practice, then normal variability around the mean due to human performance
factors will result in a 50% failure rate (i.e., the minimum standard is not achieved 50% of
the time). As a result, a higher standard of excellence must be set to achieve a margin to
minimum requirements. Another outcome of achieving minimum requirements only is
rework (Figure 3. Rework). A higher standard of excellence must be set to achieve peak
efficiency of workers and to minimize rework. However, a point can be reached when
worker efficiency begins to drop as a result of investing in more controls than are necessary.
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May 11 – 13, 2010
Meeting Minutes
Excellence
Efficiency
Minimum Requirements
Mr. Mueller said he does not believe the
Mean of
Investing
Workers
in more
shipyards currently have enough
controls
than
engineering controls in place for the work
necessary
they do. He said that systemic issues line
up like switches in a circuit to close and
create a failure even in the most unlikely
Rework
situations. The last switch is the easiest
issue to find and address. He questioned
why the shipyards spend so much time
critiquing the last switch. He cautioned
against blaming the worker for the failure.
Standards
The value of the critique is identifying the
Figure 3. Rework
preceding switches that should also be
worked. He reiterated his sense that the shipyards do not have enough controls (actions that
tend to keep switches “open”) in place (i.e., engineering controls). Mr. Mueller also
expressed concern about implementing 17 1st order criteria at the same time since people may
find the problems they identify overwhelming, given the likely population in each criterion.
He recommended gradually increasing the standards associated with the criteria; otherwise, it
could create a shock to the system. He recommended spending more time teaching people
how to see the problems in front of them every day.

Route to Zero (Mr. Mueller). Mr. Mueller discussed the DuPont Route to ZERO (Injuries)
model. The model has four levels, depicted as a progression that characterize the kinds of
thinking that lead to improved safety performance. Level 1 is Reactive – Survival Of The
Fittest. Level 2 is Dependent – My Supervisor Is Responsible For My Safety. This level
relies on fear and discipline. Level 3 is Independent – I Am Responsible For My Safety.
This level aims to train the workers to be responsible for their own safety [Soule – this
should be familiar to anyone involved in the Navy Nuclear Power Program]. Level 4 is
Interdependent – We Are Responsible For the Safety Of Each Other (what the Navy calls
“watch team back up”). Each of these levels is present in the Navy ship repair and
maintenance business, with the mean behavior probably resting on Level 2 (Dependent). The
group noted that critiques often blame the worker for the failure. An objective is to create a
culture of openness, with no fear of reprisal for bringing up uncomfortable, but accurate,
information in critques and fact finding meetings. In “Managing the Risks of Organizational
Failure,” James Reason identified four sub-cultures necessary to support a Safety Culture: a
Reporting Culture, a Just Culture, a Flexible Culture, and a Learning Culture. Mr. Mueller
discussed the concept of a Just Culture. A just culture protects people’s honest mistakes
from being seen as culpable. The goal is interdependence, or actively caring for the people
around you. The group discussed whether the Route to ZERO model is a series progression
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May 11 – 13, 2010
Meeting Minutes
(does an organization have to pass through each of the stages?). DuPont might say it is a
progression because DuPont passed through each progression in developing the model.
However, because industry learned DuPont’s lessons, it may be possible to work on
achieving Interdependence without going through all of the progressions [Soule – this seems
terribly naïve. Workers are not just going to “get it” because you explain something well to
them or show them a fancy diagram. They have to internalize new ways of thinking and
behaviors so it would seem very unrealistic to think an organization could be composed of
some advanced form of human that could skip stages in this developmental process for their
thinking.]. Mr. Mueller recommended cultivating openness of workers in critiques. He
talked about the pilot project SEA08 has undertaken with conducting worker-led critiques,
with assistance from a facilitator, followed by a management summary meeting. This
approach would empower the workforce to own the problems identified. Mr. Mueller also
recommended cultivating a Reporting Culture. There is value in writing down problems and
reporting them, both personally and organizationally. Problems that are written down are
more likely to be fixed. Mr. Mueller recommended several books to the group that present
insights discussed herein. Refer to Enclosure (3), Bibliography.

NAVSEA Leadership Perspective (VADM McCoy). VADM Kevin McCoy, Commander,
Naval Sea Systems Command (SEA 00), gave the group his perspective on improving safety
performance in the Navy’s ship repair and maintenance business. He said that he is very
concerned about safety performance. Current performance is unsatisfactory, with two
fatalities occurring in the past year. The investigation of the first fatality at Norfolk Naval
Shipyard indicated that managers do not understand what is happening on the deck plates.
The investigation of the second fatality in USS RONALD REAGAN (CVN 76) indicated
neglect on the part of shipyard workers to prevent the fatality of a Sailor. The Voluntary
Protection Program has focused lots of attention on small things to reduce injury rates, yet
the corporation has experienced two pinnacle events in a brief time frame. VPP principles
have not penetrated the culture or they may be insufficiently understood and practiced.
NAVSEA leadership will accept some number of strains and sprains, but industrial activities
must prevent pinnacle events. The investigation of the arc flash mishap in USS CHEYENNE
(SSN 773) documented that the worker received a job briefing before starting the job. This
fact raises the question, “What was in the job briefing?” The chain of events leading to more
serious incidents is happening every day. By luck, a switch is open, thereby preventing a
life-altering event from occurring. Lower-level indicators in safety are not being monitored
to prevent the more serious incidents. VADM McCoy asked the group to take extra time to
define the problems they see well. He believes that a problem well-defined is half-solved.
He asked the group to consider a series of questions: What is the problem? Have we become
safety-blind because of the risks we are routinely accepting? How are we really going to
manage risk? What messages are we sending? How is life going to be different after this
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Meeting Minutes
meeting? High risk events need to be identified and managed. Managers must know how
the work is being done. The group discussed various aspects of the problem, in both the
public- and private sector shipyards. He agreed that the Program Executive Officers (PEOs)
are not looking at safety. He agreed that the RMCs have been neglected. However, VADM
McCoy questioned whether the problem has been properly defined. He noted that a shipyard
can have accident-free days and go right to a pinnacle event because managers do not fully
understand how the work is being accomplished. There are two at-risk groups in the
workforce – the least experienced workers and the most experienced workers. He advised
the group to pick a reasonable number of things to work on, figure out what to do differently,
and go and do. He said that we are flying blind because we don’t track the precursors to
pinnacle events. He suggested that we do not know what the problem is because we do not
have the knowledge base.

