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2019 Human Performance, Root Cause, & Trending (HPRCT) Conference
June 17-21, 2019
Cheyenne Mountain Resort
Colorado Springs, Colorado

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Tuesday, June 18
 

7:00am MDT

Breakfast
Tuesday June 18, 2019 7:00am - 8:00am MDT
Mountain View Dining Room

8:00am MDT

Opening Welcome & Logistics
Tuesday June 18, 2019 8:00am - 8:10am MDT
Colorado Ballroom

8:10am MDT

Making Connections and Understanding Them
This 1-hour general session topic discusses the complexity of a simple term – making connections. In HP (HOP, Others) it is important to understand where we came from in order to avoid some of the challenges of the past. It is also important to learn where things can go. Making those connections avoids some of those challenges and ensure that organizational capacity and resilience are built into the process providing sustainable improved performance. The types of connections that will be discussed:
• Individual connections (networking and learning from others, personality diversity and inclusion)
• Systemic connections (what does HP have to do with Safety?)
• Process connections (do HP and procedures really need to coexist instead of being part of one another?) • Method connections (learning teams, coaching, mentoring, root cause…)
• Technological Connections (Cloud, Apps, Using technology to manage risk…)
• Philosophy connections (Safety First, Zero Harm, Safety Differently, Just Culture, HOP…)
• Conference connections (HP-RC-T)

Speakers
avatar for Rob

Rob

President and Director of Operations, Fisher Improvement Technologies
Rob Fisher is the President, Owner, Director of Operations of Fisher Improvement Technologies. Rob spent almost ten years in the US Navy before working at the South Texas Nuclear Project for twelve years. During this time Rob worked in Operations, Radiation Protection, Chemistry... Read More →


Tuesday June 18, 2019 8:10am - 9:00am MDT
Colorado Ballroom

9:00am MDT

Break
Tuesday June 18, 2019 9:00am - 9:10am MDT
Common Area Outside of Colorado Ballroom

9:10am MDT

High Performance and HRO: Where Do I Start?
Since 2003 a network of consultants in Netherlands and Germany is active in using HRO concepts and methods for improving the performance of organizations by strengthening collective proactive behaviors and mindsets. Performance meaning: performing more reliable or having less safety incidents. They have executed quite a few change and learning programs in order to facilitate management and employees to establish a broader repertoire of behaviors and interactions, supported by a wide range of tools and methods. In this presentation Bert Slagmolen will start giving an informed overview of programs (using cases from Chemical Process Industry, Steel Industry, Transportation, and Electricity Grid Maintenance and Management) and the way HRO is used. The main lessons learned will be shared (successes and failures). With the help of these concrete cases (and some video’s) he will also inform the audience about the ‘European’ interpretation of HRO and underlying ‘change traditions’. In the second part of his presentation he will give an overview of the 5 most effective change strategies that were developed in practice and in cooperation with the companies involved. This overview is based on Kotter’s model op ‘creating sustainable change’. It helps to frame questions, and translate them into actions, related to ‘where do I start’ and ‘how do I go’. Finally some thoughts and experiences will be given on: ‘how do I know’.

Speakers
avatar for Bert

Bert

Human Factors Lead, Apollo 13 Consult
Dr. Bert Slagmolen (1952) started his professional career as a researcher and consultant in the field of organizational development and management of change. Since 2002 he is primarily devoted to High Reliability Organizing (HRO) and Organizing for Resilience. He was and is involved... Read More →


Tuesday June 18, 2019 9:10am - 10:00am MDT
Colorado Ballroom

10:00am MDT

Break
Tuesday June 18, 2019 10:00am - 10:10am MDT
Common Area Outside of Colorado Ballroom

10:10am MDT

What I learned from Bill Corcoran Beyond Root Cause Analysis
With the passing of Bill Corcoran in July of 2018, the high-hazard industries lost one of the gurus of event investigations and thoughtful inquiry into human performance. Bill’s career spanned 55 years, starting with his graduation from the US Naval Academy in 1959 until he closed his consulting company (Nuclear Safety Review Concepts Corporation) in 2014. I worked closely with Bill Corcoran in a variety of professional relationships over the course of 33 years, and was honored by his request to become a co-editor (along with Mike Quinn) of his monthly newsletter, The Firebird Forum, at the end of 2017. He was an early and frequent contributor to the HPRCT, and is perhaps best known for his work in the area of Event Investigations/Root Cause Analysis. However, his contributions extend far beyond RCA, and include a number of “wisdom nuggets” that are applicable to all the sub-disciplines within the HPRCT. This general session covers a number of these, including (but not limited to): (1) The three bases for professional disagreement; (2) Transparency—what it is and why it’s important; (3) Maximizing the likelihood that others will accept your work without false advertising; (4) Eating your own cooking (or, living to the standards you advise others to meet); (5) A simple definition of quality applicable to personal, group, or company efforts; (6) How to sleep well after a day of professional setbacks.

Speakers
avatar for Dick Swanson

Dick Swanson

Founder and President, Performance Management Initiatives, Inc.
Richard N. Swanson, P.E. is the founder and president of Performance Management Initiatives, Inc., a consulting practice that focuses on industrial investigations and performance improvement for high hazard industries, since 1996. Mr. Swanson is the co-editor of The Firebird Forum... Read More →


Tuesday June 18, 2019 10:10am - 11:00am MDT
Colorado Ballroom

11:00am MDT

Break
Tuesday June 18, 2019 11:00am - 11:10am MDT
Common Area Outside of Colorado Ballroom

11:10am MDT

Hive-Mind Solutions in the Era of Accelerating Complexity
 In keeping with the theme this year “Creating Connections,” this presentation is intended to highlight the ways in which the letters in “HPRCT” can work together to help people solve problems faster and easier:  The world we live in today is more complex than at any other time.  This complexity is largely due to technological advances in nearly every aspect of our global society.  From cars that drive themselves to automated fulfillment centers to connected “smart” homes that we control from our “smart” phones, our world today is vastly more complicated than the world of our parents or grandparents.  And the rate of technological advance is accelerating exponentially.  According to Ray Kurzweil, technology is an evolutionary process in which the tools of prior generations are used to create those of the next.  As these tools improve, the time between advances decreases exponentially.  While it’s hard to know exactly where we are on the curve, there is no question that it’s getting steeper every single day.  Over time, accelerating complexity results in an increasing number of possible outcomes, both positive and negative.  Positive outcomes represent fresh opportunities.  But complexity leads to an increasing number new problems as well.  Attendees of the HPRCT conference share a common interest in Structured Problem Solving.  We help people solve problems faster and better.  And the importance of our contribution is accelerating in lock-step with complexity.  Therefore we need to innovate, collaborate, adapt, and – when required – rip up the playbook altogether in order to stay in front of the wave.  Our predicament has its roots in our own human intelligence.  And while we often think about intelligence in the context of the individual, a group whose members act intelligently together is much smarter than any single member.  The term “hive-mind” is one way to describe a collective group intelligence.  It took a hive of human minds to get to the moon or to develop an iPhone.  And it’s going to take a hive of human minds, operating through an intersection of methods and tools, to stay on top of the wave of accelerating complexity.  Presentation to include specific examples of how Human Performance, Root Cause, Trending, and High Resiliency intersect to form the basis for hive-mind solutions.

Speakers
avatar for Brian Hughes

Brian Hughes

Sr. Vice President and Co-Founder, Sologic
Brian works with clients to develop and implement enterprise-wide RCA programs. Brian also leads significant root cause incident investigations, including explosions, loss of primary containment, consumer product contamination, failures of critical aircraft components/systems, supply... Read More →


Tuesday June 18, 2019 11:10am - 12:00pm MDT
Colorado Ballroom

12:00pm MDT

Lunch
Tuesday June 18, 2019 12:00pm - 1:00pm MDT
Mountain View Dining Room

1:00pm MDT

The Joint Application of HP and RCA Principles on an Actual Serious Incident
With the emergence of Human Performance Improvement (HPI) investigative approaches, there has been varying perspective’s about the relevance and even the effectiveness of Root Cause Analysis (RCA) as a method to truly understand a failure event. Do the HPI principles replace the need for ‘RCA’? Is ‘RCA’ capable of incorporating HPI principles? The speakers’ had a unique opportunity to co-investigate an unfortunate serious incident using both of their extensive backgrounds in HPI and RCA. This presentation will focus on what these experts learned from the other’s process, and how this new appreciation resulted in a more detailed and comprehensive investigation. The case will be made that these approaches are actually critical to each other’s success because they are interdependent.

Speakers
avatar for Robert

Robert

CEO, Reliability Center, Inc.
Bob Latino is CEO of Reliability Center, Inc. (RCI), out of Hopewell, VA.  In 1972, RCI was originally established as an R&D Reliability Engineering arm of Allied Chemical Corporation (more commonly known as Honeywell today).  RCI spun off as an independent company in 1985 and has... Read More →
avatar for Beth Lay

Beth Lay

Consultant, Lewis Tree Service, Inc.
Beth joined the Lewis family of companies as Director of Safety and Human Performance in 2018. She brings significant expertise to Lewis in the fields of Resilience Engineering, High Reliability Organizations, Safety II, Human Performance, and Operational Risk Management—and a view... Read More →



Tuesday June 18, 2019 1:00pm - 1:50pm MDT
Colorado Ballroom

1:50pm MDT

Break
Tuesday June 18, 2019 1:50pm - 2:00pm MDT
Common Area Outside of Colorado Ballroom

2:00pm MDT

Table Talk Session
Tuesday June 18, 2019 2:00pm - 2:50pm MDT
Colorado Ballroom

2:50pm MDT

Break
Tuesday June 18, 2019 2:50pm - 3:00pm MDT
Outside of Breakout Room

3:00pm MDT

Culture Development using HRO as a lens-Sharing Experiences of a 5 Years Change Journey of a Chemical Company
Speakers
avatar for Annette Gabauer

Annette Gabauer

Owner/Managing Director, ICL – Interventions for Corporate Learning GmbH
Specialist and senior expert for corporate learning and high performance & reliability organizing supporting large enterprises in their cultural change (long term change processes with BASF, ThyssenKrupp, Sabic, Commerzbank, BGETEM, Daimler etc.), 20 years of consulting experience... Read More →


Tuesday June 18, 2019 3:00pm - 3:50pm MDT
Arkansas

3:00pm MDT

Hands on HPI Training
Learn how to apply HPI tools out in the field while in the classroom by DLA's Dynamic Learninig Activites. We built portable training labs to use in break out sessions during our HPI training. We found these to be very effective and popular with our craft folks. We designed and built several DLA skids that helped support and teach HPI fundimentals. The DLA's were similar to how actual work out in the plant might look.

Speakers
avatar for Donnie

Donnie

AEP
39 years experience in power plant operations 


Tuesday June 18, 2019 3:00pm - 3:50pm MDT
White River II

3:00pm MDT

Interactive Human Performance 101- Engagement Roadmap (Part 1)
ContXt Corporation, in partnership with Luminant, has developed an innovative learning experience to help organizations build the buy-in and understanding required to effectively implement Human Performance Improvement. The learning experience combines a big picture visual with questions and exercises to engage small groups in robust conversation. Studies show that people retain 10% of what they read and 20% of what they hear. However, people retain 90% of what they see and discuss using metaphor-, story and visual-based learning and group conversations. The breakout session will allow participants to experience the workshop firsthand. Topics discussed will include: - What is Human Performance Improvement (HPI) at the highest level - The Principles of HPI - Errors and potential negative events that can happen to each of us around the home - The realization that we are all fallible - The two modes of thinking - system 1 thinking and system 2 thinking - Different types of Deviation Modes - Some of the most common reasons people deviate - Why the Blue Line never matches the Black Line - How we can best learn from events - Ways to implement Human Performance Improvement - Understanding and avoiding error traps, ensuring proper defenses are in place, utilizing the HPI tools - Best Practices and Lessons Learned The workshop: - Provides a big picture understanding of HPI in 90 to 120 minutes - Accelerates the learning process by combining visualization with small group conversation - Learners will spend less time in the classroom and more time on the job - Creates an organization ready to implement HPI - Quickly aligns the entire organization on the benefits of HPI, helping to foster the cultural change process - from the OLD to NEW view of Human Performance - Can train large numbers of people in a short amount of time The Breakout Session will also address best practices for implementing the workshop within organizations.

