Systematic Methods to Address Root and Contributing Causes

Report
Expectations in
NRC Inspection Procedures 95001 and 95002
Frederick J. Forck
4Konsulting, LLC
USE A TOOL
USE A TOOL TO BUILD
CAUSE ANALYSIS TOOLS
Fault tree analysis
2. Critical incident techniques
3. Events & causal factors analysis
4. Pareto Analysis
5. Change analysis
6. Barrier analysis
7. Management Oversight & Risk
Tree (MORT) analysis
8. Why Staircase
1.
NRC IP 95001
USE TOOLS TO RECONSTRUCT



Clearly identify problem
State assumptions
Data


 Timely collection
 Verification


Preserve evidence
Document analysis so
• Progression of the problem
is clearly understood
• Any missing information or
inconsistencies are identified
• Problem can be easily
explained and/or
understood by others
NRC IP 95001

Determine cause & effect
relationships resulting in
Identification of root and
contributing causes that
Consider the following types
of issues:
• Hardware: design, materials, systems
aging, and environmental conditions;
• Process: procedures, work practices,
operational policies, supervision and
oversight, preventive and corrective
maintenance programs, and quality
control methods; and
• Human performance: training,
communications, human-system
interface, and fitness for duty (which
includes managing fatigue).
Gather information
Reconstruct the incident.
Discover causes.
Recommend corrective actions
Incident
Avatar International Inc., 1985
Job/Task Analysis
Incident Analyst
Manage Information
Scope
The
Problem
Investigate
The
Factors
Reconstruct
The
Story
Establish
Contributing
Factors
Validate
Underlying
Factors
Plan
Corrective
Actions
Report
Learnings
Facilitate Investigation
© 2008, 4Konsulting, LLC, 573-645-8854, www.4konsulting.com
Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis Process
Written
Followed
Include
Acceptance Criteria
10CFR50, App. B
Callaway Plant Lead Auditor Training
Issues that drove, influenced,
or allowed the incident
Accurate, factual
information
Scope The
Problem
Investigate
The Factors
Intervention(s) that improve
design or change behavior
Reconstruct
The Story
Establish
Contributing
Factors
Validate
Underlying
Factors
Progression of the
problem
Precise, complete, bounded
problem statement
Plan
Corrective
Actions
Report
Learnings
Auditable,
defensible record
Correctable root and
contributing causes
Output/Results
Scope the
Problem
Techniques
Deviation Statement
Difference Mapping
Problem Description
Extent of Condition Review
Methodology Selection
Investigate
the
Factors
Techniques
Evidence Preservation
Interviewing (What & How)
Perform Analysis Worksheet
Culpability Decision Tree
Substitution Test/Survey
SORTM questions
Establish
Contributing
Factors
Techniques
Difference Analysis
Defense Analysis
Production/Protection Strategy
(Defense-In-Depth) Analysis
Factor Tree
MORT Analysis
Exposure Factors
Moderating Factor
Triggering Factor
Incident
Aggravating Factors
TW
Accurate,
factual information
How?
Progression of the
problem
IN
Incident Systems Analysis Steps
With Techniques
How and Why?
Validate
Underlying
Factors
Techniques
WHY Factor Staircase
A-B-C Analysis
HOW-To-WHY Matrix
Cause & Effect Tree
Root Cause Test
Root Cause Evaluation
Extent of Cause Review
Common Cause Analysis
Safety Culture Tree
Excellent Human Perform Tree
Stream Analysis
Why?
Plan
Corrective
Actions
Techniques
Change Management
Action Plan
Active Coaching Plan
Barriers & Aids Analysis
Solution Selection Tree
Solution Selection Matrix
S.M.A.R.T.E.R.
Effectiveness Review
Communication Plan
Contingency Plan
What next?
Report
Learnings
Forms
Report Template
Grade Cards/Scoresheets
© 2010, 4Konsulting, LLC, 573-645-8854, www.4konsulting.com
Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis Process
A precise, complete,
and bounded
problem description
Who, When, Where?
Reconstruct
the
Story
Techniques
Fault Tree
Task Analysis
Critical Activity Charting
Actions & Factors Chart
Flawed
Defense
What?
The factors
that drove,
influenced, or
allowed the incident
Correctable root and
contributing causes
Intervention(s) that
improve design or
change behavior
An auditable,
defensible record
Focus
on
Results
Changed,
Improved
State of the
Business
Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis Process
Incident
Scope the
Problem
Techniques
•Deviation Statement
•Difference Mapping
•Problem Description
•Extent of Condition Review
•Methodology Selection
What?
A precise, complete,
and bounded problem
statement
Identify the GAP: What is the Problem?
Method 1: Deviation Statement (noun/verb)
 OBJECT: What is the item that is affected?
 DEFECT: Identify the “DEVIATION” from the “EXPECTED” or
“REQUIRED STANDARD of PERFORMANCE.”
Example: Five gallons of oil spilled (defect)
on the “B” Emergency Diesel Generator room floor (object) .
OR Use:
Method 2: Expected vs. Actual Statement
 Compare “WHAT SHOULD BE”*: Requirement, Standard, Norm, or Expectation
with
 “WHAT IS”: The existing, as-found condition”
*Sometimes the “What Should Be” is implied.
Kepner-Tregoe, The New Rational Manager
BPI Problem Solving-Decision Making-Planning