Mainstreaming Safety (Mr. Brice). After lunch, Mr. Brice reviewed key points from the
morning’s discussions:
1. It is personal – compared to RADCON, have a long way to go
2. Leaders set the example – need a communication plan
3. Learn how to see – ownership aspect
4. Define the problem – what is the problem?
5. Meter out how to work on this – need to focus on the critical few, but end state is VPP+
6. Understand how work is done – how is work really being executed, cited AIM disconnect
7. Visibility of levels
8. Higher standards versus minimum requirements
9. Adequate resources
10. Reach the contractors
11. Creacte a culture of openness
12. Ship’s force interface must be considered (they are not maintenance experts)
13. Margin to the pinnacle event
14. Interdependence (Route to Zero)
Mr. Brice reviewed feedback received from the industrial activities in response to NAVSEA
data calls. He presented the findings from the investigation of the fatality in USS RONALD
REAGAN as a series of switches which lined up and resulted in the fatality [Soule – While
the “switch theory” approach to understanding accident causality is instructive, it tends to be
misleading because it is contaminated by the brilliance of hindsight – after the accident,
having studied it in near infinite detail, it appears “obvious” what the errors were and
observers are left wondering, “How could they have been so stupid?” In most cases, the
parties involved were doing the best they could consistent with their training with the
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Meeting Minutes
knowledge they had at the time]. Studying
Safety
injuries is not the answer. It is better to
Quality
Engineering
understand the switches that are closed. He
reviewed four conclusions: (1) need more of a
risk based approach focused on reducing
hazards and potential for serious injuries; (2)
need to find and fix safety problems instead of
Worker
Supervision
them finding us; (3) we need a long range
Training
vision of zero injuries [Soule – this is of
dubious value since human variability in
attention and other cognitive processes make it
exceedingly unlikely that everyone is always
Figure 4. Work Model
going to follow all procedures or that no
equipment will ever fail to operate as designed]; and (4) need to embrace and adopt proven
models – Nuclear Safety, Radiological Safety, Crane Safety, DuPont Route to Zero, High
Reliability Organization theory, etc. Mr. Brice reviewed the Route to ZERO (Injuries)
progression. He asked the group to characterize the average state in the Route to Zero
progression in their organization. The group identified the public-sector shipyards as being
largely Reactive (Natural Instincts) to Dependent (Supervision). The group identified the
private sector new construction shipyards as being slightly more advanced than the publicsector shipyards (i.e., possibly Independent). They identified the private sector maintenance
shipyards as being largely Reactive (Natural Instincts). The group reviewed the elements of
the VPP+ model. The agenda for the remainder of the Safety Summit is based on working to
achieve the VPP+ end state. The group discussed the leadership role of unions. Mr. Mueller
said that the OSHE Offices (Code 106) are not viewing themselves as the regulator of safety.
He asked the question, “What does it mean for Code 300 (Operations) and Code 900
(Resources) to own safety?” He reviewed the nuclear work model, comprised of
Engineering, Supervision, and Training (Figure 4. Work Model). The group concluded that
the production departments require more safety training to be able to own safety. The
objective is to enable the production departments to engineer safety into work planning and
to ask the OSHE Office if it is sufficient. The OSHE Office will tell the production
departments what they think and walk away. Codes 105, 106, and 130 oversee production
(Figure 4. Work Model). The group endorsed the Safety Pyramid, ALARA, and Route to
ZERO concepts and the VPP+ model. Mainstreaming Safety should move everyone to the
Interdependent state.
RADCON
Production
Projects

Level 1 and 2 Safety Problems (Ms. Gochenouer). Ms. Lyrita Gochenouer, PHNSY&IMF
(Code 106) led a discussion to define criteria for Level 1 incidents and Level 2 problems,
based on work completed by PHSNY&IMF to adapt SEA 08’s 17 criteria to ship repair and
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Meeting Minutes
maintenance work following the USS CHEYENNE arc flash incident. The group agreed on
four high-risk areas (i.e., work that could immediately affect life or health): (1) Electrical
Safety, (2) Fall Protection, (3) Confined Space Entry, and (4) Energy Control. The group
agreed on the definition of Level 1 incidents as comprising events requiring Trouble Reports
(sent outside the organization). The group agreed on the definition of Level 2 incidents as
comprising events requiring a Critique (remaining inside the organization). Using the
PHNSY&IMF list, Ms. Gochenouer led the group through a discussion of Level 1 criteria in
the four high-risk areas, followed by a discussion of Level 2 criteria. The group produced a
draft list of Level 1/2 Criteria. Ms. Gochenouer noted that PHNSY has conducted 10 times
more critiques since implementing the new Level 1/2 criteria.

Trouble Report Documentation (CAPT Soule). CAPT Soule (SUPSHIP NN) reviewed what
he believes are best practices for improving the quality of Trouble Reports and Incident
Reports. The purpose of the Trouble Report or Incident Report is to share information about
an incident or problem and what an organization learned to do differently. He recommended
answering seven questions: (1) What happened? (2) Why was it significant? (3) What
principles were violated (i.e., key errors)? (4) Can I (or anyone else) use this incident for
training? (5) What corrective actions were taken? (6) If we were to do it over again, what
would we do differently? (7) Who is the point of contact (i.e., for more information
concerning the incident)? CAPT Soule recommended listing key errors in chronological
sequence, calling them out specifically in the text with a label like “Error One), and
extending the chronology as far back in time as necessary to capture appropriate corrective
actions. He recommended incorporating comments received/provided of Trouble Reports
and Incident Reports in organizational self-assessments. CAPT Soule provided several
example Trouble Reports and Incident Reports he wrote to illustrate his points. He
recommended reading a newly published book, The Checklist Manifesto: How to Get Things
Right by Atul Gawande, because it could help organizations produce checklists for writing
better Trouble/Incident Reports. Refer to Enclosure (3) Bibliography. Capt Soule provided a
suggested checklist for writing incident reports:

Summary no more than one to two paragraphs. Three to four sentences would be ideal.
Summary briefly explains