Speakers
avatar for Wes Havard

Wes Havard

OE Senior Consultant, Luminant
I was born at an early age, but I got older. After being accidentally left outside an all-you-can-eat barbecue joint outside Uncertain, Tx, I was adopted by a small family of Sasquatch. Eventually I made my way to the Martin Lake Power Plant where I was adopted by a family of OEs... Read More →
avatar for Charles Major

Charles Major

Director of Fossil Generation Operational Excellence, Luminant


Tuesday June 18, 2019 3:00pm - 3:50pm MDT
Rio Grande/Gunnison

3:00pm MDT

Learnings about PTSD from situations occurring in the air force
Speakers
avatar for Torrey

Torrey

Vice President, Performance Contractors
Torrey Garrison has been in the Safety Industry for more than 20 years.  Along with working with Performance Contractors he is also in the Air Force Reserves.  He states that life can be boring without a little laughter and even if he knows his jokes aren’t funny he tries them... Read More →


Tuesday June 18, 2019 3:00pm - 3:50pm MDT
Cheyenne I

3:00pm MDT

Let's Rock and Roll: Practices for Ensuring a Great Start to an Incident Analysis
Incident Analysis Teams are often cobbled together and thrown into the fray with minimal consideration of the elements needed to ensure their success. Unfortunately, a haphazard approach to starting the analysis can significantly hamper the team’s efficiency and effectiveness in solving the problem. Rick Foote, co-author of IEEE Standard 1707-2015 (IEEE Recommended Practice for the Investigation of Events at Nuclear Facilities), will discuss approaches that enable Incident Analysis Teams to get off to a great start. Attendees will learn about key activities that should precede team formation, such as evidence preservation by line personnel and establishing a team charter. Rick will discuss factors organizations should consider in order to establish lean and mean teams tailored to solving the specific incident at hand. Attendees will also learn ways to get their teams off to a running start once formed, such as how to perform effective kick-off briefings, and a structured methodology for identifying initial and subsequent task assignments for team members.

Speakers
avatar for Richard

Richard

Senior Consultant, Fisher Improvement Technologies Inc.
Rick Foote, a Senior Consultant with Fisher Improvement Technologies Inc. and owner of Compass Performance Improvement LLC, is a co-author of IEEE Standard 1707-2015 (Recommended Practice for the Investigation of Events at Nuclear Facilities). He’s successfully led incident analysis... Read More →



Tuesday June 18, 2019 3:00pm - 3:50pm MDT
White River I

3:00pm MDT

Shifting the Model of Performing Investigations in Biotechnology: The Biogen Story
The purpose of this talk will be to describe Biogen’s journey of integrating Human Performance principles into the investigation process in the biotechnology industry; from initially walking in the footsteps of the “Old View,” to blazing a new path based on the “New View.” This presentation will describe the path taken by Biogen starting in 2015 with an overemphasis on “human error” to a systematic approach in investigations. Advancing to a systematic approach led to identifying causes at the organizational level as opposed to only uncovering causes at the local level. In addition to the above, organizational analysis presented challenges to the biotech industry, which led to confusion about the application of Human Performance principles into the investigation process. The state of investigations at Biogen in 2019 is quite different from 2015. The integration of the systems approach, use of multi-causal causal analysis methods, delineation of local and organizational factors, evaluation of extent of condition and cause, and learning teams have defined excellence in investigations and established a framework for resilience.

Speakers
avatar for Natalie

Natalie

Manager of Investigations, Biogen
Natalie Upchurch Manager, Investigations, Performance & Process Improvement Biogen, North American Region.  Natalie’s role as a Manager of the Investigations Team is inclusive of Biogen’s RTP Drug Substance and Drug Product site operations. Natalie and staff are pioneers of implementing... Read More →
EW

Ellery Ward

Investigator l, Biogen
Ellery Ward Investigator I, Investigations Performance and Process Improvement Biogen, North American Region Ellery Ward is currently an Investigator at Biogen. She graduated from North Carolina State University in 2013 with a B.S. in Chemical Engineering and a concentration in Biomanufacturing... Read More →


Tuesday June 18, 2019 3:00pm - 3:50pm MDT
Cheyenne ll

3:50pm MDT

Break
Tuesday June 18, 2019 3:50pm - 4:00pm MDT
Outside of Breakout Room

4:00pm MDT

Functional Stupidity--the Positives and Pitfalls
Functional stupidity is described in Mats Avelsson and André Spicer's 2016 book The Stupidity Paradox. Through describing its characteristics, highlighted through examples, it describes what they label functional stupidity. Recognizing that different circumstances demand different approaches, they counsel that functional stupidity is not universally bad, but that on the whole, we need to recognize it and be aware of our societal (and organizational) drift toward thoughtless conformity. This talk leverages this book and other resources to help illustrate the concept of functional stupidity, why we need to understand it, and what we can do about it for the betterment of our organizations, as well as ourselves and society as a whole.

Speakers
avatar for Tanya

Tanya

Canadian Nuclear Safety Commissiopn
Tanya Hewitt received her PhD in Population Health from the University of Ottawa. She has a BSc in Physics from the University of Guelph, an MSc in Medical Physics from Carleton University, and a Graduate Certificate from the University of Ottawa in Risk Assessment and Management... Read More →


Tuesday June 18, 2019 4:00pm - 4:50pm MDT
White River I

4:00pm MDT

How to Create and Sustain HPI Advocates
Advocates are the life blood of the HPI culture, they are the veins that we use to transfer the life giving blood to the all areas of the plant, region etc. This will define the process of the "how to" get started and the areas to avoid.  Sustainment will also be discussed.

Speakers
avatar for Alvin Davis

Alvin Davis

Journeyman Electrician in Coal Plant.  36 years at Luminant


Tuesday June 18, 2019 4:00pm - 4:50pm MDT
White River II

4:00pm MDT

How to Get Started with Staff Rides
Speakers
avatar for Bert

Bert

Human Factors Lead, Apollo 13 Consult
Dr. Bert Slagmolen (1952) started his professional career as a researcher and consultant in the field of organizational development and management of change. Since 2002 he is primarily devoted to High Reliability Organizing (HRO) and Organizing for Resilience. He was and is involved... Read More →
avatar for Annette Gabauer

Annette Gabauer

Owner/Managing Director, ICL – Interventions for Corporate Learning GmbH
Specialist and senior expert for corporate learning and high performance & reliability organizing supporting large enterprises in their cultural change (long term change processes with BASF, ThyssenKrupp, Sabic, Commerzbank, BGETEM, Daimler etc.), 20 years of consulting experience... Read More →


Tuesday June 18, 2019 4:00pm - 4:50pm MDT
Arkansas

4:00pm MDT

Implementing and Integrating Human and Organizational Performance
Speakers
avatar for Tony Muschara

Tony Muschara

Consulting, LLC, Founder, Muschara Error Management
Over 35 years of experience in consulting, training, and management positions in commercial and military nuclear power operations. Specializes in the management of Human and Organizational Performance (H&OP) in high-hazard, industrialized environments. Recent clients include: Amgen... Read More →


Tuesday June 18, 2019 4:00pm - 4:50pm MDT
Platte

4:00pm MDT

Interactive Human Performance 101- Engagement Roadmap (Part 2)
ContXt Corporation, in partnership with Luminant, has developed an innovative learning experience to help organizations build the buy-in and understanding required to effectively implement Human Performance Improvement. The learning experience combines a big picture visual with questions and exercises to engage small groups in robust conversation. Studies show that people retain 10% of what they read and 20% of what they hear. However, people retain 90% of what they see and discuss using metaphor-, story and visual-based learning and group conversations. The breakout session will allow participants to experience the workshop firsthand. Topics discussed will include: - What is Human Performance Improvement (HPI) at the highest level - The Principles of HPI - Errors and potential negative events that can happen to each of us around the home - The realization that we are all fallible - The two modes of thinking - system 1 thinking and system 2 thinking - Different types of Deviation Modes - Some of the most common reasons people deviate - Why the Blue Line never matches the Black Line - How we can best learn from events - Ways to implement Human Performance Improvement - Understanding and avoiding error traps, ensuring proper defenses are in place, utilizing the HPI tools - Best Practices and Lessons Learned The workshop: - Provides a big picture understanding of HPI in 90 to 120 minutes - Accelerates the learning process by combining visualization with small group conversation - Learners will spend less time in the classroom and more time on the job - Creates an organization ready to implement HPI - Quickly aligns the entire organization on the benefits of HPI, helping to foster the cultural change process - from the OLD to NEW view of Human Performance - Can train large numbers of people in a short amount of time The Breakout Session will also address best practices for implementing the workshop within organizations.

Speakers
avatar for Wes Havard

Wes Havard

OE Senior Consultant, Luminant
I was born at an early age, but I got older. After being accidentally left outside an all-you-can-eat barbecue joint outside Uncertain, Tx, I was adopted by a small family of Sasquatch. Eventually I made my way to the Martin Lake Power Plant where I was adopted by a family of OEs... Read More →
avatar for Charles Major

Charles Major

Director of Fossil Generation Operational Excellence, Luminant


Tuesday June 18, 2019 4:00pm - 4:50pm MDT
Rio Grande/Gunnison

4:00pm MDT

Observing Training and Operating Experience through a Different Lens
Purpose: To encourage participants to view their current training and operating experience (OPEX) programs through a different lens. This session looks to provide a fresh perspective in reshaping and/or strengthening some common defenses (flawed or not) used throughout many high-risk industries; Training and OPEX. We’ll explore the question “Does your training and OPEX program provide enough impact to help your workforce store and retrieve the operational information they need in order to conduct their job more safely, effectively and productively?” The brain is like a massive haystack, capable of storing billions of pieces of information (needles). In and of itself, this is pretty impressive. However, it’s easily argued that the ability to retrieve the correct needle and pin an un-wanted event to the board of “Not Today”, is equally impressive. From the available research, we know the cognitive ability one uses to encode, store and retrieve information is directly related to the emotional connection an individual has to that information. This session looks to enhance your existing training program by discussing some of the available psychological and cognitive tools you can implement to change your stereotypical training session from “boring” to “memorable”. Summary: Today we are inundated with information coming at us in all directions. Getting your work force to effectively store and retrieve the information required to perform their job at a higher level may often be a daunting task. Oliver Wendel Holmes said, “A person must get a thing before they can forget it”. So how do we help them “get it”? Using some of the fundamentals of cognitive psychology discussed by Dr. Fischer (Florida International University) and Dr. Geiselman (UCLA), and current research from developmental molecular biologist, John Medina, we’ll look at some strategies one can use to help strengthen existing training programs and make them more memorable and operationally effective. Mark Spitz once said, “We all love to win, but how many people love to train?”. We’ll also take a look at some memory techniques used by Grandmaster of Memory, Kevin Horsley. During this session, participants will discover how a drift in training practices and operational excellence led to the unfortunate events of the USS McCain (DDG-56) and USS Fitzgerald (DDG-62), culminating in well over $500M in U.S. property damage and the immeasurable costs associated with the death of 17 sailors.

