Institutionalizing Lessons Learned October 25, 2006 Loren Plisco - - PowerPoint PPT Presentation

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Institutionalizing Lessons Learned October 25, 2006 Loren Plisco - - PowerPoint PPT Presentation

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Institutionalizing Lessons Learned October 25, 2006 Loren Plisco Region II Background SEP 2002 Davis-Besse Lessons Learned Task Force AUG 2004 - Effectiveness Review Lessons Learned Task Force JAN 2005 - EDO Charters

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Institutionalizing Lessons Learned

October 25, 2006 Loren Plisco – Region II

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Background

  • SEP 2002 – Davis-Besse Lessons

Learned Task Force

  • AUG 2004 - Effectiveness Review
  • Lessons Learned Task Force
  • JAN 2005 - EDO Charters Team
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Root causes

  • No “Corrective Action Program”
  • No centralized tracking system
  • Weaknesses in closeout
  • Lack of Effectiveness Review s
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Team Charter

  • Develop a program to ensure

lessons learned from significant

  • rganizational failures w ill not

recur

  • Ensure that the know ledge gained

from future lessons learned is retained and disseminated in a manner to maximize its benefit and usefulness to the agency

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Accomplishments

  • Management Directive issued
  • Internal procedures issued
  • Project Manager selected
  • Oversight Board members

designated

  • Legacy effectiveness review s

completed

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Management Directive

  • Management Directive 6.8,

“Lessons-Learned Program” w as approved on August 1, 2006

  • Establishes a formal and

structured process to ensure correction of significant agency deficiencies

  • Background and bases included
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Program Components

  • Primary sources for Lessons

Learned are task forces, major event investigations, and major audit reports

  • Establishes criteria for inclusion

into the program

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Program Components (cont.)

  • Lessons Learned Oversight Board

(LLOB) applies the threshold criteria to the recommendations

  • Corrective action plans (CAP) w ill

be developed by the lead office

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Program Components (cont.)

  • LLOB review s CAP to ensure

thoroughness and adequacy

  • Lead office implements plan
  • For closeout, the LLOB w ill review

to determine acceptability of completed actions

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Program Components (cont.)

  • Effectiveness review s planned and

conducted to confirm that root causes have been addressed

  • Dedicated lessons learned

program manager (LLPM)

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Procedures

  • OEDO Procedure 0930, Task Force

OEDO Procedure 0930, Task Force Charters, issued July 27, 2006 Charters, issued July 27, 2006

  • OEDO Procedure 0940,

OEDO Procedure 0940, Implementing the Lessons Implementing the Lessons Learned Oversight Board, issued Learned Oversight Board, issued September 26, 2006 September 26, 2006

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What’s Different About This Approach ?

  • More structure and formality
  • More management involvement
  • Dedicated staff
  • Centralized tracking
  • Effectiveness review s
  • Focus on institutionalization
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How have the root causes been addressed?

No “Corrective Action Program” No centralized tracking system Weaknesses in closeout Lack of Effectiveness Review s

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Legacy Effectiveness Review s

  • List of candidates developed
  • Template developed and piloted
  • Six reports selected for review
  • Legacy effectiveness review s

tasked to offices

  • Review s completed
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Review s Conducted

  • Vogtle Loss of Vital AC Pow er
  • Indian Point 2 Tube Failure
  • General Electric Potential

Criticality

  • Indiana Regional Cancer Center
  • Turkey Point (Hurricane Andrew )
  • TMI 1 Unauthorized Forced Entry
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Legacy Effectiveness Review Conclusions

  • No outstanding safety issues

identified

  • No significant deficiencies in

corrective actions review ed

  • Additional review w arranted for

some actions

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Legacy Effectiveness Review Comments

  • Review s w orthw hile
  • Locating documents
  • Independence and know ledge
  • Environment and regulatory

changes

  • View of importance
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Future Enhancements

  • Configuration Management (CM)
  • Know ledge Management (KM)
  • Web-based system automation

enabling desktop availability

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Challenges

  • Change management
  • Legacy information
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Opportunities

  • Encourage a culture of continuous

improvement

  • Integrate w ith and support the

agency’s KM initiatives

  • Encourage self-assessment in the

NRC Offices and share problems and solutions

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Summary Summary

  • Lessons Learned Program is in

place - Charter tasks completed

  • Lessons Learned Program adds

structure to completing important corrective actions

  • Program enhancements needed

to integrate w ith KM program and provide more value to the staff

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Acronyms

  • CAP – Corrective Action Program
  • CM – Configuration Management
  • EDO – Executive Director for Operations
  • KM – Knowledge Management
  • LLPM – Lessons Learned Program

Manager

  • LLOB – Lessons Learned Oversight Board