What happened

Problem clearly stated

Why significant

Key errors with a little context that ties to them to the problem
Errors are called out in the chronology with enough text to make it clear what the error was,
not merely “Error 1” (e.g., the operator failed to ..., personnel approved the procedure without




adequte experience to identify the risk, etc.).
Don't mince words about what was done wrong. Use clear, brief language (“the engineer failed”
A junior employee, not involved in the incident, can read the summary and corrective actions and
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Meeting Minutes




explain what went wrong and why. They can also explain how it applies to the work they do.
There is a brief explanation of each error, separate from the chronology, that shows how the errors
tied to fundamental practices.
There is a brief section that explains how the work would be done differently next time (this is
where the real learning is demonstrated).
Minimize use of passive voice (since it obscures who did what).
A Point of Contact is identified for follow up.
Wednesday, May 12, 2010

Case for Change (Mr. Brice). Mr. Brice opened the second day of the Safety Summit by
reviewing the Case for Change:
1.
2.
3.
4.
5.
Fatalities are unacceptable in the work we do
Need hazard focus – understand and keep “switches” open
Learn to “see”
Our attitudes need to be “It is personal”
Understand how work is actually done, not the way you imagine it should be done.
The group revisited the Mainstreaming Safety topic, discussing the leadership role of the
unions, the work model (and the shared ownership for safety by engineering and production),
worker training, safety drills, reporting culture, customer support, and the overarching need
for the right standards

USS BATAAN Incident (Mr. Pristou). Mr. Walt Pristou, Norfolk Naval Shipyard (Code 106),
briefly related news of an incident that occurred in USS BATAAN (LHD 5) the previous
day, while undergoing repair and maintenance at BAE Systems Ship Repair in Norfolk,
Virginia. Six non-BAE contractors were nearly overcome by carbon monoxide poisoning
while conducting sandblasting operations. Several of the workers were treated for carbon
monoxide poisoning in hyperbaric chambers at a Norfolk hospital. Details of the incident
were still under investigation. The group noted that except for one or more open switches,
this incident could have been the multiple fatality pinnacle event discussed the previous day.

Engineering for Reduced Risk (Mr. Brice). Mr. Brice led a discussion on engineering for
reduced risk. He reviewed the findings from the investigation of the fatality in USS
RONALD REAGAN as a series of switches again. Investigations concluding that problems
included ship’s force training and shipyard supervision and technical control were
inadequate. The crew did not understand how NSTM 300 applied. The crew did not
question doing work in an energized condition. The division prioritized maintenance
efficiency over maintenance safety. The Work Authorization Form (WAF) was not
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NAVSEA Industrial Activity Safety Summit
May 11 – 13, 2010
Meeting Minutes
adequate, in that the shipyard did not clearly specify ship’s force and shipyard
responsibilities. A shipyard electrician was the team leader, but he did not provide
supervision to ship’s force personnel because he thought it was not his place to do so. The
shipyard allowed work with no briefing and did not stop the work when a problem occurred.
In conclusion, the shipyard is the maintenance expert and must provide technical control.
Ship’s force and shipyard personnel must work to the same standards. The shipyard must
examine who performs the work and evaluate their capability to do so safely. It is not right
to assign energized work to ship’s force personnel because they have different requirements.
The group discussed how the lessons learned from the USS RONALD REAGAN fatality
apply across the board (i.e., new construction shipyards, MSMO shipyards, etc.). The group
noted that the capability of ship’s force personnel to perform maintenance may have dropped
significantly over the past ten years with the downsizing of the Ship Intermediate
Maintenance Activities. However, in the case of the USS RONALD REAGAN fatality, the
group noted that the mishap victim was nuclear-qualified and a skilled electrician. In the
case of new construction or carrier Refueling Complex Overhauls (RCOHs), the SUPSHIP,
as the Naval Supervising Authority (NSA), does not oversee ship’s force personnel or
manage the work. The SUPSHIP is not the regulator for ship’s force; the Type Commander
is. However, SUPSHIP personnel should not walk past a problem they recognize. Likewise,
the Multi-Ship, Multi-Option (MSMO) ship repair contractors utilize the WAF process. The
Port Engineer brokers availability work packages to the private-sector shipyard and to ship’s
force. The private-sector shipyard provides no oversight of ship’s force in this circumstance.
The group acknowledged that during an availability, the ship’s force does little that is not
related to the availability.

High Risk Work in Naval Reactors Field Activities (Mr. Weishar). The group returned to the
discussion of controlling high-risk work. SEA 08 developed a permitting process for highrisk work (described previously by Mr. Mueller). The proposal is that SEA 04 adopt this
practice. Mr. Tom Weishar (Naval Reactors) reviewed SEA 08’s High Risk Work Permit
process. He distributed a copy of Section 6 (High Risk Work) from the Safety Requirements
Manual (S9213-55-MAN-000/(U), ACN 1, May 2010. This chapter included the definition
of high-risk work (Article 601 – High Risk Work) and the process to authorize high-risk
work (Article 602 – Authorization to Perform High Risk Work). Focus is placed on assuring
that managers are aware of planned high-risk work and authorize it, that the workers
understand the risks before executing the work, and ultimately, that engineers develop
appropriate controls to eliminate or minimize the risk. Another element is developing
appropriate precautions in technical work documents (Article 603 – High Risk Work
Controls in Formal Work Procedures) and specifying the knowledge requirements of
engineers to write technical work documents (Article 604 – Knowledge Requirements for
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NAVSEA Industrial Activity Safety Summit
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Meeting Minutes
Preparation of Formal Work Procedures with High Risk Work Controls). The High Risk
Work Permit process has yielded a number of benefits in the five joint DON/DOE facilities
supporting the U.S. Naval Nuclear Propulsion Program. Senior managers review high risk
work for the coming week. Senior managers question why high risk work needs to be
performed (e.g., work on energized components). The process drives managers and workers
to think about the work and eliminate wasted risk. In response to questions from the group,
Mr. Weishar noted that the facilities have limited work involving diving operations. The
facilities rely on the diving program controls to assure safe diving operations. The facilities
also have limited confined space entry work (i.e., less than 12 times at a year at all five
facilities).