Speakers
avatar for Jason Brustad

Jason Brustad

Field Liaison
Jason M. Brustad is a retired U.S. Navy Master Diver with over 26 years of operational experience in underwater ship repair, maritime and aviation salvage, open-ocean towing, hyperbaric chamber operations and various projects involving national security interests. He has extensive... Read More →


Tuesday June 18, 2019 4:00pm - 4:50pm MDT
Cheyenne ll

4:00pm MDT

We Finished the Interview, Now What?
The vast majority of investigations involve interviews as a source of evidence. The problem with interviews is that, while information obtained through interviews is often the most useful we can uncover, it also tends to be the most unreliable, for a variety of reasons. Some of those reasons include: (1) witnesses miss a lot; (2) witnesses forget; (3) memory changes over time; (4) the interviewer impacts the answers; (5) interviewers have their own biases; and (6) the interview record is an imperfect summary of the information exchanged during the interview. This breakout session will discuss the use of interview evidence once the interview is completed, including: (1) Evidentiary Standard; (2) Recognizing “Key Testimony” (3) Establishing Testimony Credibility (4) Establishing Witness Credibility (5) How to Recognize When You Have a Credibility Problem This breakout session will not discuss how to conduct interviews. While my personal focus lies primarily in Event Investigations/Causal Analysis, this breakout session may be of potential interest to anyone who is tasked with using information obtained from interviews.

Speakers
avatar for Dick Swanson

Dick Swanson

Founder and President, Performance Management Initiatives, Inc.
Richard N. Swanson, P.E. is the founder and president of Performance Management Initiatives, Inc., a consulting practice that focuses on industrial investigations and performance improvement for high hazard industries, since 1996. Mr. Swanson is the co-editor of The Firebird Forum... Read More →


Tuesday June 18, 2019 4:00pm - 4:50pm MDT
Cheyenne I
 
Wednesday, June 19
 

7:00am MDT

Breakfast
Wednesday June 19, 2019 7:00am - 8:00am MDT
Mountain View Dining Room

8:00am MDT

Welcome Back & Daily Logistics
Moderators
avatar for Charles Major

Charles Major

Director of Fossil Generation Operational Excellence, Luminant

Wednesday June 19, 2019 8:00am - 8:10am MDT
Colorado Ballroom

8:10am MDT

The Hidden Science of Reliability
The Problem Statement: Sometimes in business, as in life, you get exactly what you expect. We make plans and hope things work out accordingly. They usually do. But sometimes, the unexpected happens. When accidents happen or we don’t get the results we expect, we’re often left wondering why we didn’t see it coming.

Wouldn’t it be better if we could understand the causes of these unintended outcomes and keep them from happening? Leading your organization has always been about focusing on what you do well – serving the needs of the marketplace through the efficient delivery of products and service, providing energy, treating patients, or transporting passengers, for example.

So What’s the Solution?
There’s a pattern to how bad things happen, and a science to preventing them. This session is about that science, and how it can help you get better results for your organization and in your everyday life. It’s the hidden science of reliability.

And it’s been hiding in plain view.

Scott Griffith’s upcoming book, The Hidden Science, describes an innovative new approach to improving organizational performance: combining elements from engineering system design, behavioral and organizational psychology, and the legal and ethical principles guiding individual accountability into a distinctive, state-of-the-art approach to achieving high reliability.

Griffith will present excerpts from his book and show dynamic new ways of achieving organizational improvement, calling for improved strategies focusing on the sequence of sociotechnical science. This approach, known as the Sequence, includes the following:

1. First see and understand risk.

2. Manage reliability in this order:
   a. System performance
   b. Human performance
   c. Organizational performance

Please join us as Griffith explains how you can learn The Hidden Science and guide your organization to become sustainably reliable.

Speakers
avatar for Scott

Scott

Co-Founder and Managing Partner, SG Collaborative Solutions, LLC
Scott Griffith is the Co-Founder and Managing Partner of SG Collaborative Solutions, LLC. Scott gained his reputation for world-class reliability and collaborative skills through success in high-consequence industries across the globe. He came to prominence in the field of aviation... Read More →



Wednesday June 19, 2019 8:10am - 9:00am MDT
Colorado Ballroom

9:00am MDT

Break
Wednesday June 19, 2019 9:00am - 9:10am MDT
Common Area Outside of Colorado Ballroom

9:10am MDT

The Blame Paradox
The presenter is a long-time investigator, teacher, and coach who has intentionally not sought-out the lastest thinking about blame, discipline, and related issues -- but has instead allowed his own experiences to form his opinions. This presentation explores where the presenter has come from, what experiences he's had, and what conclusions he's come to about the VALIDITY of BLAME -- and the way to handle it in a way that leads to constructive personal and organizational change. Presenter plans on using Poll Wizard through his talk.

Speakers
avatar for C.ROBERT

C.ROBERT

Founder/CEO, Failsafe-Network
C. Robert Nelms is a degreed Aerospace Engineer, having graduated from Texas A&M University in 1970. He worked at McDonnell Douglas until 1973, then became employed at Allied Chemical’s Nylon plant in Chesterfield, Virginia --an internationally recognized leader in Manufacturing... Read More →


Wednesday June 19, 2019 9:10am - 10:00am MDT
Colorado Ballroom

10:00am MDT

Break
Wednesday June 19, 2019 10:00am - 10:10am MDT
Common Area Outside of Colorado Ballroom

10:10am MDT

Human Performance Implementation: A Short History and How To Ensure Success- The Factor to Go to the Next Level
Speakers
avatar for Shane Bush

Shane Bush

Founder and Principal, BushCo
T. Shane Bush is the co-founder of BushCo HPI, Inc. whose primary mission is to “assist companies in eliminating unwanted outcomes related to human error” through the implementation of Human Performance Improvement (HPI). BushCo, Inc. clients include organizations such as Bell... Read More →


Wednesday June 19, 2019 10:10am - 11:00am MDT
Colorado Ballroom

11:00am MDT

Break
Wednesday June 19, 2019 11:00am - 11:10am MDT
Common Area Outside of Colorado Ballroom

11:10am MDT

Making Connections between HuP, HRO, RE, and RCA: Is there a right place and right time for each?
Making Connections between HuP, HRO, RE, and RCA:  Is there a right place and right time for each?   Using a case study, in a light-hearted and fun way, we will illuminate how each of these domains contributes to prevention, managing the unexpected, event learning and ultimately, organizational success.  While there are overlaps and gaps, we believe each brings a unique contribution and that recognizing when and how to use each approach with its unique tools and practices can create a holistic approach to success and safety in complex high-risk systems. Using a sample event, the panel of experts will explore: • Through the perspective of a timeline of an event (before, during, and after), which tools and practices come into play? • What does each approach assume about how the world works? • Where are perspectives and practices similar? What are the overlaps? • Where are perspectives and practices different? Where are they in conflict? • What would happen if we were really good at all of them? Panel discussion Riz Shah facilitator, Laurin Mooney / Bert Slagmolen- HRO, Asher Balkin / Beth Lay - RE, Bob Latino – RCA, Charles Major / Wes Havard – HuP Theme song: Dr. John: Right Place, Wrong Time   Theme song: https://www.youtube.com/watch?v=G5zPqgQ67yo

Speakers
avatar for Riz Shah

Riz Shah

Organizational Cultural Advisor/ Veteran Advocate, US Department of Energy
Rizwan Shah provides direct consultation (assistance) to the Department of Energy (DOE) as well as contractor senior officials and their organizations on the development, management, assessment and improvement of organizational culture, and performance reliability programs and interventions... Read More →


Wednesday June 19, 2019 11:10am - 12:00pm MDT
Colorado Ballroom

12:00pm MDT

Lunch
Wednesday June 19, 2019 12:00pm - 1:00pm MDT
Mountain View Dining Room

1:00pm MDT

Lessons Learned from Analysis of Serious Industry Events- A Crucial Conversation
This session discusses what we, as practitioners, can learn from the result of analyses of serious incidents or accidents at facilities that have implemented, or are implementing, Human Performance Improvement (HPI) or High Reliability Organization (HRO) principles. Our mission as practitioners in the field of human performance, root cause, and trending is almost always conducted in a high stakes environment, with multiple opinions, and strong emotions. Whether we come into our mission with a root cause, human performance, or reliability perspective our common goal is helping our organizations achieve safety and reliability by preventing events and organizational learning. As such, we should always be striving to learn about the successes and failures when we implement these principles into organizations. This session presents learnings from cause analyses of significant events including major equipment failures, injuries, and fatalities. In many of these events, the organization had implemented, or were implementing human performance or HRO principles. While the events are tragic, analysis of these events can give us insights into how to more effectively implement HPI or HRO principles into our organizations to avoid future events. This session is not intended to point fingers or place blame for lapses in implementation of these principles; it is intended as a crucial conversation so that we all can learn important lessons that will improve our efforts.

Speakers
avatar for Frederic

Frederic

President, WD Associates, Inc.
Fred uses the experience he gained in the U.S. Navy, commercial nuclear power plants, and as a consultant to help clients solve difficult problems in their organizations. He has a BS in Organizational Development from Immaculata College. Fred splits his time between Phoenix, Arizona... Read More →



Wednesday June 19, 2019 1:00pm - 1:50pm MDT
Colorado Ballroom

1:50pm MDT

Break
Wednesday June 19, 2019 1:50pm - 2:00pm MDT
Common Area Outside of Colorado Ballroom

2:00pm MDT

Poster Session
Poster Session Participant
avatar for C.ROBERT

C.ROBERT

Founder/CEO, Failsafe-Network
C. Robert Nelms is a degreed Aerospace Engineer, having graduated from Texas A&M University in 1970. He worked at McDonnell Douglas until 1973, then became employed at Allied Chemical’s Nylon plant in Chesterfield, Virginia --an internationally recognized leader in Manufacturing... Read More →
avatar for Carmen

Carmen

Southern California Edison
Senior Advisor overseeing this initiative responsible for managing the strategic design, development, change management, implementation planning and execution, sustainability and evaluation using industry and internal best practices. Over ten years of work experience project managing... Read More →
avatar for Chelsea Miller

Chelsea Miller

Chevron
Chelsea has worked in the oil and gas industry for a total of 15 years with the past 5 years at Chevron. Chelsea has held positions in Environmental Compliance, Process Safety and Managing Safe Work with the last year dedicated to Human Performance and Learning Teams.
CW

Corinne Wigness

Investigation Specialist, Sinclair
Corinne Wigness Corinne Wigness is currently employed at the Sinclair Wyoming Refining Company in Sinclair, Wyoming as the Investigation Specialist. In this position, she is responsible for monitoring entries into the incident management system, assigning priorities, and working with... Read More →
avatar for Dorien

Dorien

Human Error Specialist, Stedin
Dorien Janssen, MSc. +31 6 1592 5886 Human Error Specialist at Stedin, a Dutch DSO of 5000 employees, providing critical infrastructure for 2,2 million customers including the second largest port in the world and the Rotterdam metropolitan area. Fields of expertise: safety culture/HRO... Read More →
avatar for Drew Seidel

Drew Seidel

Plant Manager- Welsh Plant, AEP
Drew Seidel is the VP of Distribution Region Operation for AEP SWEPCO. He has worked in the electric utility industry for over 25 years. Prior to serving in his current role Drew managed 5 different power plants for American Electric Power. He is currently an HPRCT board member and... Read More →
EH

Even Hochberg

Childrens National
Evan Hochberg, MBA, RN, CPN – Evan Hochberg serves as the Lead Patient Safety Consultant for Children’s National Health System. In this role, Mr. Hochberg leads and facilitates event cause analysis, organizational culture measurement and improvement, and with provides internal... Read More →
avatar for Heather Zettel