Evaluate ONLY from Problem Description Perspective
Deviation Statement: Object
Application
Object
(Person, Place, Thing)
Defect
Application
(Activity, Form, Fit, Function)
Defect
(Flaw, Failing, Deficiency)
Deviation Statement

Then evaluate various combinations
•
•
•
•
•

Same  Same  Same
Same  Same  Similar
Similar  Same  Same
Similar  Similar Same
etc.
Document the basis for bounding with
the associated risk and consequence
Lewis Allen , STP, 15th Annual HPRCT
Same-Same-Same
An Identical Object
in an Equivalent Application
with a Matching Defect
Same-Same-Similar
An Identical Object
in an Equivalent Application
with a Related Defect
Similar-Same-Same
A Comparable Object
in an Equivalent Application
with a Matching Defect
1
Does potential
exist for this
problem to cause further
impact to this SSC* or
Process?
YES
Human Performance Tool
Peer Check
NO
1. Describe why this is an
isolated problem/issue.
2. Verify, using OE**, that this
is not an industry issue.
Describe where,
when, and how it
will be impacted
Recommend
corrective
actions
NO
2
Does potential
exist for this
problem to impact
other SSC*s or
Processes?
YES
*SSC-Structure, System, Component
**OE-Operating Experience
Adapted from information provided by Duke Power personnel
A precise, complete,
and bounded
problem statement
Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis Process
Investigate
the
Factors
Techniques
•Evidence Preservation
•Interviewing (What & How)
•Performance Analysis Worksheet
•Culpability Decision Tree
•Substitution Test/Survey
•SORTM questions
Who, When, Where?
Accurate,
factual information
1.
Determine how best to fill your information needs.
(Information you have vs. Information you still need)
•
•
•
•
2.
review of logsheets, charts, drawings, etc.
area walkdowns
interviews
Decide who to interview and what you hope to learn from them.
Determine which information to pursue first.
Considerations:
• Focus on issues that appear to be key.
• Management Sponsor may need certain information first
(e.g. restart issues).
• Interviewee availability may pose an impact.
3.
Determine who will obtain the information.
• Divide responsibilities among team members
• If no team, you can still seek assistance from cognizant parties e.g.
system engineer can research material history
Adapted from Incident Investigation Training, Callaway Plant
Prepare
Open
Question
Close
IAEA-TECDOC-1600
Reduced
Severity of
Incidents
Successful
Results
Reduced
Frequency of
Incidents
AND
Error
Free
Incident
Free
Practices
Rigorously Use
Error-Prevention Tools
Processes
Aggressively Control
Defense-In-Depth
Human Factors Prong
System Factors Prong
AND
AND
Engineered
Defenses
1st Line
Administrative
Defenses
2nd Line
Work
Preparation
Oversight
Defenses
3rd Line
Work
Performance
Work
Feedback
Cultural
Defenses
4th Line
Adapted from INPO 06-003
Flawed
Defense
Exposure Factors
Moderating Factor
Triggering Factor
Incident
Aggravating Factors
TW
IN
Phoenix Handbook, Corcoran
Dana Cooley
Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis Process
Accurate,
factual information
Reconstruct
the
Story
Techniques
•Fault Tree
•Task Analysis
•Critical Activity Charting
•Actions & Factors Chart
How?
Progression of the
problem
INCIDENT
FAILURE MECHANISM:
SPECIFIC EQUIPMENT
FAULT THAT RESULTED IN
THE LOSS OF CAPABILITY
OR FUNCTION
DEGRADATION
MECHANISM:
PHYSICAL PHENOMENA
INVOLVED IN THE FAILURE
EXAMPLES:
FAILED TO; OPEN, CLOSE,
START, ACTUATE, ENERGIZE
LOSS OF; INDICATION,
COOLING, HEATING, PRESSURE
TRIPPED, OVER PRESSURIZED,
OVERHEATED
OUTCOME OR
CONSEQUENCE
FAILURE MODE:
LOSS OF CAPABILITY
OR FUNCTION
FORM
FIT
DEFORMATION
MATERIAL CHANGE
FRACTURE
REACTIVE
ENVIRONMENT
FORCE
DEGRADATION
INFLUENCES:
PROCESS OR PROGRAM
DEFICIENCIES THAT EXIST
IN SUFFICIENT MAGNITUDE
OR DURATION TO INDUCE
THE FAILURE
DISPLACEMENT
ALIGNMENT
SEPARATING
TIME
TEMPERATURE
ASSEMBLY/
INSTALLATION
DEFECTS
MATERIAL
DEFECTS
DESIGN CONCERN
FUNCTION
FABRICATION/
MANUFACTURING
ERRORS
EXAMPLES:
BROKEN VALVE STEM, TORN
DIAPHRAGM, BLOWN FUSE, SEAT
LEAKAGE, SCORED FLANGE,
LOOSE VALVE PACKING, LOOSE
FITTING, LOW VOLTAGE, GROUND
FAULT, SHORT CIRCUIT, ODOR...
EXAMPLES:
BLOCKAGE, STICKING,
CORROSION, CRACKING,
WEAR, PITTING, EROSION,
FRACTURE, MELTING,
CAVITATION...
MAINTENANCE
DEFICIENCY
IMPROPER
OPERATION
Adapted from Callaway Plant “Fault Tree Analysis” Training
Step 1:
Identify the
Undesirable
Incident
Step 2:
Identify
1st Level
Inputs
Step 3:
Link Using
Logic Gates
Step 4:
Identify
2nd Level
Inputs
Step 8:
Determine
Contributing
Factors
“Physical
Roots”
Step 7:
Investigate
Remaining
Inputs
Step 6:
Develop
