Departmental Representative to the Defense Nuclear Facilities Safety Board

ATTACHMENT
4. FORMAT AND CONTENT GUIDE FOR IMPLEMENTATION PLANS

I. Purpose

This guidance incorporates experience gained and lessons learned from developing and completing implementation plans, in response to Board recommendations, over many years; helps to focus Departmental resources on preparing complete, effective implementation plans which improve safety and provide for recommendation closure; provides for consistency of plan format and contents to permit efficient review and use; and addresses the Board’s identified criteria for judging the adequacy of implementation plans.

The technical content is the primary measure of an effective plan; this guidance should help focus development of that technical content. This guidance should also aid Departmental personnel in developing implementation plans that cogently and clearly communicate their technical content. Much of this guidance will be applicable for all implementation plans. However, the subjects of implementation plans can differ significantly, and, in some cases, exceptions and additions to the recommended format and content may be appropriate and necessary on a case-by-case basis.

II. Board Criteria

Board PS-1, “Criteria for Judging the Adequacy of Department Responses and Implementation Plans for Board Recommendations,” October 19, 1990, identifies the following six substantive criteria that must be satisfied before the Board judges an implementation plan to be adequate.

1. Understanding. The Department’s implementation plan shows an understanding of the safety issues raised by the Board recommendation.
   
   
2. Responsiveness. The Department’s planned course of action addresses the complete Board recommendation and accomplishes satisfactory resolution of the identified safety issues.
   
   
3. Assumptions. The Department identifies important baseline assumptions for successful plan implementation.
   
   
4. Planning Detail. The Department’s implementation plan is described in sufficient detail to permit the Board to independently determine that the approach and schedule are reasonable and achievable.
   
   
5. Technical Basis. The Department’s plan is based on sound technical evaluation, including identification of underlying causes.
   
   
6. Focus on Closure. The Department’s plan defines completion deliverables for demonstrating safety issue resolution in a verifiable manner.
   
   

In addition to the substantive criteria, the Board PS-1 also identifies five procedural requirements for implementation plans: (1) plan submittal meets statutory deadlines; (2) plan provides a realistic and achievable schedule which includes intermediary milestones; (3) plan includes a process for change control of plan itself; (4) plan addresses quality assurance, if appropriate; and (5) plan provides a reporting scheme and schedule.

III. Format and Content

Implementation plans are written for three key audiences: Departmental personnel/contractors, the Board and its staff, and the public. Departmental personnel and contractors will implement the actions described; they need sufficient detail on the scope, schedule, and basis of planned actions so that implementation will be effective and efficient. The Board and its staff will review the Department’s plan for adequacy, monitor the plan implementation, and ultimately close out their recommendation based on completion of actions described in the plan. The public is notified of all Board recommendations and often follows the Department’s plans to ensure their safety interests are satisfied. The format and content described below are designed to satisfy all three audiences. Each implementation plan should contain the following contents in the format described below.

Title Page

The title page should include the Department’s plan title, the plan date, the plan revision number (if not original), and Board recommendation number. The title should be a Departmental title, demonstrating Departmental ownership of the plan. For example, the plan title could be “Department of Energy Plan for Improving the Technical Capability in Defense Nuclear Facilities Programs and Training and Qualifications,” and the title page might include beneath this title, “(Implementation Plan for DNFSB Recommendation 93-3).”

Executive Summary

The executive summary should summarize: (1) the relevant safety issues, (2) their underlying causes, (3) the resolution approach and schedule, (4) the management approach to ensure plan implementation, and (5) any baseline assumptions critical to successful implementation. If initiation of safety issue resolution is urgent for safety reasons, this summary should highlight key completed and near-term actions.

Table of Contents

The table of contents should include the contents defined in this guidance, in the order described below. The section headings and section numbering provided below should be adopted to ensure that implementation plans are in a consistent format, permitting ease of review and use.

1. Background

This background section should demonstrate an understanding of the problem(s) being addressed. It should provide a clear statement of the safety issues and their significance as determined by the Department’s analysis of the problem. The implementation plan should be consistent with the approach described in the Secretary’s response letter to the Board’s recommendation. In particular, if the Department has set any conditions or limitations on its acceptance of the recommendation, these should be reiterated.

The background section should identify and briefly describe the principal safety issues addressed by the plan. These may be derived directly from the Board’s recommendation, from a synthesis or combination of the various Board sub-recommendations, or from the Department’s own analysis and implementation planning. The safety issues represent the Department’s template to organize and structure implementation actions. Remaining sections of the implementation plan should be structured based on the identified safety issues.