Heather Zettel

Root Cause Investigator, Bruce Power
Katrina Wyatt Human Performance Manger, Bruce Power Katrina Wyatt is a Human Performance Manager at Bruce Power Nuclear Generating Station in Tiverton Ontario. Katrina is a recent graduate from the University of Western Ontario and has used her Kinesiology degree and heavy psychology... Read More →
avatar for Jake Rehlander

Jake Rehlander

Safety Specialist, Lewis Tree
Jake Rehlander is a Safety Specialist at Lewis Tree. He has been in the tree industry for seven years, starting as a ground man on a residential crew and working his way up to a climber, then a foreman. In 2016 he achieved his CTSP and ISA certifications before moving into a career... Read More →
avatar for Jessica Nelms Hall

Jessica Nelms Hall

Principal | HPRCT Secretary, Failsafe-Network
Jessica is a graduate from Virginia Tech with a BS in Mechanical Engineering. During her time at Virginia Tech, Jessica and a small team of 4 other people designed and built a multiple award-winning mobile organ preservation system. This experience helped Jessica manifest a need to... Read More →
avatar for Joe Estey

Joe Estey

Principal Performance Improvement Specialist, Lucas Inc
Lucas Engineering and Management Services, located in Richland Washington, is a provider of solutions in operations as diverse as nuclear and industrial engineering, environmental remediation and construction, human performance and conduct of operations training, consulting and coaching... Read More →
avatar for Jon Boisoneau

Jon Boisoneau

Sologic
Jon oversees development and delivery of Causelink software and the Sologic e-learning courses. He helps Sologic understand customer needs, then develops and delivers product improvements and new features that directly meet those needs. Jon also manages Sologic’s software support... Read More →
avatar for Kevin Wright

Kevin Wright

Specialist, Safety Culture, Enbridge Inc.
Kevin began his safety career in automotive and non-automotive manufacturing where he developed, implemented and monitored the safety management systems for Toldo Corporation's seven business units in Canada, the US and Mexico. In 2007, Kevin joined Spectra Energy where he worked... Read More →
avatar for Lauren Mooney

Lauren Mooney

Founder, Be Highly Reliable
Laurin Mooney BSN MS.  Laurin is committed to helping people understand and integrate High Reliability Organizing strategies into healthcare delivery.  She is driven by the questions, “How can it be that we are harming the very patients we intend to help?” and “What do we... Read More →
L

Leah

AEP/SWEPCO
Leah is currently Plant manager at Knox Lee Power Plant in Longview Tx. and has worked for SWEPCO since 2008. Her previous role was SWEPCO Generation Performance Improvement manager with responsibilites in human performance and continuous improvement. Her background includes Evironmental... Read More →
avatar for Mike Blevins

Mike Blevins

Board Member, HPRCT
After more than 40 years with TXU and Energy Future Holdings, Mike now serves as a consultant to the energy industry primarily in organizational, executive and leadership development. He works with a number of companies in organizational and leadership assessments, team and individual... Read More →



Wednesday June 19, 2019 2:00pm - 2:50pm MDT
Common Area Outside of Colorado Ballroom

2:50pm MDT

Break
Wednesday June 19, 2019 2:50pm - 3:00pm MDT
Outside of Breakout Room

3:00pm MDT

7 Questions for a High Reliability Mindset
Are you interested in applying HRO in your work but are not sure where to begin? You can get started working with a High Reliability Mindset today. In this fun and interactive session, you will learn 7 simple questions that operationalize the 5 HRO strategies in any setting.   You will also learn:  Why working in a complex sociotechnical system demands we ask these questions How mindfulness factors in Why plans can cause problems How language contributes to failures How to approach ambiguity What not to say when you are unsure   We will explore and learn all these using sketches you will create to help you remember these powerful concepts and share them with others.    

Speakers
avatar for Lauren Mooney

Lauren Mooney

Founder, Be Highly Reliable
Laurin Mooney BSN MS.  Laurin is committed to helping people understand and integrate High Reliability Organizing strategies into healthcare delivery.  She is driven by the questions, “How can it be that we are harming the very patients we intend to help?” and “What do we... Read More →


Wednesday June 19, 2019 3:00pm - 3:50pm MDT
Arkansas

3:00pm MDT

Generating and Maintaining Buy-In and Support for Investigations
In 2014 there were very few people at our contract pharmaceutical sterile filling site who believed that effective investigations would be the key to unlocking the performance potential of our site. Support for investigation processes is a regulatory requirement in the pharmaceutical industry, and our level of support was sufficient to meet the requirement, but quality had to drive and pull teams to meet the standard. Today our site and culture are different. Our investigations are considered “best in class” in our contract manufacturing network and we have received this feedback from FDA, ANVISA, Russian Ministry of Health, EMEA, and other regulatory authorities. Leading the team that drove these improvements has been the highlight of my career and our success can be attributed to deep cultural support more than any other factor. This support was challenging to generate and has even been withdrawn at times.   We faced multiple complex problems generating and maintaining buy in to do investigations well even though our process was obviously improved. From 2014-2018 we have had double digit year on year reduction in deviations. We have had investigation cycle time decrease from over 150 days to less than 30 while improving the quality. We have gone from identifying causes in <50% of deviations to 98%. We have gone from human errors being assigned as the cause in 75% of deviations to <10%.  We also went from 30 average days to close back up to 70 and then back down again. We had to identify the causes of shifting support and put processes in place to prevent them in the future. My hope is that others can benefit if I share some very challenging problems and our solutions.  
• How do you get organizational leaders excited support for investigations?
• How do you ensure that stakeholders in each investigation are engaged, honest, and effective?
• How do you motivate a team that has to solve the hardest problems the company faces?
• How do you promote a culture where ownership and accountability?
• How do you recover from the support that led to your success being withdrawn?
• How do you complete investigations quickly without compromising the content?
• How do you facilitate operators and technical teams in finding the most efficient solutions?
• How do you translate quality metrics to financial ones?

It is a complicated and challenging task to get teams excited about investigations. If you love investigating, you are just a little bit of a unique snowflake! It is also so rewarding and satisfying to part of a quality centered organization that embraces change and data driven solutions. Our experience can be used in any industry or environment, because once the case for quality is made in an effective way, support and engagement is the natural response.

Speakers
avatar for Joseph Longworth

Joseph Longworth

QA Manager Compliance and oversight, Jubilant HolisterStier
I have worked in the pharmaceutical industry for 7 years with Jubilant HollisterStier. We are a contract sterile filling site with 2 high speed lines, a clinical trial area, and 2 lower volume fill areas. We also have our own brand of allergenic immunotherapies. I have worked in Validation... Read More →


Wednesday June 19, 2019 3:00pm - 3:50pm MDT
Cheyenne ll

3:00pm MDT

Making Connections to Future Performance: Moving Past Yesterday's News
Many company leaders are very adept in utilizing descriptive statistics to understand the past performance of their firm.  However, many of these leaders have not adopted the subsequent innovations of Predictive and Prescriptive Analytics, which precludes the use of Machine Learning and other profitable innovations.  Because of the competitive advantage afforded by Industry 4.0 technologies, the Internet of Things (IoT), and Artificial Intelligence (AI), it has never been more essential to the performance and sustainability of the firm that managers and executives move beyond descriptive analytics and connect with the full potential of their data to enhance their decision-making processes (Evidence-Based Decision Making).  By taking the next step into predictive and prescriptive analytics, leaders can understand the working relationships between variables that they monitor better, accurately forecast near-term performance, project long-term results, and use predictive modeling to provide decision support.    Often the most significant challenge is understanding how to evaluate the need for these innovations, how to implement these technologies, and how to evaluate the results of adding innovations to the operations of the business.  A thorough description of predictive and prescriptive analytics, as well as the principles for implementation, are included to enable the practical application of the leading edge concepts in this presentation.

Speakers
avatar for Jack

Jack

Chief Business Consultant, By the Numbers, LLC.
With over 15 years in Nuclear Power, Jack Bower has been assisting companies with business start-ups, Causal Analysis, Data Analytics implementation, Business Strategy, Operational Research, and Evidence-Based Decision Making.  He specializes in Nuclear Industry 4.0 technologies... Read More →


Wednesday June 19, 2019 3:00pm - 3:50pm MDT
Platte

3:00pm MDT

Principles and the Power of Storytelling to Improve Human Performance
An ever-present challenge for organizations of all shapes and sizes is how to send people home in the same condition in which they showed up to work. An organization’s senior leaders may espouse values about a robust safety and operational culture, but how do they demonstrate that it’s more than just talk?  It’s not enough for an institution to simply have a “safety program” or a list of procedures. Rules and regulations cannot adequately protect those engaged in research and development (R&D). Because of the special characteristics and unique hazards of R&D, the organizational culture must incorporate a healthy safety culture, founded on a collective commitment to put safety first. This commitment applies to everyone in the organization, from the laboratory director to the individual contributor.   At Pacific Northwest National Laboratory (PNNL), a Battelle-operated Department of Energy (DOE) multi-mission laboratory with 4,400 staff members, the answer to the challenge has been creating a connection between eight “Safe Conduct of Research (SCoR)” principles and the behavior and decision-making (human performance) of staff members.   These eight principles set the expectation for how each staff member should approach their work. The principles are institutionalized through an awareness campaign which includes an engaging series of videos that demonstrate the principles in action, featuring staff members at all levels of the organization.  The video stories told don’t just feature the “wins”; they also tell of work that didn’t go as planned in an effort to encourage organizational learning and continuous improvement. These stories serve to create “sticky” memories by attaching emotions to occurrences and keep top-of-mind awareness with staff. As a recent article in the Harvard Business Review puts it, “A story can go where quantitative analysis is denied admission: our hearts.”   Through the success of the campaign, the SCoR principles are becoming common in work planning and reflection on completed work; staff are willingly incorporating them in pre- and post-job reviews, safety shares, and staff events. This coincides with PNNL’s lowest recordable injury rate in the last 14 years.   “I would rather have ten staff members who actively incorporate the SCoR principles into their thinking and behavior than fifty who are married to procedures,” says one of the presenters.   The end game? An engaged staff, a significant improvement in safety performance, and less reliance on processes and procedures.  In this presentation, you’ll learn more about the SCoR principles from an operations perspective and see examples of the messaging that has been so successful in an R&D environment.

Speakers
avatar for Shannon

Shannon

Lessons Learned Program Manager, Pacific Northwest National Laboratory
Shannon manages the Lessons Learned/Operating Experience program at Pacific Northwest National Laboratory (PNNL). A former radio and television news anchor, she also shoots, writes, and edits many of the videos that PNNL distributes toward the improvement of its safety culture. Shannon... Read More →
avatar for Rob Cuello

Rob Cuello

Pacific Northwest National Laboratory
Rob has 38 years of experience performing and supporting environmental and energy research at Pacific Northwest National Laboratory (PNNL). He currently manages the Operations and Assessment Office within the Energy and Environment Directorate and is responsible for shaping culture... Read More →


Wednesday June 19, 2019 3:00pm - 3:50pm MDT
White River II

3:00pm MDT

Round Table: Why Organizations Fail to Learn: Developing a Learning Organization Driven by Curiousity not Consequences
The pattern is repeated weekly in the workplace: audits, assessment and inspections indicate all systems and processes are in place to prevent undesirable events until one occurs and the first thing those audited, assessed and inspected say is: We knew this was going to happen! Many organizations fail to learn from a genuine interest and curiosity about their own practices and processes, relying on consequences to be their guide. Near misses, good catches and close are regarded as the result of 'great planning' and resiliency, reinforcing the belief we've got the bases covered or something worse would have happened. During this facilitated roundtable, each participant will have an opportunity to dialogue with other participants and the Facilitator(s) about identifying, communicating and learning from the weak signals at a lowest level of pain rather than reacting to the pain of regret too many allow to guide their business practices.