Remaining
Inputs
Step 5:
Evaluate
Inputs
Fault Tree Analysis, Clemens
Callaway Plant “Fault Tree Analysis” Training
© 4Konsulting, LLC 2009
Frederick J. Forck, CPT
2320 Knight Valley Drive
Jefferson City, Mo 65101-2253
Phone: 573-645-8854
Fax: 573-636-7734
Email: [email protected]
www.4konsulting.com
Equipment
Runs
Incident
And
Equipment
Form
Function
Fit
Physical
Roots
Human-Machine
Interface
And
Design
Response
Materials
Assembly
Installation
Operation
Maintenance
Storage
Human
Succeeds
Think (Operation)
And
Stimulus
Human
Roots
Skill
Knowledge
Mindset
Personal Accountability
Personal Choice
Organizational
Processes
Communication
Practices
Defense-In-Depth
Latent
Organizational
Weaknesses
And
Latent
Roots
Human
Factors
Independent
Verification
Written
Instruction
Supervision
Oversight
Learning
Environ
Step 1:
Obtain
Preliminary
Information
Step 2:
Select
Task(s) of
Interest
Step 3:
Obtain
Background
Information
Step 4:
Prepare a Task
Performance
Guide
Step 8:
Evaluate &
Integrate
Findings
Step 7:
Reenact
Task
Performance
Step 6:
Select
Personnel
Step 5:
Get Familiar
With the
Guide
Step 7A:
Interview
Personnel
(Alternate
Method)
DOE-NE-STD-1004-92
Note: Not all steps of a work activity
are equally important.
Critical Human Actions (steps) include:
• Actions aimed at changing the state of
facility structures, systems, or components
• Steps that are irrecoverable or
actions that cannot be reversed
• Steps where the outcome of an error
is intolerable for personnel or facility safety
www.hanover.gov
NRC NUREG/CR-5455, NRC HPIP
A step in the activity that caused or could have
made the incident less severe.
It is a CHA if the step:
 Might cause an incident if the step is not done
 Might cause an incident if an error is made
 Might cause an incident if done some other way
 Makes incident less severe if done the right way.
Could be a “Critical Step” related to the incident
NRC NUREG/CR-5455, NRC HPIP
1. Identify the human actions to be analyzed.
(This may be all the human actions in the
incident, or it may be those that are believed
to have been responsible for the event's
occurrence.)
2. Decide which human actions caused the
incident or, if they had been performed
correctly, could have prevented the
incident or made the incident less severe
(Critical Human Actions or CHAs).
3. Collect and record information about the
CHAs.
Derived from:
1. NRC NUREG/CR-5455, NRC HPIP
2. UE QIP
Action
Action
Action
How did the factors originate?
Action
Incident
Factor
Factor
Why did this
Incident happen?
What systems allowed
The Conditions to exist?
Adapted from DOE Accident Investigation Program
Contributing
Factor
Work
Activity
Causes
Contributing
Factor
Process
Causes
Contributing
Factor
Institutional
Causes
Actions
Who did what?
What equipment did what?
Action 1
Incident that Occurred
(Reason for the Investigation)
Action 2
Incident
(Action 4)
Action 3
CF
CF
Factor 1.1
Factor 1.1.1
Factor 2.1
Factor 1.1.2
Factor 3.1
Factor 2.2
Factors or Contributing Factors
Flawed
Defense
Action 5
Progression of
the problem
Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis Process
Establish
Contributing
Factors
Techniques
•Change Analysis
•Barrier Analysis
•Production/Protection Strategy
(Defense-In-Depth) Analysis
•Factor Tree
How and Why?
Issues that drove,
influenced, or allowed
the incident
The Six Steps of Change Analysis
Incident
situation
COMPARE
Comparable
incident-free
situation
Some Factors to Consider:
- Who
- What
- Where
- When
- Work Conditions
- Task
- Triggering Events
- Management Controls
- Procedures
- Resources
Set down
differences
Evaluate
differences for
effect on
incident
Integrate into
investigation
process
Evaluate by asking these questions:
• What was different about this time from all the
other times the same hardware operated without
a problem or the same task or activity was
carried out without error?
• Why now and not before?
• Why here and not there?
Guidelines for Preventing Human Error in Process Safety. Center for Chemical Process Safety of the American Institute of Chemical Engineers, Ferry © 1988
Root Cause Analysis Training Course CAP-02, Palo Verde Nuclear Generating Station
Ammerman, The Root Cause Analysis Handbook
Local
Factor
Control
Engineered
Barriers
Admin
Controls
Oversight
Controls
Cultural
Controls
Eliminate task.
Prevent error.
Catch error.
Detect defect.
Mitigate harm.
Accept risk.
“Carelessness and overconfidence are more dangerous than deliberately accepted risk.”
Wilbur Wright, 1901 (www.faa.gov)
Muschara, Managing Critical Steps, HPRCT 2009
Muschara, Managing Defenses, HPRCT 2008