High Risk Work in Ship Repair and Maintenance (Mr.MacGinnis). Mr. John MacGinnis,
PNSY, led a discussion of how to apply SEA 08’s High Risk Work Permit process to the ship
repair and maintenance business. He synopsized the group’s discussion:
1. Define high risk work items:
a. SYs, RMCs, SUPSHIP Reps.
b. Start with 08 List.
c. Compare to NAVSEA / OSHA requirements.
2. Assess Current Processes:
a. WAFs, Briefs, JHAs, etc.
b. Define problems – lack of management visibility.
c. Worker knowledge and commitment.
3. Recommend HRWP or how to integrate into existing process (WAF).
4. Recommend how to improve engineered controls for safety.
5. Fall protection, electrical safety, ER, Nuclear, Non-Nuclear.
6. Timeframe: 6-month project.
Shipboard
1.
WAF
(JFFM)
SY/SF
(TUM)
a.
SY/SF
2.
Tagouts
2-valve
SY/SF/CO
3.
Elec. Safety
NSTM 300/Ch 230
4.
Haz Evol
(TS 099)
SY/SF/LTE
5.
Haz Evol (?)
SY/SF/LTE
6.
(ITPAM)
Prerequisites (PRL)
Briefings
Dry Runs
Readiness Reviews
Table tops
Mock-ups
Training
HRWP
Management Oversight
Direct Worker Participation
TWD/FWP Formal Work
Package Requirements
Testing
LTE
16
Facility
LOTO – OSH Manual
Dry Dock LOTO – MILSTD-1625
Comm Spec
EM-385-1-1
NFPA-70E
NAVSEA Industrial Activity Safety Summit
May 11 – 13, 2010
Meeting Minutes
7.
High Risk
(6010)
SY/SF/SSC
8.
Radiography
RASP)
9.
Hot Work
UIPI
CFR
Lifts
P-307
10.
Complex
11.
(JFFM)
SOS MIL
SY/SF
Figure 5. High Risk Work in Ship Repair and Maintenance
The group discussed reviewing ship’s force personnel safety requirements, especially
electrical safety requirements. Refer to Figure 5. High Risk Work in Ship Repair and
Maintenance. The group discussed the High Risk Work Permit process in relationship to the
Industrial Ship Safety Manual for Submarines, S9002-AK-CCM-010/6010 and the Ship
Safety Council. The group discussed integrating the High Risk Work Permit process with
the WAF process. Mr. Weishar said that the WAF would not accomplish the objective of the
High Risk Work Permit process. The High Risk Work Permit asks the workers, engineers,
and managers to be directly involved in planning the work and making it safer. The High
Risk Work Permit includes an evaluation and decision to do the work in a specific way and
to accept the risk. The High Risk Work Permit includes worker involvement and buy-in.
The group discussed the process for authorizing and performing energized electrical work
shipboard. In the current process, the ship’s Commanding Officer endorses accomplishing
this high-risk work, but the Shipyard Commander does not participate in the process. The
current process does not provide the second-level review asking, “Do we really have to do
the work this way?” The current process provides a framework, but management oversight
and direct worker participation may not be adequate. The group determined to form a
working group to review the matter. PNSY agreed to lead the working group. The working
group will address public-sector shipyard, ship repair and maintenance work as a starting
point. This initiative will be expanded to private sector shipyards and facility repair and
maintenance work later. The working group will determine if provisional measures should
be put in place in the interim (e.g., electrical safety or fall protection). The working group
will address changing behavior and culture. The working group will address specifying
safety precautions in technical work documents.

Risk Management and Worker Commitment to Safety (Mr. Wheeler). Mr. Ted Wheeler,
PSNS&IMF (Code 900S), led a discussion of risk management practices and worker
commitment to safety initiatives at Puget Sound Naval Shipyard. He said that PSNS&IMF is
revitalizing the Voluntary Protection Program initiative. He believes the shipyard has
advanced beyond the Dependent stage of the Route to ZERO model. Workers recognize risk
and do something about it, but the shipyard is not yet at the Interdependent stage.
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NAVSEA Industrial Activity Safety Summit
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Meeting Minutes
-
-
-
Response to Hazards and Mental Checklist. New employees receive 40 hours of
indoctrination training, which is all inclusive, and then they are assigned to a work crew.
Thereafter, they complete annual safety training through a computer-based training
course. The annual safety training addresses workplace hazards. All other safety training
is informal, conducted on the job. When do workers receive training in hazard
recognition and control? Schedule is the priority. Developing a mental safety checklist
without having the requisite knowledge and experience is problematic. PSNS&IMF has
issued work readiness instructions. Code 950 workers and supervisors are conducting a
dry run. The objective is to change the culture and encourage worker ownership for
safety. The shipyard has rules in place, but the workers are not following the rules
consistently. The work readiness instructions help workers to understand the work,
safety and quality. The work readiness instructions provide a mechanism to take off
schedule pressure (i.e., rushing to do a job). The group discussed how a supervisor of a
multi-trade work crew provides job briefings to other trades. Supervisors ask workers to
identify safety requirements and encourage interactive dialog. Also, supervisors
understand the work packages well enough from experience to supervisor multi-trade
crews.
Operational Risk Management. PSNS&IMF has developed an Operational Risk
Management Process Card. The worker must ask and answer three questions: (1) What’s
going to hurt me (or those around me)? (2) What am I going to do about it? (3) If I can’t
do anything, who do I tell? The worker writes concerns on the reverse side of the card
and notifies the supervisor. The card forces the supervisor and employee to interact.
PSNS&IMF is rolling out a High Hazard Checklist. PSNS&IMF is capturing Level 3
data in the Quality Performance System (QPS). The shipyard has added appropriate
codes to QPS for tracking and trending. Prior to the recent SEA 08 audit, supervisors had
to identify and report fall protection hazards (or other kinds of hazards) every day for a
week.
Active Participation in Safety Critiques. PSNS&IMF is training critique chairpersons to
include safety in all of the critiques.
Horizontal Enforcement of Safety Requirements. What makes a worker challenge a coworker to wear PPE? Workers do not challenge co-workers because there is no
consequence for failing to do it. There should a consequence for not confronting a coworker about unsafe behavior. Does a twenty year old employee confront a fifty-five
year old employee about unsafe behavior? PSNS&IMF is exploring ways to improve
horizontal enforcement of safety requirements. PSNS&IMF has also undertaken
initiatives to improve Personal Protective Equipment options and worker comfort while
wearing PPE. The group commented that lack of comfort is not the reason workers do
not wear PPE.
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NAVSEA Industrial Activity Safety Summit
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Meeting Minutes
-
-
Behavior-Based Safety. Why do workers tolerate unsafe behavior in the workplace? It
has to do with, “Let’s get it done!” Managers place the priority on schedule, along with
cost and quality. What are the consequences of unsafe behavior? PSNS&IMF is
exploring ways to improve safe behavior.
Safety Observer. PSNS&IMF is exploring ways to utilize employee safety observers.
The unions do not want employees reporting on other employees, leading to disciplinary
action. Shops and codes need to accept the role of safety observer. Can the safety
observer role be filled by Code 106 as part of the regulator role?
Problems
Ideas:
1. Workers not recognize hazards:
1. Improve training – OSHA 10 hr / 30 hr:
a. Weak training.
a. Safety training specific.
b. Not surveilling.
b. Skill – apprentice training.
2. Environment Poor:
c. High-risk areas.
a. Too many safety deficiencies.
2. Worker surveillances – employee-based.
b. Management not correcting / standards.
3. Interactive briefs – worker led.
c. No consequences.
4. Improve Environment! Fix Deficiencies.
3. Brief – one way/not interactive.
5. Management surveillances.
4. Critiques – need safety focus:
6. Union leadership too!
d. Too much on employee error.
7. Recognition of good behavior and self5. Not backing each other up!
reporting, reward / positive.
6. Too much emphasis on schedule / cost!
8. Safety Observer.
7. Resources?
Figure 6 – Risk Management and Worker Commitment to Safety
After lunch, the group developed a summary of problems and ideas from the risk
management discussion (Figure 6 – Risk Management and Worker Commitment to Safety).
The group discussed how well apprentice programs train workers in the safety requirements
associated with the trades. Safety training varies from trade to trade. The group discussed
the need for safety observers to function in a manner comparable to RADCON monitors.
Some shipyards utilize safety observers for high-risk operations identified in the Industrial
Ship Safety Manual for Submarines. To some of the participants, the concept of a designated
safety observer runs counter to mainstreaming safety and giving ownership for safety to the
worker. The group determined to assign four working groups, one from each shipyard to
address one of the four high-risk areas, to address risk management and worker commitment
to safety:
5.
6.
7.
8.
PNSY (Code 950 2730/270), Electrical Safety.
NNSY (Code 970 980/710), Fall Protection.
PSNS&IMF (Code 920/250), Confined Space Entry.
PHNSY&IMF (Code 960 2350/260), Energy Control/LOTO.
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NAVSEA Industrial Activity Safety Summit
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Meeting Minutes