Speakers
avatar for Joe Estey

Joe Estey

Principal Performance Improvement Specialist, Lucas Inc
Lucas Engineering and Management Services, located in Richland Washington, is a provider of solutions in operations as diverse as nuclear and industrial engineering, environmental remediation and construction, human performance and conduct of operations training, consulting and coaching... Read More →


Wednesday June 19, 2019 3:00pm - 3:50pm MDT
Rio Grande/Gunnison

3:00pm MDT

The 2nd Step: Preparing to be Surprised
We are working on a book chapter on this topic and it is the most interesting part of the work I’ve been doing at Lewis Tree.   Resilience Engineers say that for complex systems, surprise will happen, but we mostly neglect to discuss what to do with it.  We’ll discuss the inevitability of surprise in complex systems, the Nature of Surprise (What surprise is), and how and why surprise happens.  We’ll share tactics for preparing for and learning from surprise and managing emergent risks.  We’ll share patterns of surprise from a case study in tree work (based on 6 months of data - tree worker answers to the question “how were we surprised?” after incidents).
 

Speakers
avatar for Beth Lay

Beth Lay

Consultant, Lewis Tree Service, Inc.
Beth joined the Lewis family of companies as Director of Safety and Human Performance in 2018. She brings significant expertise to Lewis in the fields of Resilience Engineering, High Reliability Organizations, Safety II, Human Performance, and Operational Risk Management—and a view... Read More →
avatar for Asher Balkin

Asher Balkin

Research Engineer, CSEL, Ohio State
An interdisciplinary researcher who has worked in fields as diverse as public health, international security, surgical research, and human/automation interaction, Asher is known equally well for the quality of his research as for his sardonic wit.He is currently a Research Engineer... Read More →


Wednesday June 19, 2019 3:00pm - 3:50pm MDT
Cheyenne I

3:50pm MDT

Break
Wednesday June 19, 2019 3:50pm - 4:00pm MDT
Outside of Breakout Room

4:00pm MDT

Four Common Ways of Leading: It isn't just about open and closed questions anymore
You may not even know you are doing it.   Language is tricky and influence can happen in an instant. Literally, one word can make a difference.   Find that difficult to believe?   Join me for this 50 minute presentation on four ways you may be influencing your clients, interviewees, co-workers, subordinates, and peers.   I like to run a high energy, interactive presentation. If sitting back for a “point and click” is your preference, this may not be the presentation for you. Please bring your attention, your curiosity, and perhaps even a willingness to share examples from your own life.   An interviewer’s language cannot determine an interviewee’s response, but it is likely to influence their response. While interviewees are not bound to follow a question, the nature of language, social convention, the context of the interview and certain ‘cognitive biases’ add to the likelihood that an interviewee will (consciously or otherwise) restrict themselves to answering within semantic frames and presuppositions set by the question.   It is often assumed that leading questions are obvious and easy to avoid. On the contrary, learning is more subtle and prevalent than is usually imagined, and because of this, leading questions and statements are often used unwittingly.   The first step in having some choice over the use of leading or non-leading questions, is to understand the four most common types of leading.  Knowing when you are influencing others is a high-level calibration. It is not about reading people and noting their responses, it is much more subtle and happy to say, easier than that.   You don’t even need to have good people skills to know the difference. Now isn’t that a relief?  Based on a linguistic model and steeped in cognitive science Clean Language, its principles and simple questioning structure, can help you avoid unintentional influence on others.    To ask really good questions - questions that are powerful, useful, and appropriate, and NOT leading - you need a minimum of two things:   The ability to listen accurately Know the four most common ways of leading  Empirical research shows that even a single word (especially a metaphor) or presupposition can materially ‘lead the witness’.    Objectives  The presentation will provide background information and practical activities for participants to learn: (1) where clean language comes from, (2) four most common ways of ‘leading’ (3) how to use the most useful classically clean questions.  You will:  Learn the difference between Open/Closed, and leading questions.   The four most common ways of leading and how to avoid them in the future.   Experience Clean Questions in action as Facilitating Cleanly is modeled by the presenter and see how one can use this methodology live with an interactive group.  
Be given a simple questioning model that you can begin using right away - helping you avoid unintentional influence in four easy questions.


Speakers
avatar for Sharon Small

Sharon Small

Clean Language Trainer and Assessor, Clean Language Institute
Sharon Small is an independent researcher and internationally recognized Clean Language trainer and assessor. She has over 13 years of experience working in the nuclear industry, a degree in psychology, and background in NLP. She is the author of The End of Therapy, co-editor of Who... Read More →


Wednesday June 19, 2019 4:00pm - 4:50pm MDT
Arkansas

4:00pm MDT

Human Performance: What separates the implementation winners and losers
Speakers
avatar for Shane Bush

Shane Bush

Founder and Principal, BushCo
T. Shane Bush is the co-founder of BushCo HPI, Inc. whose primary mission is to “assist companies in eliminating unwanted outcomes related to human error” through the implementation of Human Performance Improvement (HPI). BushCo, Inc. clients include organizations such as Bell... Read More →


Wednesday June 19, 2019 4:00pm - 4:50pm MDT
Rio Grande/Gunnison

4:00pm MDT

Investigations Combing RCA Methodology with Learning Teams
In an effort to increase the effectiveness of learning from failure, in certain situations, we have found that combining aspects of a traditional RCA with a learning team can provide more thorough understanding of failures.  The breakout session will briefly cover the methodologies used, how the investigations are conducted, followed by a an example.  We are interested in a dialogue with other practitioners to improve our methodology.

Speakers
avatar for Derek Crane

Derek Crane

Senior Safety & Health Consultant, Conocophillips
Derek Crane received a BS degree in Fire Protection and Safety Engineering Technology from Oklahoma State University in 1998. Mr. Crane has over 20 years of HSE experience across various aspects of Oil & Gas production, including Refining, Pipelines & Terminals, Major Capital Projects... Read More →


Wednesday June 19, 2019 4:00pm - 4:50pm MDT
Cheyenne ll

4:00pm MDT

Leader-Inspired Safety: 4 must-have skills that build culutral excellence
Join presenter and author David Crouch, Senior Safety Consultant, Caterpillar Safety Services, for this dynamic presentation on Leader-Inspired Safety. Employees make choices every day on whether to work safely. The most powerful influence on those choices is the leader, who must do certain things every day to create the type of culture that inspires safe behavior in employees. After five years of research, Caterpillar has learned exactly what those things are. To be an effective safety leader requires mastery of four core skills, or domains. These four statistically validated domains, along with fourteen elements of leader-inspired safety, are introduced in this dynamic presentation. Mastering these skills enable a leader to produce a strong culture of accountability, create meaningful connectivity with others, demonstrate credible safety consciousness, and build trust. The effective safety leader becomes an effective business leader.

Speakers
avatar for David

David

David has served since 1979 as an organizational development professional helping teams and organizations of all types build and sustain safety and cultural excellence. His passion for excellence and values-driven approach enable him to relate to most anyone in any environment pursuing... Read More →



Wednesday June 19, 2019 4:00pm - 4:50pm MDT
White River II

4:00pm MDT

Learning Teams vs. Latent Cause Analysis: An Unbiased Comparison by a Practitioner that Uses Both
This break-out session will provide a brief overview of the Latent Cause Analysis and Learning Teams processes, their distinctive attributes, and the advantages and disadvantages of each in different contexts.

Speakers
avatar for Wes Havard

Wes Havard

OE Senior Consultant, Luminant
I was born at an early age, but I got older. After being accidentally left outside an all-you-can-eat barbecue joint outside Uncertain, Tx, I was adopted by a small family of Sasquatch. Eventually I made my way to the Martin Lake Power Plant where I was adopted by a family of OEs... Read More →


Wednesday June 19, 2019 4:00pm - 4:50pm MDT
White River I

4:00pm MDT

Operations Excellence Through People- The Silver Bullet
INTRODUCTION We are aware that process industries are being challenged and are under tremendous pressure to perform. The industry is wholeheartedly embracing technology, believing it is the answer to incident-free operations.  The industry has also been caught up in increasing complexity — caused by the belief that more and more procedures and management systems are the answers to incident-free operations. OPERATIONAL EXCELLENCE Companies take many approaches to operational excellence. Some believe that the answer is technology.  Others believe management systems and detailed procedures are the way to go: “If people just followed procedures, incidents would not happen.”  Whatever the approach, an inescapable fact is that people run facilities. So perhaps the best approach is to foster the success of people as the path to operational and business success. TECHNOLOGY OR PEOPLE? Technology has made great contributions to process industries over the last couple of decades, starting with the introduction of distributed control systems, through advanced control and smart transmitters, to current activity around big data and artificial intelligence.  It seems as if it could be possible to fully automate and run plants without people. WHAT ABOUT COMPLEXITY? Complexity challenges the capabilities of virtually every organization. Technology, process and regulation drive increased complexity.  Unfortunately, experience clearly demonstrates that complexity leads to more complexity and the likelihood of system failure. For example, the common response to poor performance or an incident is an investigation resulting in a list of recommendations, which invariably leads to more procedures or prescriptive ways of doing things.  Where is the danger?  Pushing  personnel to not think by encouraging people to simply check boxes and monitor systems.  HUMAN FACTORS AND ORGANIZATIONAL PERFORMANCE Discovering where technology, people and complexity converge in order to improve performance and reduce risk, requires understanding Human and Organizational Performance (HoP) and Risk Management. WORK ENVIRONMENT Does the work environment lead the workforce to achieve operational excellence?  Or is it a work environment where people just do their job and go home — leaving management frustrated about the inability to achieve operational excellence? WORKFORCE Hiring the right people is critical.  When seeking potential employees, most companies simply look at skills, experience and knowledge as expressed on resumés.  While important, greater emphasis should be placed on behaviors such as alignment with company objectives and culture. In the end, while technology and complexity increase, real and measurable competitive advantage comes through people.  The right people with the right experience and skill, able to work within the culture and with coworkers in an environment with crisp roles and responsibilities unleashes new potential, performance and productivity — while reducing operational risk in the process. SUMMARY Look no further than your workforce.  They’re already in place but, statistically, are underutilized or contributing below what they’re capable of as a result of over-emphasizing technology and process — removing from them the requirement to “think.”

Speakers
avatar for MARK

MARK

Pilko Associates, Advisor
Mark Turri has worked in the oil refining industry for over 40 years. His approach to operations excellence is based on the belief that it can best be achieved through a competent, engaged workforce with clear roles, responsibilities, expectations and aligned behaviors. This belief... Read More →


Wednesday June 19, 2019 4:00pm - 4:50pm MDT
Cheyenne I

4:00pm MDT

Rountable: Metrics that Matter-- How we Track, Trend, Evaluate and use Leading and Lagging Indicators to Improve Performance
The pattern is repeated weekly in the workplace: audits, assessment and inspections indicate all systems and processes are in place to prevent undesirable events until one occurs and the first thing those audited, assessed and inspected say is: We knew this was going to happen!  Many organizations fail to learn from a genuine interest and curiosity about their own practices and processes, relying on consequences to be their guide. Near misses, good catches and close are regarded as the result of 'great planning' and resiliency, reinforcing the belief we've got the bases covered or something worse would have happened. During this facilitated roundtable, each participant will have an opportunity to dialogue with other participants and the Facilitator(s) about identifying, communicating and learning from the weak signals at a lowest level of pain rather than reacting to the pain of regret too many allow to guide their business practices.  

