BNL Lessons Learned LL Workshop Raising the Bar

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BNL Lessons Learned (LL) Workshop Raising the
Bar
Presented by Ed Sierra Laboratory Lessons
Learned Coordinator May 15, 2007 Quality
Management Office
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Agenda

• Point to Ponder
• Purpose
• LL Program History at BNL
• Program Effectiveness
• Tips for Writing LL Documents
• Lessons Published 4th Qtr FY 06
• Customer Feedback
• LL Infrastructure
• Path Forward

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Why this Workshop?

• To prompt feedback, evaluate, and improve BNLs
  Lessons Learned Program

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Point to Ponder

• The more we stress only what we can measure, the
  more we need to remember that not everything that
  is measurable matters, and not everything that
  matters is measurable.
• 
  - Elliot Eisner

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BNL Lessons Learned (LL) Program The History

• Nov. 1998 Issue Decision Paper approved
• Feb. 1999 Full-time Lab LLC hired
• Mar. 1999 Initial Program Elements Finalized
• Mar. 2000 SBMS Components Finalized
• Jan. 2001 Lab LLC, Part-time position
• Mar. 2001 LL Incentive Program
• July 2005 Web-based LL Document
• June 2006 Free LL Subscription to all!
• April 2007 Initiation of LL Workshops

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What is a Lesson Learned?

• A lesson learned is the knowledge acquired from
  an innovation or an adverse experience that
  causes a worker or an organization to improve
• a process
• activity
• to work safer
• more efficiently
• or with higher quality.
• In short, a change in behavior occurs.

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Effectiveness

• The system can be measured for value only on
  the basis of the prevention benefits it provides
  to BNL.

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Why Document Lessons Learned?

• Those who cannot remember the past are condemned
  to repeat it.
• - George
  Santayana (1863 1952)

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Tips for Writing a LL Document

• Use the readers language
• Dont use technical language if not necessary
• Dont use slang inappropriate for written
  documents
• Dont assume your reader knows all your acronyms.
• Speaks directly to the reader in an informal,
  conversational style.
• An emphasis on explaining and interpreting causal
  analysis results rather than on methodology.

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Title of the Lesson LearnedMust Get The Readers
Attention

• Make it short . . . but tell the whole story
• Make the reader sense that this is something they
  need and want to know.
• Be specific to the incident or the situation,
  avoid using generic phrases
• The Title is what is displayed in the
  subscription service e-mail notice and in
  references to the LL document.

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Lessons Published 2nd Qtr FY 07

• Characterize Legacy Issues in Your Spaces
• Round Sling Inspection
• Knowledgeable Personnel Should Not Be Substituted
  for Procedures
• Non-NRTL Listed Power Strips Pose Shock and Fire
  Hazard
• Evaluate Hazards When Introducing New Equipment
• Painter's Spackling Knife Contacts Abandoned Live
  Wiring (BNL)
• -----------------------------Pending Final
  Review--------------------------------------
• Dont Let Your Guard Down When Preparing
  Facilities for DD (BNL)
• Safe Handling of Failed (Open Circuit State)
  Capacitor (BNL)
• Electrical Multi-Tap Power Boxes found with
  Defective Bus-bar Rivets and Loose Bus-bar Screws
  (BNL)

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LL Feedback Prompt!

• Prompt/capture feedback of published LL
  Communications
• Will adopt
• Distributed for Information
• Not applicable
• Previously adopted
• Reading for Interest only
• Under investigation

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1st Qtr FY 07 LL Feedback
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1st Qtr FY 07 LL Feedback
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A Sampling of BNL LL Feedback

• This is the first lessons learned notice I
  received.  If you were involved in adding me to
  the distribution list, I appreciate it.  This
  will prove to be helpful.  Thanks!
• This appears to be an excellent use of web media
  to convey/inform employees of pertinent safety
  information 
• Will adopt at Magnet Division. Revise Subject
  Area.
• I have incorporated this Lesson Learned into a
  Work Instruction for removing combustible
  materials from the HFBR (Building 750). This work
  will be performed under Work Permit
  DD-WP317-001 and is very fitting for the job.
  Thanks
• I try to get the big picture from lessons learned
  and incorporate any ideas, knowledge, and
  improvements into my work/life.    
• I'm trapped here. Every time I launch my web
  browser I get this feedback page 
•  

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LL Infrastructure

• https//sbms.bnl.gov/

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Color blocks help identify work flow status
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CAT Electronic Entries

• 03/13 SM, Smoldering debris near Cooling Tower
  4 by B912A, SCBNL
• 03/14 SM, Right index finger injury at
  Production Services
• 03/15 SM, Violation of BGRR RAD Admin Control
• 03/15 SM, Plumber Injures Tooth, SCBNL
• 03/19 MD, B-197 evacuation due to fire alarm,
  SCBNL
• 03/21 MD, Unidentified substance at Chemistry
  Building determined to be harmless
• 03/22 MD, Fire Alarm (false alarm) at Building
  479 Central Fabrication Services
• 03/22 MD, Minor finger laceration at Central
  Fabrication
• 03/28 AL, Radiological Continuous Air Monitor
  alarm triggered by a cell phone
• 04/05 KK, Warehouse Employee Injures Back
• 04/11 PB, Instrumentation Calibration
  Facility Operational Safety Limit Exceeded
• 04/13 PB, Legacy grenade with no active
  explosive component located
• 04/15 PB, Firefighter fractures foot while
  physical training, SC3
• 04/16 KK, ½ gal oil spill from air compressor
  at STAR
• 04/17 KK, Rad Worker Receives Splinter in
  Radiological Area
• 04/26 RK, F-18 finger contamination at PET
• 05/01 AP, Contamination in HFBR fuel vault
• 05/02 AP, Minor brush fire in Front of building
  911
• 05/03 AP, Minor fire in ventilation system at
  NSLS

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CAT Electronic Entries

• 05/05 AP, Cigarette butt results in smoldering
  mulch bed near B-735
• 05/09 SM, Impairment of Water Supply to Bldgs
  815 and 817
• 05/10 SM, Power Supplies for Booster to AGS
  trip
• 05/10 SM, Discovery of Disconnected O2 Sensor
  in B535 during Lab Calibration Audit

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Path ForwardSeeking Best in Class!

• Auto deliver LL during work planning
• Implement SBMS functionality enabling integration
  of Lessons Learned with Work Planning Control
• Initiate bi-annual LL Coordinators workshop to
  prompt feedback, evaluate, and improve BNLs LL
  Program
• What else can we do to be the best!

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Lesson to Ponder

• Myth You cant make significant changes until
  you get buy-in from everybody.
• In fact, the wait for buy-in can be interminable
  because leaders fail to acknowledge the truth
  that behavior precedes belief. In other words,
  the cycle of organizational improvement is not
  vision, buy-in, and action but rather vision,
  action, buy-in, and more action. The buy-in
  does not occur until employees first see the
  results of their actions.
• 
  - Dr. Douglas B. Reeves
• The Learning Leader
  2006

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Heaven Can Wait!