Safety Metrics (Ms. Hubby). Ms. Kim Hubby, PNSY (Code 106), led a discussion of safety
performance metrics. She provided examples of how PNSY continually assesses the
Occupational Safety and Health (OSH) Program through surveillance. The shipyards have
surveillance checklists, but surveillances cannot be based on checklists alone. The checker
must also observe what’s going on with the work and ask open-ended questions. All of the
shipyards are conducting surveillances; however, none of the shipyards currently is
performing effective trend analysis after the data are collected. Additionally, the group must
define criteria for Level 1 through 4 events in order to collect data consistently at each level
and implement the Safety Pyramid and ALARA concepts (i.e., a robust Level 3/4
surveillance program driving down Level 1/2 events). The group defined a set of safety
metrics to report corporately. The group determined to continue to report OSHA TCIR and
DART (lagging indicators) and to add reporting the number of Level 1 incidents and Level 2
problems. The group determined not to track injury-free days, as it might inhibit reporting.
1. Continue OSHA TCIR and DART:
a. Report organization-level quarterly.
b. Project level monthly.
2. Add Level 1 and 2 Problems – Number
a. Report organization-level quarterly.
b. Project level monthly.

Improving Hazard Awareness and Abatement (Mr. Medrano). Mr. Jeffrey Medrano, NNSY
(Code 106), led a discussion on improving hazard awareness and abatement. The focus is on
collecting and analyzing Level 3 surveillance and inspection data to prevent Level 1
incidents and Level 2 problems from occurring. The Radiological Deficiency Report (RDR)
system is a model for this approach. The shipyards currently employ various checklists, but
not all of the checklists are aligned with the high-risk areas. In some cases, defined
inspections are not being completed. No specific hazard recognition training is in place.
Hazard recognition training is needed to increase the involvement of many people across the
organization to identify deficiencies (i.e., learn to see). Reporting culture (i.e., self-reporting)
is weak. Information systems currently in use include HDA and ODR for workplace
deficiencies and QPS for surveillances. Some systems can track deficiencies from cradle to
grave. Lots of data are collected, but analysis is performed at a high level only. As an
example, PHNSY&IMF conducts 300 workplace inspections per quarter, identifying 600 to
700 deficiencies per quarter. The shipyards currently are not getting a lot of value from
analyzing the data. Standard attributes for high risk areas are not defined to support
meaningful analyses. The shipyards should know where they stand on a daily basis (i.e.,
better finding of deficiencies, better trending, and better fixing, plus more dynamic looks at
behavior). The RMCs are using ESAMS to track workplace deficiencies from cradle to
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NAVSEA Industrial Activity Safety Summit
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Meeting Minutes
grave. The RMCs are not conducting surveillances. The SUPSHIP organizations use a
deficiency tracking system, called TSME, funded by PMS 400. The group determined to
form a working group to improve hazard awareness and abatement, with a focus on finding
and fixing Level 3 deficiencies before they become Level 1 incidents and Level 2 problems.
This project will include a gap analysis of the RDR process. PSNS&IMF will lead the
working group. Opportunities for improvement include:
1.
2.
3.
4.
5.
6.
7.
8.