Identify each Target of hazards/threats.
Identify each Hazard (adverse effect/consequence)
Identify Barriers that should have controlled Hazard
• Prevented contact between Hazard and Target OR
• Mitigated consequences of Hazard/Target contact


Assign a Safety Precedence Sequence # to each Barrier
Assess HOW Barrier failed
• not provided/missing (not in place)
• not used/circumvented (but were in place)
• ineffective



Determine WHY Barrier failed (Step 5)
Validate analysis results
Integrate this information in E & CF Chart
Ammerman, The Root Cause Analysis Handbook
ASQ
MOST
EFFECTIVE
LOW HUMAN
INTERFACE
1. Eliminate hazards through design selection
2. Incorporate Safety Devices
3. Provide Warning Devices
$
4. Use Procedures & Administrative Controls
5. Select, train, supervise, and motivate to work safely
6. Accept risks at appropriate management level
LEAST
EFFECTIVE
MIL-STD-882D
HIGH HUMAN
INTERFACE
EFFECT/
CONSEQUENCES
(What Happened)
List one at timesequential order
not required
Ineffective
SPS #
No Yes
Not Used
Target Hazard/
Threat Defense
Missing
Failed?
HOW
Defense
Failed
BARRIER/CONTROL THAT
SHOULD HAVE PRECLUDED
THE INCIDENT
list all applicable physical and
administrative defenses for each
consequence
Corrective
WHY
Action to
Defense
Restore
Failed
Defense to
Effectiveness
Ammerman, The Root Cause Analysis
Handbook
ASQ
1977
Company installed
fixed ladder on
building.
Employee
climbed
ladder.
Employee
slipped on
ladder rung.
Ladder was
not compliant
with OSHA
requirements.
Carrying tools
Rungs were wet.
Hand not
available to
stop fall
Rungs not
slip-resistant
Hazard/
Threat
Defense
No Yes
SPS #
Employee
Employee
Slip on rungs
Falling from
heights
Slip-resistant
rungs
(provide
traction) 2
Proper
climbing
technique
5
Yes
Yes
Missing
Target
X
X
Ineffective
Failed?
HOW
Defense
Failed
Not Used
Defense
Not Used
Employee
fell from
ladder.
Defense
Missing
Employee
broke
back.
Employee
transported
to hospital.
www.sandia.gov
Corrective
WHY
Action to
Defense
Restore
Failed
Defense to
Effectiveness
Did not exist;
so did not
provide
traction
Carrying
tools; so 2nd
hand not
available to
stop fall www.sandia.gov
Evaluate factors (ovals) and flawed defense (broken barriers) on the Actions & Factors Chart by asking:
•
•
If this factor had not existed, could this incident have occurred?
If the answer is no, then you’re on your way toward finding a “Contributing Factor”!
(NRC) Causal factors are those
actions, conditions, or events
which directly or indirectly
influence the outcome of a
situation or problem.
Find
Root Cause(s)
Directly
Actions,
Conditions, or
Events
CF
Directly or Indirectly
influence the outcome of
a situation or problem?
(NRC) causes that by themselves would not create the problem, but
are important enough to be recognized as needing corrective action.
Contributing causes are sometimes referred to as causal factors.
(INPO) A causal factor that did not produce the event but did shape
the outcome or exacerbate the consequences.
(Entergy) facilitates the occurrence of a condition or event, increases
its severity, or lengthens the time to discovery.
Indirectly
Contributing
Factor
Construct
Root Cause(s)
The actions or conditions that set the stage for a human performance
problem to occur, but, alone, were not sufficient to cause it...may be a
long-standing condition or a series of prior events and problems that,
while unimportant in themselves, increased the probability of error.
Develop action plan to
prevent recurrence (CAPR)
OR
Justify why action will not be
taken to address this cause.
OR
Justify only developing
corrective action (CA)
© 2008, 4Konsulting, LLC, 573-645-8854, www.4konsulting.com
NRC Inspection Procedure 95001
Issues that drove,
influenced, or
allowed the incident
Techniques
•WHY Factor Staircase
•A-B-C Analysis
•HOW-To-WHY Matrix
•Cause & Effect Tree
•Root Cause Test
•Root Cause Evaluation
•Extent of Cause Review
•Common Factor Analysis
•Stream Analysis
Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis Process
Validate
Underlying
Factors
Why?
Correctable root and
contributing causes
Symptom
WHY 1
Practices