Speakers
avatar for Joe Estey

Joe Estey

Principal Performance Improvement Specialist, Lucas Inc
Lucas Engineering and Management Services, located in Richland Washington, is a provider of solutions in operations as diverse as nuclear and industrial engineering, environmental remediation and construction, human performance and conduct of operations training, consulting and coaching... Read More →


Wednesday June 19, 2019 4:00pm - 4:50pm MDT
Platte

6:00pm MDT

HPRCT Evening Reception
Come celebrate the 25th Annual HPRCT Conference in the Cheyenne Courtyard from 6:00 pm to 9:00 pm. 


Wednesday June 19, 2019 6:00pm - 9:00pm MDT
Cheyenne Courtyard
 
Thursday, June 20
 

7:00am MDT

Breakfast
Thursday June 20, 2019 7:00am - 8:00am MDT
TBA

8:10am MDT

The Five Principles of Human Performance
Speakers
avatar for Todd Conklin

Todd Conklin

Senior Advisor and Consultant, Los Alamos National Laboratory
Dr. Todd Conklin has spent 27 years as a Senior Advisor for Organizational and Safety Culture at Los Alamos National Laboratory.   Dr. Conklin has honed his craft in Human Performance at Los Alamos and through his interactions as an international speaker and thought leader in the... Read More →


Thursday June 20, 2019 8:10am - 9:00am MDT
Colorado Ballroom

9:00am MDT

Break
Thursday June 20, 2019 9:00am - 9:10am MDT
TBA

9:10am MDT

Advanced Defense Systems - Investigative Methodology – Illustrated with "Ethiopian 737 MAX Crash" that occurred on March 10, 2019
A thorough investigation is required in order to reach full understanding of failures in a complicated multidisciplinary defense system while still under development.

This presentation describes our best practices for obtaining full understanding and reaching broad insights to minimize similar failures across the organization.
the major steps of our failure analysis methodology are :

  1. Understanding the problem and the system
  2. Brain storming and constructing an initial failure tree of the possible causes
  3.  Gathering and analyzing the evidence
  4. Going through the physical, human and latent causes that led to the failure
  5. Explaining the chain of events leading to the failure
  6.  Insight output - corrective actions taken by the project and the higher levels in the organization.

The presentation will include a real life example of a failure analysis of a multidisciplinary system.

Speakers
A

Amit

Chief Engineer RD&E Mechanical Department of the RD&E Division, Rafael Advanced Defense Systems LTD
Amit has worked 35 years as a Mechanical Engineer in various managerial positions.  These days, he is the Chief Engineer RD&E Mechanical Department of the RD&E Division.  Here,  he guides "failure analysis methodology".  He is also a chairman of failure investigations committ... Read More →


Thursday June 20, 2019 9:10am - 10:00pm MDT
Colorado Ballroom

10:00am MDT

Break
Thursday June 20, 2019 10:00am - 10:10am MDT
TBA

10:10am MDT

This Will Hurt a Bit: What Every Oranization Needs to Learn from the Cryptocurrency Crisis in the Northwest
Anyone watching the torrid ups and downs of Bit Coin, RXP, Pot Cash and Etherium recognizes the risk, rewards and potential robbery this new source of spending and investing represents. What many do not know, outside the NW USA communities that have had to deal with the unintended consequences first hand, is that there are many unmanaged and unimagined risks that have had a much dire impact than losing money on a blockchain transaction. Error likely situations, flawed defenses and latent organizational weaknesses helped to create unsafe conditions and uncertain futures for those not benefitting from the cryptocurrency mining operations in small communities where mining operations are springing up in apartments, homes and C-Boxes. Using this current day crisis as a case study, Estey will discuss the common denominators between the Bitcoin mining phenomenon and the extent of condition and causes effecting every business or operation at some point in the evolution of their work.  

Speakers
avatar for Joe Estey

Joe Estey

Principal Performance Improvement Specialist, Lucas Inc
Lucas Engineering and Management Services, located in Richland Washington, is a provider of solutions in operations as diverse as nuclear and industrial engineering, environmental remediation and construction, human performance and conduct of operations training, consulting and coaching... Read More →


Thursday June 20, 2019 10:10am - 11:00am MDT
Colorado Ballroom

11:00am MDT

Break
Thursday June 20, 2019 11:00am - 11:10am MDT
TBA

11:10am MDT

Culture Change that's Built to Last: Six Questions that Lead to Success
After a two year journey to implement HPI on an organizational level, we've learned many of the questions that we believe any newcomer should ask to set themselves up for a successful culture change (and we wish we'd known ourselves).   We will present the 6 questions executives must answer, plus resources that can help do so for each, and key takeaways for a crafts field practice in HPI.   The Six Questions: 1. Does the org believe in the science of error? 2. What is your appetite for discretion in work? 3. Is your leadership ready to model a culture of error? 4. Are you committed to transforming how you plan, execute and learn from work? 5. Do you understand the implications for discipline? 6. Are the necessary resources ready?

Speakers
avatar for Jeremy

Jeremy

Organizational and Employee Development Manager, Chelan County PUD
Jeremy Jordan is a Certified Professional in Learning and Performance, and the Organizational & Employee Development Manager for Chelan County PUD, where he is responsible for leading the HPI strategic implementation for the District's 800 employees as part of the Safety & HPI Team... Read More →
avatar for Greg Smith

Greg Smith

Organizational and Employee Development Manager


Thursday June 20, 2019 11:10am - 12:00pm MDT
Colorado Ballroom

12:00pm MDT

Lunch
Thursday June 20, 2019 12:00pm - 1:00pm MDT
TBA

1:00pm MDT

The "T" In the Three Legged Stool of HPRCT
HPRCT is a three legged stool – Human Performance, Root Cause analysis, and Trending.  This session will show you how the third leg, Trending, can work with the other two legs to provide a firm foundation for your facility’s success.   The third leg has been challenging and confusing to many – this is the opportunity to understand the opportunities gained through successful trending, while understanding the costs of arbitrary targets, reaction to random noise, and the misdirection caused by moving averages.  We can learn from 80 years of industrial experience with statistical understanding of data, and apply modern techniques to understand what our data are telling us, how to heed that call, and apply that knowledge in preventive and corrective actions.   This presentation is a practical application of Drs Shewhart and Deming’s groundbreaking work at six different nuclear sites which has improved operations and quality and stakeholder satisfaction.  You will learn how to predict the future and detect Trends in a formal, objective manner.  And if you can understand your trends, you can predict the future, and you can manage the future.

We will cover trend detection using Statistical Process Control analysis of Human Performance and Causal Data. We will show how Trend results can and should influence the scope of Root Cause and Human Performance efforts. You will learn when one should performance a Root Cause analysis of a recent event versus when to do a Root Cause analysis of the stable process that created that event (and will continue to create future events). “Cognitive” trending theory and examples will also be provided. Finally, a tool to integrate this information together to create knowledge and wisdom will be provided to you – the Statistical Process Control based Dashboard. This provides a methodology to quickly display HP-RC-T results in an integrated whole, allow ability to drill down to sources of failure . . . and success. You will be able to provide this integrated view for quick understanding by your senior management and regulators. You will make objective data-driven decisions while including the necessary subjective information and expert opinions. This will allow for holistic, well-rounded actions to be developed, implemented, and the effects determined leading to facility success. Your presenter has 25 years of experience trending and interpreting data at U.S. and Canadian nuclear facilities including Fernald, Hanford, Portsmouth, Paducah, Savannah River and Chalk River (Canadian Nuclear Laboratories). He has been contracted by nuclear and non-nuclear companies to assist with their understanding of their data and made more than 100 presentations and publications on the subject. Please join us in an exploration of YOUR data and how YOU can put your data to WORK for YOU.

Speakers
avatar for Steven

Steven

Savannah River National Laboratory
Steven S Prevette is a Fluor corporation employee supporting three nuclear sites and Fluor Government Group headquarters with safety, security, quality, and human performance metrics. Steven is also a college instructor first for City University of Bellevue WA at its Richland WA campus... Read More →



Thursday June 20, 2019 1:00pm - 1:50pm MDT
Colorado Ballroom

1:50pm MDT

Break
Thursday June 20, 2019 1:50pm - 2:00pm MDT
TBA

2:00pm MDT

My Organization Wants to Become an HRO-Now What? ( Case Study: How ConocoPhillips Canada is Establishing and Sustaining an HRO)
My Organization Wants to Become an HRO – Now What? (Case Study: How ConocoPhillips Canada is Establishing and Sustaining an HRO)  So, you’re excited about your organization becoming a High Reliability Organization (HRO) - now what? What are the tangible steps you need to take? What role do leaders, front line workers and individuals play in making this change? What resources do you need? How do you measure success? These, and more, were the questions faced by ConocoPhillips Canada’s leadership six years ago when we decided we needed something different to take our safety performance to the next level. Since then, we have been on an exciting journey towards becoming an HRO and changing our culture.  
As we worked to answer these questions, we learned from HRO thought leaders, started learning differently and created a fit-for-purpose HRO Framework that is enabling our team to implement HRO concepts in a way that works for our business – both in the field and in the office. While working to establish an HRO, we have learned the importance of:

• Leadership commitment and engagement in creating an environment where an HRO culture can flourish. • Taking a deliberate approach to organizational change management.
• Implementing tools that enable the application of HRO concepts in a practical way. This may include aligning and enhancing existing tools.
• Patience and perseverance.

Are we there yet? No, we never will be. Becoming an HRO is about the journey. It’s a journey we are committed to, and though it isn’t a straight path, our commitment remains strong. We have seen a measurable change in our safety performance and our reliability in other areas of our business, as we continue to work to implement the concepts of an HRO in our organization.

Speakers
K

Kimberly

External Relations Manager, ConocoPhillips Canada
Kimberly Iverson is manager, Government and External Relations for ConocoPhillips Canada. In this role, she is responsible for the Stakeholder and Indigenous Relations, Regulatory Affairs, and Government Relations teams. Iverson began her career working for the Alberta Energy and... Read More →


Thursday June 20, 2019 2:00pm - 2:50pm MDT
Colorado Ballroom

2:50pm MDT

Break
Thursday June 20, 2019 2:50pm - 3:00pm MDT
TBA

3:00pm MDT

Domtar's Journey in the Human Performance Philosophy
Domtar is a leading manufacturer of pulp and paper and fiber related products. With 10,000 employees in North America and Europe, Domtar operates over 30 production and distribution facilities. The company started a journey in 2013 to adopt HPI principles. Although improving the safety results was a prime objective, managers realized that human error was present in every aspect of Domtar’s business such as environmental impacts, product quality, reliability and productivity of equipment. This presentation will give an overview of the HPI journey, identifying key steps, successes and challenges.  Training and awareness: From 2013 to 2018 Domtar sponsored in-depth introduction to HPI principles and philosophy to all the key managers in all production facilities and corporate offices. The main gain was to create a common language across the corporation. The key challenge is to maintain the knowledge as staff turnover increases. A few sites did give training to all personnel with mixed results.  Investigations: In 2015, a new investigation process was rolled out. This methodology is based on the DOE Accident and Operational Safety Analysis Handbook. Domtar published its own Incident Investigation Handbook, incorporating HPI elements, and created a 3 level certification for investigators. The bronze level is intended for front line personnel for quick and accurate data collection from events as well as to develop interview skills. The silver level is targeted at managers, subject matter experts, and union representatives. Since 2016, over 250 silver investigators have been trained on the 4 part / 16 step investigation process. The gold level investigators are experienced individuals that serve as peer reviewers and off-site investigators.  Implementation of proactive tools: Education about proactive tools started with initial training and awareness. In 2017, Domtar launched leadership training for front line supervisors and incorporated a gradual introduction to HPI concepts and proactive tools.  Data collection and analysis: In order to support the corporation in various initiatives, including HPI philosophy, Domtar created software in 2015 to track business related events such as audits, investigations and continuous improvement activities. The HPI concepts were directly integrated into the investigation portion. The data can be extracted to see what are the key organizational weaknesses, what error precursors are most prevalent and create action plans accordingly.  Work organization: Senior leaders are knowledgeable and support the HPI philosophy. Each site has an HPI specialist, usually from the safety group. The corporation also mandated one person to be the corporate HPI specialist. This person was responsible for investigation training, supporting the investigation certification program, supporting the content of the leadership training and the development of the data collection software.  In summary, there are 3 key elements of success for Domtar in the deployment of the HPI philosophy:  senior leader’s belief in, support of, and acceptance of the total HPI methodology and philosophy, the adoption of HPI philosophy in all business areas, not only safety and the supporting data collection system which integrates key HPI elements.