2. Underlying Causes

This section should identify the underlying cause(s) of the subject safety issues, so that it is clear why the planned actions are appropriate. The underlying cause(s) can only be arrived at by understanding and evaluating the direct causes of any technical problems and then identifying the underlying causes that allowed the situation to occur. Underlying cause(s) may relate to hardware performance or capabilities, operation procedures, management controls, personnel performance, and management performance. With these causes identified, the broader implications, beyond the identified situation, should be fully considered in developing a complete and effective resolution approach.

Underlying causes that relate to other Departmental implementation plans in progress should be identified. The extent to which these other plans contribute to the resolution of the subject recommendation’s safety issues should also be described.

3. Baseline Assumptions

This section should present the primary assumptions, if any, upon which the implementation planning has been based. These may include engineering, technical, administrative, or legislative assumptions. For example, the following categories of baseline assumptions may be relevant: availability of general or specialized personnel resources, availability of unique or specialized expertise, hardware or system performance, availability of specialized equipment or parts, legal or statutory requirements, successful completion of precursor activities in other programs, satisfactory progress of necessary research and development efforts, availability of sufficient approved funding in the type and amount needed, and impact of scope changes or expansions on schedule performance. The plan should describe each real and relevant assumption in sufficient detail to allow understanding of potential impact (e.g., what specifically? how many? how much? how long? of what type? how likely?). It is important to fully identify the real and relevant assumptions that may potentially impact successful plan implementation.

4. Summary of Completed and Near-Term Actions

This section should describe mitigating actions that are already complete. The purpose of describing key completed actions is to demonstrate responsiveness during the period between issuance of the Board recommendation and completion of the Department’s implementation plan. It may be beneficial to mention the parties involved in plan preparation to show that: (1) the Departmental organizations, including field representatives that are necessary for successful implementation were involved in the planning process, and (2) there will be a smooth transition from plan preparation to plan implementation. Near-term actions identified in the Secretary’s response letter should be included in this section.

In some cases, for safety issues that involve a strong sense of urgency or that will require an extended period to achieve resolution, the Department should describe important near-term initiatives and compensatory actions that will be implemented no later than 6 months, for example, after plan issuance to reduce safety risks associated with the recommendation. These will also demonstrate the Department’s commitment to bring the identified safety issues to final resolution. Near-term actions should be extracted and summarized from the full description of planned actions, presented in section 5, Safety Issue Resolution.

5. Safety Issue Resolution

This is the main section of the implementation plan and should be structured using the Department’s identified safety issues, with one section subheading for each issue. As an alternative, this section can be structured by the sub-recommendations contained in the Board’s recommendation. Under each subheading, the following structure should be provided: Issue Description; Board Recommendation; Resolution Approach; and Deliverables/Milestones.

Issue Description. The issue description should consist of a summary restatement of the problem, why the problem needs to be addressed, and how addressing the problem will provide a specific safety improvement for the Department. Description of safety improvement objectives should show consistency with overall Departmental safety objectives.

Board Recommendation. After the Department’s issue description, the text of the original Board recommendation that is pertinent to the issue should be quoted verbatim. The purpose of repeating the Board’s recommendation is so that the reader may easily correlate the Department’s plan to the Board’s recommendation and demonstrate that the plan is responsive. The portion that should be repeated in the body of the implementation plan is the text of the recommendation itself (i.e., the numbered sub-recommendations), rather than the introductory and contextual material. The entire text of the Board recommendation may be included as an attachment to the plan if desired.

Resolution Approach. The resolution approach needs to provide: (1) a specific description of the Department’s intended course of action that is clear, tangible, and concise, and (2) sufficient detail so that one may independently determine whether the approach is reasonable and achievable. This section should specifically describe the safety improvements and how they will be achieved. For example, the resolution approach should not consist of a plan to make a plan or a plan to do an assessment to make a plan. Any changes in equipment, process, procedures, and/or personnel should be discussed in terms of their impact on safety. Where it is absolutely necessary to perform some prior action before the final scope of the resolution actions can be determined, the resolution approach should describe the specific process and criteria that will be used to make these determinations.

Resolution of an issue (i.e., completion of all actions identified in the implementation plan) should result in tangible improvement to safety within the Departmental defense nuclear facilities complex. If possible, the resolution scope should be established based on the goal of completion within 1 year of plan issuance. To accomplish this goal, the resolution focus may need to be on gaining substantive control of an issue rather than closing all loose ends. For example, issue resolution may need to be defined in the implementation plan as developing training and conducting initial sessions, rather than as completing training of all Departmental personnel and performing a follow-up evaluation. The goal of resolution within 1 year, based on the expectations of Congress in establishing the Board, should be strictly pursued for recommendations that are narrowly focused and affect only one site and one Headquarters office. Recommendations that involve major systemic changes, multiple Headquarters offices, and multiple sites can require more than 1 year for resolution. Exceptions to the 1 year goal should be carefully considered.