Improve Safety Deficiency Reports (SDRs).
Better focus on finding L3 hazards to prevent L1 and L2.
Integrate safety issues associated with work.
Standard Attributes (High Risk), align L3 with L1 and L2.
Hazard Awareness and Training (“Learn to See”).
Start with focus on High Risk.
Consider the RDR process.
Start with the four naval shipyards. RMCs participate.
Self Assessments (Mr. Ueda). Mr. Herb Ueda, PNSY (Code 106) reviewed the OSH Program
Assessment Process. This self assessment process is aligned with UIPI 0090-002 (SelfAssessment) and OPNAVINST 5100.23, Chapter 5 (Prevention and Control of Workplace
Hazards). The self-assessment process is an ongoing, year-round process. Significant
findings are elevated immediately. Data are reviewed at least monthly. Training is included
in the self-assessment. Mr. Ueda reviewed programs currently being assessed. Mr. Ueda
discussed issues with the self-assessment process. For example, it is difficult to get
customers to accept action items from the self assessment and complete them. Briefing self
assessment results in an appropriate management forum, such as the OSH Policy Council,
helps to direct attention to correcting findings of the assessment. Mr. Kim Taylor, SEA
04RS, provided NAVSEA feedback concerning the shipyards’ self-assessment processes. He
noted that recent SEA 08 and SEA 04 inspections identified significant issues that were not
identified in the self-assessments. Self assessments must be performed under the OSHE
Office lead, but with participation from other shipyard departments. Functional self
assessments for safety are not just an OSHE Office responsibility, but a shipyard-wide
responsibility. The standard for self assessments must come up. Self assessments must
identify significant issues. The expectation is that the shipyards are finding problems in
high-risk areas, addressing the problems, and preventing Level 1/2 events from occurring.
Mr. Taylor briefed the group on a Chief of Naval Operations message CNO 121425Z FEB10
(Subj: SECNAV / SECDEF Reduction Goal). This message requires field activities to
identify the top-five safety concerns, along with safety program deficiencies, weaknesses,
successes, and roadblocks to successful mishap prevention efforts. The first assessment
under this new guidance is due to NAVSEA by March 1, 2011, for Calendar Year 2010.
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NAVSEA Industrial Activity Safety Summit
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Meeting Minutes

Safety Summit Wrap-Up (Mr. Brice). Mr. Brice led a wrap-up of the Safety Summit. The
group briefly returned to the criteria for Level 1 and 2 events. Rather than attempt to
complete the list in the time remaining, Mr. Brice said that SEA 04R, the shipyard OSHE
Offices, the RMCs, and the SUPSHIP organizations would take the lead with other codes to
complete the list during the following week. This working group will align the
accident/injury language in several of the criteria with the Navy’s Class A and B language.
The plan then is to update the Trouble Report instruction with the Level 1 criteria and the
Critique UIPI with the Level 2 criteria. Members of the group questioned why a Trouble
Report and critique are required in the case of a fatality when a SIR is required. The Trouble
Report and critique need to be completed to distribute the lessons learned from the incident
quickly. The SIR necessarily takes time to complete. Mary Anne Zivnuska (SEA 00L) said
that she would contact the Naval Safety Center to discuss NAVSEA’s intention to complete a
Trouble Report and a critique for a fatality in advance of the SIR. Finally, the group
discussed the idea to develop a ship repair and maintenance safety manual, patterned after
SEA 08’s safety manual for the joint DON/DOE facilities. An advantage of such a safety
manual is that it could be invoked in ship repair and maintenance contracts.
Thursday, May 13, 2010

Safety Summit Out-Brief Preparations (Mr. Brice). Mr. Brice led the group through a review
of the draft out-brief presentation to RADM Campbell. The group recommended minor edits
to individual slides in the PowerPoint presentation. The group discussed two issues that
require follow-up after the meeting. The first issue concerns the ability of NAVSEA to
provide input to the Joint Fleet Maintenance Manual (JFFM) since it is not a NAVSEA
document. SEA 04R will follow up with the fleet concerning how NAVSEA can provide
input to the JFFM. The second issue concerns addressing ship’s force unsafe practices
occurring in shipyards that have nothing to do with the ship’s availability. SEA 04R will
follow up with the fleet and the Naval Safety Center concerning addressing ship’s force
unsafe practices not related to a ship availability.