Incident

Execution
Preparation
Feedback

WHY 2

Conditions


WHY 3
Process
Program

Plan/Do/Check/Act

Vision
Beliefs
Values

WHY 5
Culture
Phoenix Handbook, Corcoran
Root Cause, Martin, HPRCT 2006

Outcomes
Methods
Resources

WHY 4
Capabilities/Limitations
Task Demands/Environment


Thoughts
Culture
Anticipate
Job-Site
Conditions
Task Demands
TWEnvironment
IN
Work
Analysis
Individual
Capabilities
Human Nature’s Limits
Foresee
Results
Manage
Potential
Consequences
List critical human actions
Modify task or work environ
Predict error-likely situations
Task
Evaluate
defenses for flaws
Preview
Change Job Performers
Review previous
lessons learned
Plan contingency measures
Pre-Job
Modify orBrief
add defenses
Job
Performer
Behavior
Use Worker
and Supervisor
Feedback
Goals &
Values
Eliminate causes of
Post-Job
error precursors
Eliminate
causes of
Review
flawed defenses
Strengthen
defense-in-depth
Business
Incident
Results
INPO Human Performance Fundamentals Course
Desired behavior: Wear safety glasses
•
•
•
•
•
A
B
Safety policy
Safety signs
Safety procedure
Safety briefing
Just-in-time training
• Wear safety glasses
C
•
•
•
•
Ears hurt
Can’t see clearly
Uncomfortable
Feel odd
Consequences for current or past behaviors have
the strongest influence on our future behavior.
Foundations of Behavioral Accident Prevention: Eagles Management Support Course, BST, Inc.
Performance Management, Daniels
Desired behavior: Wear safety glasses
A
B
• Peers don’t wear
• Supervisors
occasionally don’t wear
• Leave at home
• Embarrassed to ask for
spare pair
• Work w/o safety
glasses
C
• Ears don’t hurt
• Can see clearly
• Less bother
Consequences for current or past behaviors have
the strongest influence on our future behavior.
Foundations of Behavioral Accident Prevention: Eagles Management Support Course, BST, Inc.
Performance Management, Daniels
Uneasy Attitude
Morale Written Instruction Quality
Job Performer Skill, Knowledge, Proficiency
Housekeeping
Equipment Labeling & Condition
Work-Arounds & Burdens
Tool Quality & Availability
Equipment Ergonomics
Lockout-Tagout
Fitness-For-Duty
Walk-downs
Task Preview
Pre-Job Brief
Turnover
Processes/
Practices
Questioning Attitude
Procedure Use
Procedure Adherence
Self-Check
Place-keeping Observations
Conservative Decision-Making
3 Part Communication
Stop…When Unsure
Tasks/
Behaviors
Walk-downs
Task qualifications
Performance Feedback
Task assignment
Interlocks
Independent Verification
Personal Protective
Equipment
Alarms
Goals/
Values
Staffing
Continuous Learning
Clear Expectations
Change Management
Benchmarking
Problem-Solving
Reviews & Approvals
Communication Practices
Simple, Effective Processes Management Practices
Accountability Rewards & Reinforcement
Handoffs
Peer Check
Results/
Incident
Consequences
Post-Job Critiques