As part of this discussion, the technical basis for the selected approach should be provided. This technical basis should demonstrate that the Department has performed a reasonable, logical, and, if possible, quantifiable technical evaluation of the problems and solutions and should address the underlying causes described in section 2, Underlying Causes. A strong technical basis is particularly important for resolution approaches that are experimental or unprecedented, or differ from the expectations of the Board and its staff.

The resolution approach should be consistent with the Secretary’s response letter to the Board’s recommendation and should reiterate any conditions or limitations on the Department’s acceptance of the recommendation, along with supporting bases. Where credit is taken for implementation actions described in other Departmental programs or implementation plans, this should be identified; the implementation plan should not establish new commitments and commitment dates for other ongoing implementation plans in response to Board recommendations.

Deliverables/Milestones. The plan must clearly provide a method for demonstrating completion or closure in a manner that can be readily verified. Commitment deliverables should be tied to plan milestones, readily verifiable, and transmittable to the Board for review. The plan should demonstrate a focus on closure; the resolution actions and schedule should not be open-ended. For example, rather than defining the resolution scope and closure actions through an ongoing process, such as through periodic reports to the Board, the plan should establish a firm structure for achieving closure. The plan should also reflect a systems engineering approach for resolving the issue that methodically defines the entire effort, from inception to closure, for achieving the identified safety improvement.

In describing intermediary deliverables or commitments, the plan should establish only that number needed to measure performance of the planned resolution approach. Frequently, further definition of intermediary actions is needed to fully describe and measure accomplishment of a commitment. These intermediary actions should not be identified as unique commitments, but may be noted as actions contributing to commitment completion. For example, completion of a committee evaluation could include the following noted actions, if appropriate: forming the committee, preparing the charter, developing the evaluation procedure, conducting the evaluation, preparing a draft report, resolving comments, and preparing a final report. Only those actions considered critical to successful completion of the commitment should be identified and described.

The following information should be provided for each commitment: (1) a complete statement of the commitment; (2) the manager responsible for implementation; (3) the facilities and programs to which it applies; (4) the implementation activities and deliverables that will constitute completion; and (5) the specific due date (such as December 15, 2005) for completion. In addition, to facilitate commitment tracking, each commitment should be uniquely and sequentially numbered. Due dates should correlate to the date for the Department to provide completed deliverables to the Board.

The schedule should be realistic and achievable, and reflect the results of a representative resource-loaded schedule and cost estimate (see discussion on stand-alone attachment on resource-loaded schedule and cost estimate). Intermediary deliverables and milestones should provide meaningful measures of accomplishment toward final issue resolution.

6. Organization and Management

This section describes how the Department will organize and manage implementation of the plan. The cognizant Secretarial Officer and Responsible Manager need to be clearly identified along with their functions, authorities, and responsibilities for successful plan implementation. To ensure plan performance, strong consideration should be given to establishing a central project manager who has broad, cross-organizational authorities. To the extent possible, single line authority should be established for plan implementation. If useful, a figure describing the organizational structure for plan implementation should be provided.

This section should also describe specific management systems and controls the Department will use to accomplish planned deliverables on the committed schedule. For example, this section might include a discussion of action item tracking and monitoring, including use of and interface with the Department’s Safety Issues Management System. Methods for holding personnel and organizations accountable for their performance should also be described, particularly where personnel and organizations responsible for portions of the plan performance do not report directly to the Responsible Manager. Management controls over funding and budget allocation should be described. The following management systems should be addressed specifically.

Change Control. Each implementation plan must include a description of its change control process. The following paragraph is recommended to be used for all plans.

“Complex, long-range plans require sufficient flexibility to accommodate changes in commitments, actions, or completion dates that may be necessary due to additional information, improvements, or changes in baseline assumptions. The Department’s policy is to (1) provide prior, written notification to the Board on the status of any implementation plan commitment that will not be completed by the planned milestone date, (2) have the Secretary approve all revisions to the scope and schedule of plan commitments, and (3) clearly identify and describe the revisions and basis for the revisions. Fundamental changes to the plan’s strategy, scope, or schedule will be provided to the Board through formal revision and reissuance of the implementation plan. Other changes to the scope or schedule of planned commitments will be formally submitted in appropriate correspondence approved by the Secretary, along with the basis for the changes and appropriate corrective actions.”

Reporting. Each implementation plan must include a description of its reporting scheme and schedule. Acceptable means of reporting include periodic briefings and periodic progress reports. Briefings have proven to be more effective than written reports. The frequency of these periodic briefings or reports depends on the total scope and schedule of planned actions. Historically, many plans have offered a quarterly reporting frequency. Less frequent reporting, such as on a semi-annual or annual basis, is appropriate where the plan milestones are few and spread out, or the effort is winding down to completion. The following sample paragraph addresses reporting.