Safety Summit Out-Brief (RADM Campbell). CDR Gelker, assisted by designated members
of the group, briefed RADM Campbell and Mr. Mueller on the results of the Safety Summit
meeting using a PowerPoint presentation *(reference outbrief presentation). Concerning the
review of the USS RONALD REAGAN fatality, RADM Campbell asked how the
corporation will assure that the shipyards and ship’s force personnel will work to the same
standards. He questioned whether it is clear who should be doing work on energized
equipment. He asked who will review the decision to work energized before taking the work
package to the shipyard’s Project Superintendent and ship’s Commanding Officer. A change
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NAVSEA Industrial Activity Safety Summit
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Meeting Minutes
is required, and the working group for High Risk Work must address this issue, including
determining the need for interim controls. Concerning the Trouble Report for the USS
BATAAN incident, RADM Campbell asked if this Trouble Report was distributed to
everyone in the group. There may be a problem with distribution of the reports to SUPSHIP
organizations. Mr. Paul Mieszczanski (SEA 04XQ) will make sure the SUPSHIP
organizations are on the distribution list. Mr. Mueller noted that the Headquarters regulator
has to concur with three parts of the Trouble Report. Trouble reports must be evaluated.
Approximately 25% of nuclear-related Trouble Reports are rejected. Concerning
Engineering for Reduced Risk, Mr Mueller asked who decides how high-risk work items are
accomplished. His view is the answer should be that Engineering decides. In the Work
Model (Figure 4), Engineering is on top because Engineering they drive the technical control
of the work we do. The shipyard’s Project Superintendent and ship’s Commanding Officer
can approve, but Engineering decides. Concerning Risk Management and Worker
Commitment, Mr. Mueller asked why the supervisor is not being held accountable for a
worker committing an unsafe act. Concerning Self Assessments, Mr. Mueller asked how the
SUPSHIP organizations and the RMCs perform self assessments. The SUPSHIP
organizations’ self assessment process is not as in-depth as the shipyards’ process. The
RMC’s use ESAMS to conduct self assessment. Mr. Mueller said that it was a mistake to
focus on process first. Focus on people, their training, and their capability to do the work
first. People who do not think with good engineering discipline write bad self assessments.
Concerning the Plan of Action and Milestones, RADM Campbell asked if a strategic
communication plan is required to help the workforce understand these safety initiatives.
The group must determine how to explain the initiatives to the workforce. Finally, several
members of the group expressed concern for resources to address these initiatives and current
workload. Mr. Mueller said that the shipyards, RMCs, and SUPSHIP organizations are not
being asked to do extra work. The two fatalities we have had this year indicate that they are
already not meeting the requirements. RADM Campbell asked if the group understands what
the problem is yet. He asked the group to consider if what the corporation is doing with
safety will enable or inhibit the core business. If it enables the core business, then resources
will take care of themselves. If it inhibits the core business, then additional resources will be
required. RADM Campbell thanked the members of the group for their efforts. The meeting
adjourned.
23
NAVSEA Industrial Activity Safety Summit
Agenda
1. Date: 11-13 May 2010
2. Time: 0800 – 1700 (T&W) and 0800-1200 (Th)
3. Location: 1100 New Jersey Ave, Washington DC 20003
Room: 850
4. Participants: SUPSHIP, RMC and Shipyard Code 106/ESH Managers
NSY Code 300 and 900
Other SUPSHIP/RMC Reps
5. Purpose: To improve safety across the NAVSEA Industrial Activities and drive safety
hazards and mishaps to “As Low as Reasonable Achievable”
6. Objectives:
a. Achieve alignment on Case for Change to raise standards, drive injuries to zero, and
significantly reduce risks for serious mishaps.
b. Mainstream safety into the entire organization where work is engineered for reduced
risk, all hazards are reduced to ALARA, and workers mature from compliance mode to
commitment with interdependency (backup).
c. Develop Safety Pyramid and VPP+ model to achieve these objectives. Specific
deliverables are as follows:
(1) Definition of Level 1 and Level 2 safety problems.
(2) Update guidance to require Critiques and Trouble Reports for these problems.
(3) Develop guidance for High Risk Work Permit program.
(4) Operational Risk Management (ORM) by workers in execution of work.
(5) Update metrics for projects/availabilities in addition to current metrics.
(6) Update Training programs for high risk programs to require practicals, annual
refreshers, and level of knowledge examinations.
(7) Develop new guidance for surveillances and standardize documentation in
Safety Deficiency Reports (SDRs).
(8) Develop action to improve self-assessments.
7. Agenda:
Tuesday, 11 May 2010
1
Enclosure (1)
NAVSEA Industrial Activity Safety Summit
Agenda
0800-0900
Introduction & Welcome (SEA 04R – Jim Brice)
•
Summit Goals & Objectives
•
Around the Room Expectations
0900-1000
Safety at Naval Reactors Facilities (SEA 08R – Troy Mueller)
•
Fundamentals of Safety
•
Mainstreaming Safety
•
ALARA and Dupont Road to Zero
•
Risk Approach – Switch Theory
•
Safety Ownership – Total Workforce
1000-1015
Break
1015-1100
Safety at Naval Reactors Facilities (SEA 08R – Troy Mueller) – continued
1100-1200
NAVSEA Leadership Perspective (SEA 00 – VADM McCoy)
•
Interactive Session
•
Participants be prepared to discuss biggest challenges in achieving a step improvement in
safety.
1200-1230
Lunch
1230-1400
Mainstreaming Safety (SEA 04R – Jim Brice)
•
Case for Change - Alignment
•
Review of Assessment Findings
•
VPP+
•
Safety Ownership – 106 Role
1400-1530
Definition of Level 1 and Level 2 Safety Problems (Pearl Harbor NSY –
Lyrita Gochenouer)
•
Objectives
•
Break
•
Breakout Sessions to define Level 1 & 2 Problems
1530-1630
Level 1/2 Problem Group Discussion and Way Ahead (Pearl Harbor NSY –
Lyrita Gochenouer)
1630-1700