Speakers
avatar for Michel

Michel

Domtar Corporations
Michel Paquette has been in the paper industry for 23 years, starting with E.B.Eddy in Ottawa (Ontario, Canada) as a coop student. He graduated in Chemical engineering in 1995 and in 2013 with an MBA from Sherbrooke University (Quebec, Canada).After spending 3 years as environmental... Read More →


Thursday June 20, 2019 3:00pm - 3:50pm MDT
Platte

3:00pm MDT

Event Learning/ RCA: A Facilitated, Audience-Driven Session About the State of Root Cause Analysis
The audience will be broken into smaller groups.  We'll all explore 3 questions -- one question at a time.

  1. what concerns you the most about your "root cause" efforts wherever you work
  2. what do you think are the causes of that concern
  3. what can YOU do about the causes of the concern that are SMART?

 All persons interested in RCA should attend this event. 

Speakers
avatar for C.ROBERT

C.ROBERT

Founder/CEO, Failsafe-Network
C. Robert Nelms is a degreed Aerospace Engineer, having graduated from Texas A&M University in 1970. He worked at McDonnell Douglas until 1973, then became employed at Allied Chemical’s Nylon plant in Chesterfield, Virginia --an internationally recognized leader in Manufacturing... Read More →


Thursday June 20, 2019 3:00pm - 3:50pm MDT
Cheyenne I

3:00pm MDT

How to get Top Leadership Support or How to Support Top Leadership
I am sure there are many ways to get a seat at the executive table. All I can present in this session are ways that have been proven successful in my career. I will share how to be successful in Human Performance and the paradigm shifts I needed to make. I am betting that either you had to make the same shifts or you may need to make them in the future.  In this breakout session we will explore those proven methods on how to get to top leadership for initiatives involving Human Performance. My definition of top leadership is senior leadership such as CEO and Presidential level support. To accomplish this, it usually requires a stair step approach through levels of management to work your way up to the top.   We will explore a number of common paradigm shifts that may be necessary to set the path to the top level support. For each paradigm shift I will share the situation, how I learned and internalized the enlightenment moment.    Some of the following potential paradigm shifts that will be explored are:  

1. Don’t go to the leadership asking for support. Take a different approach. Redefine what you are there to present or discuss. It is a proven method to get there permission to have you support leadership and not leadership supporting you. We will explore how to control the expectations and the roadblocks that are almost always there. The path for arrival depends on organizational culture. Due to the duration of the presentation we will explore the most probable and difficult type of culture you will encounter with a brief discussion of the other types of culture.
2. Redefine you role in the organization. You are not and should not be an employee. Many may think of yourselves as employees of your organization. Although you are getting paid by your organization and you are in an organizational chart you are really internal consultants. We will explore what that means and how to transition into that role.
3. Need to thoroughly understand what Human Performance is and what it encompasses.
4. Management doesn’t really know the true issues within their organization so you need to develop ways to for you to know. Management wants to know but they know that they only know part of what is going on. If they truly knew what was really going on they would implement effective corrections to eliminate the issue so you wouldn’t have to be involved. This means that you have to live by the consultant’s number one rule: “Give them what they need disguised as what they want.”

Other life lessons will be mentioned but due to time limitations not developed. My goal is to shift some paradigms to allow more effective Human Performance implementations and define a path to get to interface with the top levels of your organization on your own terms.

Speakers
avatar for John

John

Director of Organizational Effectiveness and Human Performance, Williams Industrial Service Group, Inc.
John A. Shaeffer, SRO, has over 40 years’ experience in industrial operations spanning both nuclear, pharmaceutical/biotechnology, and construction industries. He has designed, produced and implemented manufacturing, quality, engineering, management and training systems using human... Read More →



Thursday June 20, 2019 3:00pm - 3:50pm MDT
White River I

3:00pm MDT

Making Connections to Create a HRO at Distribution Center-- A Case Study

How do you engage a company of 5000 employees in becoming an HRO? What is the first step? How to create awareness that soft factors have strong impact? These are a few of the questions Stedin is dealing with since the beginning of its HRO-journey in 2016. Stedin is a Distribution System Operator providing critical infrastructure for 2,2 million customers including the second largest port in the world and the Rotterdam metropolitan area with its complex infrastructure. We have a highly responsible and high risk societal obligation as we provide gas and electricity behind front doors of families, entrepreneurs and companies. We operate in an ever-changing environment; policies, sustainable ambitions – which we encourage! -, safety requirements and an 24/7 alert media. We simply need to be reliable. That’s why we invest in becoming an HRO. In this poster session we will share our journey so far. The first step was an assessment by the BR- Group based on delta 5TM to learn about the gap between our current behavioural patterns and the HRO principles. Then we took a step back and started a dialogue with the BR-Group. Only after an extensive exchange of thoughts, possible scenarios and sharing ideas did we conclude that HRO was the way to go. A project board was formed with experts from various departments: Board Members, Communication-, HSSE- and Training experts, Company Lawyers, Work Council representatives, our Line management, and consultants from the BR-Group. By bringing together a wide range of expertise on a monthly basis we made optimal use of knowledge within the organisation and were we able to create widespread engagement. This board agreed upon a set of ground rules: 1. We aim for a positive approach, based on the psychology that rewarding good behaviour is more effective than punishing undesirable behaviour. 2. We realize the difficulty of changing behaviour – we are lenient towards colleagues and ourselves. 3. We allow every colleague their own learning curve and realise there will be differences within departments, groups and individuals. In 2017 Stedin started raising awareness on a large scale; in one-size-fits-all HRO-sessions for up to 12 people, every employee experienced that having procedures alone is not enough to reach goals: it was time to look critical at the impact of our own behaviour. Simultaneously Communication launched a campaign with the slogan; ‘Veiligheid – goed voor elkaar!’, which loosely translates as both: ‘ Safety - Good for each other’ and ‘Safety – well arranged’. The combination of workshops and the campaign created the buzz we needed: it shifted the conversation from ‘if you follow all the rules, you will be safe’ towards ‘safety outside begins at the office’ and ‘everyone has a part’ . In 2018 we were able to engage with different groups using gamification and tailor-made learning. Depending on the training question it could be a conversation starter or a HRO deep dive. In 2019 we will intensify the dialogue and challenge employees even more to share their HRO-story and truly grow towards a reliable organizational culture.

Speakers
avatar for Dorien

Dorien

Human Error Specialist, Stedin
Dorien Janssen, MSc. +31 6 1592 5886 Human Error Specialist at Stedin, a Dutch DSO of 5000 employees, providing critical infrastructure for 2,2 million customers including the second largest port in the world and the Rotterdam metropolitan area. Fields of expertise: safety culture/HRO... Read More →


Thursday June 20, 2019 3:00pm - 3:50pm MDT
Arkansas

3:00pm MDT

RCA of a Business Loss due to Contaiminated Raw Material
Contaminated raw materials in a manufacturing process will often result in significant financial loss.  Off-specification finished products cannot meet the needs of customers, and in some cases, inadvertent reactivity between materials may ultimately lead to loss of containment.    In this case study, contaminated bulk raw material arrives at a manufacturing plant and is introduced to a storage tank and processing equipment.  Upon discovery, a flawed original investigation points to unspecified sources of cross-contamination at a loading terminal.  After a recurrence, the root causes are much deeper within the supply chain.  Multiple “touch points” for the raw material, blending procedures, non-dedicated equipment, and analytical procedures are all found to be causal factors in this complex problem.  After using  a cause and effect methodology to identify and chart all activities, behaviors, and conditions for a series of causal events, the manufacturing team generated a list of solutions to recommend new administrative and engineering controls.  In the end, the controls needed to assure a supply of material within the needed specification range were too onerous for the supplier, and the manufacturing customer chose to replace the supplier.

Speakers
avatar for Dana Walker Blair

Dana Walker Blair

Manager of EHSS, W.R.Grace
Dana is a Manager of Environmental, Health, Safety and Security for W.R. Grace.  She holds a BS in Chemical Engineering from N.C. State University, and a certificate in Process Safety Practice from Texas A&M.  With over 25 years of experience in chemicals manufacturing, Dana has... Read More →


Thursday June 20, 2019 3:00pm - 3:50pm MDT
White River II

3:00pm MDT

Using a change platform to create a HRO safety culture within a sector: the case of creating continuous improvement and collective learning between Railway organisations
he Dutch railway sector consists of several Train Companies, but only one major Maintenance and Traffic control Company named ProRail. ProRail collaborates with a limited number of certified engineering companies and certified contractors, when it comes to the installation and maintenance of the Railway safety systems. ProRail realized at a certain point that, although each company was trying to enhance their own safety culture, the safety culture on a sectoral level was suffering from fragmentation, competitive obstacles, and a severe lack of sectoral learning. ProRail then decided to launch a three year, sector wide HRO program in order to accomplish a level 4 proactive safety culture on the sectoral level. Apollo13 was having a key facilitating and advisory role in this program. One of the key success factors of the approach was creating a change platform instead of a change program. In the change platform all relevant parties (ProRail, engineering companies and contractors) were represented; they were also owners of the program. Thus the program focused on ‘horizontal organizing’ and transformational change. The members of the Change platform decided which activities were to be launched an how to proceed. Key intervention domains were:

• enhancing collective learning ability
• improving communication and interaction ability
• strengthen change and development capacity
• enhance ability to act. It worked out into a very successful program.

In this breakout session we will inform you about the HRO intervention strategy we used, the specific factors which contributed to the success of the program, the several lessons learned and above all the typical ‘new’ struggles related to horizontal organizing.

Speakers
avatar for Robert

Robert

Consultant | Partner, Apollo13 Consult
Robert J.M. Taen MSc (1954) has been working for more than 25 years as a consultant and partner at Apollo13 Consult in The Netherlands. His main focus area is the development of High Performance and High Reliability Teams and Organisations. Robert’s consultancy work is within the... Read More →


Thursday June 20, 2019 3:00pm - 3:50pm MDT
Cheyenne ll

3:00pm MDT

Visual Literacy: How "learning to see" benefits occupational safety
The concept of visual literacy has been around for decades, and has typically been used in developing better teaching and learning techniques in the classroom. Recently however, visual literacy has been gaining traction in the workplace as a skill and tool to better identify occupational hazards that could lead to safety incidents. This presentation will provide background and preliminary results of a new research collaboration between the Campbell Institute and the Toledo Museum of Art to demonstrate how visual literacy relates to occupational safety.   The argument we will present is relatively straight-forward – being more visually literate allows individuals to perceive and understand more about their work environment, enabling them to see hazards and imagine the potential consequences that can result from those hazards. Having this heightened ability enables workers to be proactive about their work environment and take measures to mitigate hazards before they can cause an incident.  Learning Outcomes:

(1) Understand previous outcomes of research in visual literacy.
(2) Understand how visual literacy has been applied to the field of occupational safety.