“To ensure that the various Departmental implementing elements and the Board remain informed of the status of plan implementation, the Department’s policy is to provide periodic progress reports until implementation plan commitments are completed. For this plan, the Department will provide quarterly briefings to the Board and/or its staff, within 1 month of the close of each quarter during plan implementation. Quarters will coincide with the calendar and fiscal year quarters: January-March, April-June, July-September, and October-December.”

Progress reports may be used to report minor schedule variances to plan commitments, but not to make changes to planned commitment dates, unless approved by the Secretary. For example, if commitment completion will be delayed by several weeks from the committed due date, this variance should be reported in the periodic progress report. The report of a schedule variance acknowledges that the commitment is overdue and provides current status information, but does not seek to adjust or change the established schedule. Progress reports should not be used to make changes to plan commitments.

Quality Assurance. In appropriate cases, the plan should specify how quality of the planned actions will be ensured. Quality assurance may include qualification of people involved; internal checks on the implementation as the task is completed; final verification; independent oversight; and chain of custody on records, samples, and other critical data and documentation.

Attachments to Implementation Plan (Optional)

Glossary. The glossary should define terms used in the implementation plan that are unique, unusual, or of a highly technical nature that would not be commonly understood.

Acronyms and Abbreviations. This attachment should identify and define all acronyms and abbreviations used in the implementation plan. A minimum number of acronyms and abbreviations enhances general understanding and readability of the plan.

References. This attachment provides bibliographic information for all documents referenced in the implementation plan.

Summary of Commitments. This attachment lists all Departmental commitments established in the implementation plan. Inclusion of this attachment may be useful to delineate in summary fashion the complete scope of commitments that the Department considers are made by section 5 of the plan. If used, this information should be presented in the same format that will be employed to report status in the periodic progress reports. The following should be provided for each commitment: (1) statement of commitment, (2) Responsible Manager, (3) applicable facilities and programs, (4) closure deliverable(s), and (5) due date.

Summary Schedule. This attachment provides a top-level summary time line that shows the start and end dates of resolution activities for each safety issue. Lower-level schedule summaries may also be necessary to provide an overview understanding of the scope and relationship between major activities.

Crosswalk to Board Recommendation. When the Department has structured the issues in a different manner than portrayed in the Board’s recommendation, this attachment should be used to provide a matrix showing that the recommendation is fully addressed. If necessary, the matrix should provide and include the following headings: Board sub-recommendation, Departmental issue, Plan references, and Discussion.

Stand-Alone Attachment: Resource-Loaded Schedule and Cost Estimate

To ensure that the planned scope and schedule are realistic and achievable, each implementation plan should be submitted for Departmental management review and approval along with a separate, stand-alone attachment that provides a resource-loaded plan schedule and cost estimate and describes the Departmental funding to support committed actions. The attachment should also identify the critical path activities on the integrated schedule. The cost estimate should be sufficiently accurate (i.e., rough order of magnitude) to permit the Department to evaluate the cost/benefit of these safety improvements. More detailed attention should be given to complex activities that involve installation or operation of equipment or accomplishment of multiple, dependent activities. The desired degree of accuracy for this planning cost estimate is minus 50 percent to plus 100 percent (see DOE G 430.1-1, Cost Estimating Guide).

The resource-loaded schedule should identify what types of resources are needed, when they are needed, how long they are needed, and the total amount of each resource type needed. Budget requirements should include personnel resources by type, contract resources, and capital equipment and expenditures. Resource summaries should be provided by year (e.g., for each fiscal year) and by organizational unit (e.g., responsible Headquarters organization, Operations Office, primary contractor, specialty contractors, supporting Departmental organizations, etc.). This document should also identify the source of identified budget funds and the type of funding (e.g., capital or operating budget). Where funding needs to be appropriated by Congress, the amounts, schedules, and organizations requesting funding should be identified.

IV. Presentation Tone and Style

The overall tone of the implementation plan should demonstrate the Department’s ownership of the identified safety issues. To show ownership, the Department needs to assess the identified problem area independently, perform its own analysis of the underlying safety issues and causes, reach its own conclusions regarding issue significance, and develop an effective approach for issue resolution. The implementation plan is the Department’s plan for resolving the identified safety issues, not just a mechanism for responding to the Board’s recommendation.

The plan should be clear and concise. Executive Secretariat Style Guide, prepared by the Office of the Executive Secretariat, is a useful tool to help in the preparation of effective, well-written materials (available on the Internet at www.hr.doe.gov/es/estable.htm). A review by a technical editor should be considered. Figures should be included where possible to demonstrate understanding of the safety issues and causes, to illustrate resolution approaches and schedules, and to show management structure and controls. The use of “will” statements should be carefully limited. Every “will” statement could be interpreted as an explicit or implied commitment. Where a commitment is not intended, alternate word choice should be selected.