Professional Documents
Culture Documents
Mark Paradies
President System Improvements, Inc. 238 S Peters Road Knoxville, TN 37923 865-539-2139 www.taproot.com
Mark Paradies
BIG THREE
1. TOTAL RESPONSIBILITY 2. Technical competence (outstanding people) 3. Facing the facts (do the right thing despite costs)
www.taproot.com/wordpress/archives/16148
4. Conservatism of design 5. Designing the plant to avoid accidents to reduce the likelihood of the need to use emergency systems 6. Redundancy of equipment to avoid shutdowns or activation of emergency equipment
OSHA PSM
No No No
Comparison Continued
Nuclear Navy
Conservatism of design Design to avoid accidents Redundant equipment
OSHA PSM
d. Process safety information?
(not really)
CCPS PSM No No
No
Comparison Continued
Nuclear Navy
Inherently stable plant Full testing Maintenance
OSHA PSM
No No j. Mechanical integrity
Comparison Continued
Nuclear Navy
Detailed operating procedures
OSHA PSM
f. Operating procedures
(doesnt address technical participation)
No
Comparison Continued
Nuclear Navy
Incident reports
OSHA PSM
m. Incident investigation
(no sharing f info required)
Audits/inspections
Yes
(not independent + not frequent )
Comparison Continued
Nuclear Navy
Independent review by government Personal selection of leaders Initial technical training + hands on training
OSHA PSM
No No g. Training
(but does not include initial technical training)
Comparison Continued
Nuclear Navy
Advanced training for senior mgmt jobs Extensive continuing training & requalication Strict enforcement of standards Self Assessments
OSHA PSM
No No
CCPS PSM
Human Factors
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#1 Managements Effect
What They Say But Beyond That
Knowledge / Standards What They Ask For (Demand) Budget - What Gets Cut? Involvement/Attention/Tracking Who Is Assigned/Evaluations/Promotions Do They Insist Their Subordinates are Trained?
Copyright 2009 by System Improvements Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
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Bad Example
No Budget - No Travel Best of the Rest Skip Quarterly Meetings Big Backlog or No Tracking Heard a Talk Once Asks Who Did It & Fires Asks Why Would They Need Training?
Copyright 2007, Great Systems!
Copyright 2009 by System Improvements Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
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Understands Keys to Process Safety Improvement Understands Theory & Practice of Root Cause Analysis
Copyright 2009 by System Improvements Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
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Copyright 2009 by System Improvements Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
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Copyright 2008 by System Improvements Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
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Analysis Action Serious Incident Incident Near-Miss At-Risk Behaviors Latent Conditions
Good Root Cause Analysis Then Fix Fast Analysis Then Fix Very Little Analysis Then Fix No Analysis Maybe Fix?
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Analysis Action Serious Incident Incident Near-Miss At-Risk Behaviors Latent Conditions
Root Cause Analysis Then Fix Root Cause Analysis Then Fix Categorize Repair
Category 1: 1-5 Category 2: 30 - 100 Category 3: 100 - 1000 Category 4 & 5: 1000 - 4000
Fix Only If
Adverse Trend
Copyright 2008 by System Improvements Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
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#5 Effective Trending
Measuring Performance Damage of Over-reacting
Copyright 2009 by System Improvements Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
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Lost Time Injuries (L TI)
9 6 4 4 5 7 5 4 7 4 2
Dec Jul Jan Feb Jan Mar Apr
9 6
6 4 5 4 2 2
Aug May
Nov
Dec
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Copyright 2008 by System Improvements Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
Oct
Sep
Jun
Jul
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Natural Variation
Copyright 2009 by System Improvements Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
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What Did Reactive Approach & Over-Reacting Do? Davis-Besse Reactor Hole
What Did Reactive Approach & Over-Reacting Do? Davis-Besse Reactor Hole
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Copyright 2009 by System Improvements Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
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