Speakers
avatar for Joy

Joy

Research Associate, Cambell Institute- National Safety Council
Joy Inouye is the research associate for the Campbell Institute, the EHS center of the excellence at the National Safety Council. Responsible for researching Environmental Health and Safety (EHS) best practices, Joy has led several research efforts at the Institute, including studies... Read More →


Thursday June 20, 2019 3:00pm - 3:50pm MDT
Rio Grande/Gunnison

3:50pm MDT

Break
Thursday June 20, 2019 3:50pm - 4:00pm MDT
TBA

4:00pm MDT

Improving Written Guidance Quality and Usage
This 1-hour workshop covers the top 5 procedure error traps and introduce a methodology and process for determining:

1. Is written guidance needed based on the risk and complexity of the task?
2. What KIND of written guidance (card, checklist, procedure, SOP, training and reference material, etc.) should be developed?
3. What should the level of detail be?
4. How should the written guidance be used (usage criteria)? Each participant will be provided an Effective Written Guidance Checklist and Written Guidance Needs Analysis Worksheet to use when they return to their facility.

Speakers
avatar for Rob

Rob

President and Director of Operations, Fisher Improvement Technologies
Rob Fisher is the President, Owner, Director of Operations of Fisher Improvement Technologies. Rob spent almost ten years in the US Navy before working at the South Texas Nuclear Project for twelve years. During this time Rob worked in Operations, Radiation Protection, Chemistry... Read More →


Thursday June 20, 2019 4:00pm - 4:50pm MDT
White River I

4:00pm MDT

Interviewing From Start to Finish
This will be a discussion about interviewing as part of an investigation.  we will go through why you need to interview, who you need to interview, when to interview, what to do before interviewing, how to perform a successful interview, and what to do with the results of an interview.    we will also discuss personal experience of the presenter on interviews gone wrong, how to identify and handle misleading interviewees, and the most important question you need to ask in every interview.

Speakers
avatar for jack

jack

Vice President | President Emeritus of HPRCT, BackpackerJack, Inc.
Jack is President Emeritus of HPRCT and Vice President of a privately owned business that evaluates and offers suggestions for improvement for corrective action and Human Behavior programs.  He also trains, consults, and mentors high hazard industries in the analysis of significant... Read More →


Thursday June 20, 2019 4:00pm - 4:50pm MDT
Cheyenne I

4:00pm MDT

Kepner Tregoe and Sologic: How Two RCA Methods Compliment Each Other
Kepner-Tregoe (KT) have been leaders in the structured problem solving business for 60 years.  Sologic is a dynamic business offering a combination of RCA services supported by the software Causelink.  In the summer of 2018, KT and Sologic decided to try working together to offer a comprehensive set of analytical processes and tools with the goal of providing the best and most complete solution to the client.    KT’s end-to-end management framework consists of the following components:   Situation Appraisal:  How does a manager organize and prioritize their efforts given the barrage of issues they face?  KT Situation Appraisal provides managers with a way to develop a comprehensive understanding of what’s happening and what actions to take. Problem Analysis:  Problems represent significant deviations from the intended pathway.  KT Problem Analysis helps managers create an accurate and complete specification of the problem by examining what the problem is, as well as what the problem is not. Potential Problem/Opportunity Analysis:  It is best to solve problems before they happen.  KT Potential Problem/Opportunity Analysis helps managers with predicting and anticipating risks and potential future opportunities. Decision Analysis:  Managers need to decide the best way forward in an environment of uncertainty.  KT Decision Analysis helps a manager make the best possible decision when presented with alternative choices.  The Sologic process uses conditional (if/then) logic to analyze how combinations of causes work together to cause any event.  The result is detailed causal model that clearly shows how the event happened.  All conclusions are supported by evidence.  This produces an accurate representation of the problem, which then leads to the identification of a set of effective solutions.    The KT and Sologic processes complement each other in interesting ways without a lot of overlap.  This session will explore how these two methods can be used collaboratively to help identify a clear and complete understanding of the problem as well as how to most effectively solve it.

Speakers
avatar for Brian Hughes

Brian Hughes

Sr. Vice President and Co-Founder, Sologic
Brian works with clients to develop and implement enterprise-wide RCA programs. Brian also leads significant root cause incident investigations, including explosions, loss of primary containment, consumer product contamination, failures of critical aircraft components/systems, supply... Read More →
avatar for Michael

Michael

Senior Principal, Kepner-Tregoe
Senior Principal who  manages global practice  Experienced, hands-on, global consulting Leader with years of experience providing strategy consulting and operational improvement consulting to the C Suite, senior leadership and plant leadership. Currently serves in the areas of strategy... Read More →


Thursday June 20, 2019 4:00pm - 4:50pm MDT
White River II

4:00pm MDT

Managing Distractions, a Dynamic Learning Activity
The guy who brought you the “Human Performance Film Festival” last year is back with a bunch of ideas on how to make your classrooms more interactive, engaging, and fun for your learners. Take a trip with him as he explores what it is like using Virtual and Augmented Reality in the classroom as he shows you how to tie learning concepts to engaging activity.  Games open up a new world of serious play in the classroom, from video games to Legos and everything in between, James has been on a mission to find the best learning tools and put them together in a creative and innovative way to deliver training content. Let a multiple best practice and Excellence in Training award-winning INPO Certified Trainer with a background in Workforce Education Development from Southern Illinois University be your guide to excellent instruction and delivery.  Revitalize your training program with new learning activities that challenge workers and leaders alike. Creative and interactive training that gets students involved immediately helps them understand and use skills to recognize the situation and become more immersive in the learning. These methods translate directly into the work environment and can be customized to scenarios applicable to your learners’ type of work.

Speakers
avatar for James

James

Co-Owner, Human Performance Tools
As a practitioner, James leverages his instrument & controls and nuclear power industry background to attack problems and develop realistic and applicable solutions.  He has developed solid leadership work observation programs and training used in commercial power generation and... Read More →


Thursday June 20, 2019 4:00pm - 4:50pm MDT
Platte

4:00pm MDT

Managing Risk in Human Space Flight with High Reliability and Resilience as Foundational Factors
Managing risk in human space flight programs has evolved greatly since America celebrated Alan Shepard’s historic flight into space in 1961. By the time of the Apollo program, the National Aeronautics and Space Administration (NASA) had firmly established the use of quantitative risk assessment methodologies, and eventually moved towards decision making approaches based on qualitative risk factors. Among these factors were: • Reviews of all significant equipment modifications, • Identifying single point failures in systems and components, • Reviews of all launch vehicle and spacecraft systems tests results, • Reviews of significant failures and corrective actions, and • Reviews of unsolved problems (Fragola, 1996). As U.S. human space flight moved into the Space Shuttle era, managing risk continued to focus on hardware and software, but also encompassed human factors related to mishaps and close calls. Not how the human-machine interface might be flawed, but what the operator or maintainer did or didn’t do to cause a high reliability system or component to fail. This included, especially in the tragic Shuttle Challenger and Columbia accidents, management’s role in contributing factors of the failures of this complex launch system. Now, on the eve of the great private space race, the risks of space travel shift from the government as a customer of one to private citizens as the customers of many. With lenient safety regulations governing the private space industry, space flight participants (the people who pay to play) are required to sign waivers of liability should the launch provider injure or kill them during their suborbital or orbital adventure. And, in a profit-driven environment, space transportation providers may be expected to operate as lean as possible in order to maximize profits and further expand their base of operations. For this reason, safety and mission assurance academics and specialists, especially those with a pedigree in human space flight, have become the champions for influencing the industry to integrate organizational resiliency and high reliability in their risk management programs and practices. In order to move from reactive to proactive safety management, the new generation of space transportation entities must be able to identify the key ingredients that ensure resources are allocated to accommodate the unexpected events, with risk management woven into the cultural fabric of the organization (Perera, 2011). Not just for crisis management, resilience allows organizations to maintain a high level of performance even when the operational tempo or environment imparts pressure on the teams, when issues crop up and uncertainties begin to grow (Boin & van Eeten, 2013). High reliability organizations ensure that expertise is not necessarily matched with a chain of command, allowing operators to expect even the unexpected, to facilitate an informed culture, with clarity around roles and responsibilities and expertise (Scubert, Arbinger & Morena, 2016). This paper will document the evolution of human space flight risk management in terms of the growing influence and interconnectedness of high reliability, resiliency, and safety culture, particularly moving from the Space Shuttle Program and ground operations, to the rapid growth of the private space transportation and tourism industry.

Speakers
avatar for Tim Riley

Tim Riley

Program Lead - Scaled Wind Farm Technology (SWiFT) Facility, Sandia National Labs
I have a passion for safety of people and programs that has grown over 30 years of aviation and aerospace adventures. From turning wrenches on helicopters, to being part of the incredible Space Shuttle launch and landing teams, to corporate safety in new wind farm construction, to... Read More →



Thursday June 20, 2019 4:00pm - 4:50pm MDT
Arkansas

4:00pm MDT

Reacting when things go wrongly, and how to improve without poor outcomes
Reacting when things go wrongly matters.  This talk presents a common type of reaction, that asks what went wrong, who is responsible, what should the punishment be, and gives some problems with these types of questions.  It presents the anatomy of an event, and the problems with retrospective understanding.  It then presents a different view of human performance, and asks questions that could be asked when things are not going wrongly.  It then presents a few tools (root cause analysis of normal work, post job brief questions, and prioritizing learning) to help organizations learn more about themselves, and become safer in the process.  

Speakers
avatar for Tanya

Tanya

Canadian Nuclear Safety Commissiopn
Tanya Hewitt received her PhD in Population Health from the University of Ottawa. She has a BSc in Physics from the University of Guelph, an MSc in Medical Physics from Carleton University, and a Graduate Certificate from the University of Ottawa in Risk Assessment and Management... Read More →


Thursday June 20, 2019 4:00pm - 4:50pm MDT
Rio Grande/Gunnison

4:00pm MDT

Using HRO Concepts to Make Organizations More Proactive: The Case of Schipol
In 2016 the Royal Schiphol Group started its journey developing a proactive safety culture. Schiphol uses the HRO perspective to frame the word ‘proactive’ in one of its corporate strategy targets ‘to achieve a proactive safety culture (maturity level HRO4) by 2020.´ For Schiphol ‘proactive’ means: [a] notice weak signals of potential risks earlier, [b] acting faster and with more resilience in managing unexpected events and [c] search for underexposed or subconscious patterns of behavior to prevent repeating incidents. To give the implementation of ´proactive´ a boost the program Schiphol4Safety (S4S) was drafted. After three years, the program will end and leave it to the business to further a proactive safety culture. In 2020, Schiphol will assess the achievements. In this presentation Maryse Schermerhorn, senior Safety Culture Expert at Schiphol, will give an overview of how HRO was used in the design and execution of this journey including the applied methods and tools. Using concrete examples and videos, she will show how Schiphol uses HRO as a source of inspiration for proactive thinking and doing and as an instrument to crack resistance to change and learning.  

Speakers
avatar for Maryse

Maryse

Senior Advisor Health Safety & Environment, Royal Schiphol Group- The Netherlands
Short biography of Maryse Schermerhorn (1961), Senior Advisor Health Safety & Environment at Royal Schiphol Group, the Netherlands. Maryse Schermerhorn has over twenty years of experience in the aviation safety field e.g. advising top and line management on safety policy, the implementation... Read More →


Thursday June 20, 2019 4:00pm - 4:50pm MDT
Cheyenne ll