Improving Trouble Report Documentation (CO, SUPSHIP NNS - CAPT Soule)
2
Enclosure (1)
NAVSEA Industrial Activity Safety Summit
Agenda
Wednesday, 12 May 2010
0800-0945
Engineering for Reduced Risk (SEA 04R – Jim Brice, SEA 08R – Tom Weishar,
Portsmouth NSY - Rep)
•
Technical Control Procedures and Processes
•
Interactions with Ship’s Force
•
Control/Coordination of Contractors
•
Use of High Risk Work Permits
0945-1000
Break
1000-1100
Risk Management and Worker Commitment to Safety (Puget Sound NSY – Ted
Wheeler)
•
Response to Hazards and Mental Checklists
•
Active Participation in Critiques
•
Horizontal Enforcement
•
Behavior-based Safety
•
Safety Observer
•
Follow-on Discussion in 300/900 Meeting
1100-1200
Safety Metrics (Portsmouth NSY – Kim Hubby)
•
Leading Indicators
•
Organization and Availability Metrics
1200-1300
Lunch - (Code 300 and 900 dismissed for their meeting)
1300-1445
Improving Hazard Awareness & Abatement (Norfolk NSY – Jeff Medrano)
•
Surveillances & SDR Process
•
Data Collection and Analysis
•
How do I improve to Mirror RDR Process?
1445-1500
Break
1500-1600
Safety Training Lessons Learned (SEA 04RS – CDR Gelker)
•
Review of Assessments
•
High Voltage Electrical
•
Fall Protection Trainer
•
OSHA 10-hour and 30-hour course
•
Supervisor and Risk Management
3
Enclosure (1)
NAVSEA Industrial Activity Safety Summit
Agenda
1600-1700
Self-Assessments (SEA 04RS – Kim Taylor, Portsmouth NSY – Herb Ueda)
Thursday, 13 May 2010
0800-0930
Electrical Safety – Feedback on Effectiveness of Improvement Actions (SERMC
– Joey Cartwright)
•
Deep Dive Responses
•
(Entire Group Reconvene and discuss)
0930-1000
Finalize products and POA&M
1000-1200
Group Presentation/Question and Answer with SEA 04 and 04B
8. Agreements: TBD
9. Action Items: TBD
Notes: Refreshments including lunch will be provided on Tuesday and Wednesday for a
refreshment fee of $25. Morning refreshments will also be provided on Thursday. VTC
capabilities are not available for this meeting. Will be computer, projector, and screen.
Checking webinar capabilities.
4
Enclosure (1)
NAVSEA Industrial Activity Safety Summit
Attendance Roster
Name
Stewart Adams
Chuck Almond
Rich Anderson
Marc Baillargeon
Andrew Blanco
Larry Blevins
Geno Borelli
Marc Boutin
Jim Brice
CAPT Mark Bridenstine
Tim Brorson
Roger Brown
Luis Campos
Joey Cartwright
Russell Chantry
Leslie Cole
Darrilyn Cranney
Robert Fogel
Frank Dodderer
Bill Docalovich
CDR Garrett Farman
Tony Frey
CDR Jennifer Gelker
Lyrita Gochenouer
CAPT William Greene
Jose Gutierrez
James Holdman
Kim Hubby
Tim Hughes
Michael Tim Jacks
Penny Jones
Troy Kaichen
David Kopack
CAPT Dean Krestos
Jeff Lawrence
Rich Luke
John MacGinnis
Rick Marvin
Jeffrey Medrano
Activity
NAVSEA 04RE
NAVSAFECEN
PHNSY&IMF
PNSY
SEA 04RS
NNSY
SUPSHIP BA
PNSY
NAVSEA 04R
NNSY
PSNS&IMF
PSNS&IMF
SWRMC
SERMC
NNSY
PSNS&IMF
ODASN (Safety)
PHNSY&IMF
SERMC
NGSB Newport News
SRF-JRMC
PSNS&IMF
NAVSEA 04RS
PHNSY&IMF
PSNS&IMF
SEA 04Y
SWRMC
PNSY
SUPSHIP GC
NNSY
PSNS&IMF
PNSY
SEA 04RE
SUPSHIP BA
SERMC 2A2
NAVSEA PNSY
PNSY
Naval Reactors
NNSY
1
E-Mail Address
stewart.d.adams@navy.mil
charles.almond@navy.mil
richard.w.anderson@navy.mil
marc.baillargeon@navy.mil
andrew.blanco@navy.mil
larry.d.blevins@navy.mil
eugene.borelli@supshipba.navy.mil
marc.boutin@navy.mil
james.brice@navy.mil
mark.bridenstine@navy.mil
timothy.brorson@navy.mil
alvah.brown@navy.mil
luis.c.campos@navy.mil
joey.c.cartwright@navy.mil
russell.chantry@navy.mil
leslie.cole@navy.mil
darrilyn.cranney@navy.mil
robert.fogel.@navy.mil
francis.dodderer@navy.mil
bill.docalovich@ngc.com
garrett.farman@srf.navy.mil
anthony.frey2@navy.mil
jennifer.gelker@navy.mil
lyrita.gochenouer@navy.mil
william.c.greene@navy.mil
jose.i.gutierrez@navy.mil
james.holdman@navy.mil
kimberly.hubby@navy.mil
timothy.hughes@supshipgc.navy.mil
michael.jacks@navy.mi
penny.jones@navy.mil
troy.kaichen@navy.mil
david.kopack@navy.mil
jeffrey.m.lawrence@navy.mil
richard.luke@navy.mil
john.a.macginnis@navy.mil
richard.d.marvin@navy.mil
jeffrey.medrano@navy.mil
Enclosure (2)
NAVSEA Industrial Activity Safety Summit
Attendance Roster
Name
Bill Miller
Mike Monju
Aaron Moore
Troy Mueller
Don Noyes
Raphael Okimoto-Rive
Steve Perkins
Jerry Phillips
Walt Pristou
Bill Qualls
Andres Quinones
Andrew Ramsey
Michael Rice
Dennis Rickabaugh
Anthony Ruiz
Nick Smith
Jenifer Solomon
CAPT Ralph Soule
Sheril Sprague
Kim Taylor
Gerald Thomas
Randy Toole
Benjamin Toyama
Herb Ueda
Ted Wheeler
Thomas Weishar
Bob Wright
Mary Anne Zivnuska
Activity
SUPSHIP GR
SUPSHIP GC
SERMC
Naval Reactors
NAVSEA 04RS
PHNSY&IMF
NAVSEA 04XR
SUPSHIP NN
NNSY
CACI
SWRMC
SUPSHIP GR
NNSY
PSNS&IMF
SWRMC
NNSY
NGSB Newport News
SUPSHIP NN
PNSY
NAVSEA 04RS
PNSY
PNSY
PHNSY&IMF
PNSY
PSNS&IMF
Naval Reactors
SERMC
NAVSEA 00L
2
E-Mail Address
william.miller@supshipgr.navy.mil
michael.monju@supshipgc.navy.mil
aaron.e.moore@navy.mil
troy.mueller@navy.mil
don.noyes@navy.mil
raphael.okimoto-rive@navy.mil
steven.perkins@navy.mil
jerry.phillips@supshipnn.navy.mil
walter.pristou@navy.mil
bqualls@caci.com
andres.quinones@navy.mil
andrew.ramsey@supshipgr.navy.mil
michael.a.rice1@navy.mil
dennis.rickabaugh@navy.mil
anthony.ruiz1@navy.mil
nick.a.smith@navy.mil
jl.solomon@ngc.com
ralph.soule@supshipnn.navy.mil
sheril.sprague@navy.mil
david.taylor8@navy.mil
gerald.l.thomas3@navy.mil
randy.toole@navy.mil
benjamin.toyama@navy.mil
herbert.ueda@navy.mil
theodore.wheeler@navy.mil
thomas.weisher@navy.mil
robert.j.wright@navy.mil
mary.zivnuska@navy.mil
Enclosure (2)
NAVSEA Industrial Activity Safety Summit
Bibliography
Dekker, Sidney. Just Culture: Balancing Safety and Accountability. Burlington, VT: Ashgate
Publishing, 2007.
Dekker, Sidney. The Field Guide to Understanding Human Error. Burlington, VT: Ashgate
Publishing, 2006.
Gawande, Atul. The Checklist Manifesto: How to Get Things Right. New York, NY:
Metropolitan Books, 2009.
Reason, James T. and Alan Hobbs. Managing Maintenance Error: A Practical Guide.
Burlington, VT: Ashgate Publishing, 2003.
Senge, Peter M. The Fifth Discipline: The Art & Practice of The Learning Organization. New
York, NY: Currency Doubleday, 2006.
Weick, Karl and Sutcliff, Kathleen. Managing the Unexpected: Resilient Performance in an Age
of Uncertainty. Jossey-Bass; 2 edition, 2007.
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Enclosure (3)