Root Cause Analysis
Independent Oversight
Performance Indicators
Task assignment
Berms
Redundant trains
Equipment Reliability
Containment
Equipment Protection Systems
Safeguards Equipment
INPO Human Performance Fundamentals Course
In order to understand why people do what they do,
beyond asking,
"Why did they do that?"
ask,
"What happens to them
when they do that?"
When you understand the consequences,
you are able to understand the behavior.
Daniels, Aubrey C., Ph.D.; Performance Management, Performance Management Publications, Tucker, GA, 1989, pp. 23-24.
Safety Culture
Areas (4)
Safety (13)
Components
Culture
Aspects
AND
Human
Performance
(H)
Problem Identification
& Resolution
(P)
Safety Conscious
Work Environment
(S)
Other Issues
(O)
NRC IM Chapter 0305 Areas
Do Last!!!
Components Within
Cross-Cutting Area
Human Performance
1.
2.
3.
4.
Decision Making
Resources
Work Control
Work Practices
Any weaknesses
within component?
Yes
Yes
No
Yes
No
Yes
No
Yes
No
No
Problem Identification & Resolution
1. Corrective Action Program
2. Operating Experience
3. Self and Independent Assessments
Yes
Yes
No
Yes
No
Yes
No
Safety Conscious Work Environment
1. Willingness to Raise Concerns
2. Preventing and Detecting Retaliation
Yes
Yes
No
Yes
No
Other Safety Culture Components
Accountability
Continuous Learning Environment
Organizational Change Management
Safety Policies
Yes
Yes
No
Yes
No
Yes
No
Yes
No
1.
2.
3.
4.
Corrective
Action Needed
Tasks/
Behaviors
No
Processes/
Practices
No
No
Goals/
Values
NRC IMC 0305
Made the
Incident
Happen?
Action
or Factor
Made the
Consequences
Worse?
No
Yes
No
Is NOT
“Causal”
Yes
Is “Causal”
Root Cause
No
Caused* by a
More Important
Underlying Factor?
Yes
NOT
Root Cause
*Caused-driven, permitted, influenced, triggered, released
Adapted from work of Dr. William R. Corcoran, NSRC Corp.
1
Does potential
exist for the causes of this
problem to impact other
SSC*s or Processes?
YES
Describe where, when, and
how it will be impacted
NO
1, Describe why this is an
isolated cause/condition.
2. Verify, using OE**, that this
is not an industry issue.
Recommend corrective actions
Human Performance Tool
NO
2
Peer Check
Does potential
exist for the conditions
Describe triggering conditions
YES
that triggered behaviors in this
and where they are likely to
problem to trigger similar
trigger similar behaviors
behaviors in other
processes?
*SSC-Structure, System, Component
**OE-Operating Experience
Adapted from information provided by Duke Power personnel
Step 1
Determine the
Scope of
the CFA
Step 2
Gather
Data
Step 3
Determine Which
Information to
Evaluate
Step 4
Categorize
the Data
Step 5
Identify Areas
for Further
Analyses
Step 9
Report
Learnings
Step 8
Plan
Corrective
Actions
Step 7
Develop and
Validate Causal
Theories
Step 6
Analyze
Areas of
Interest
Adapted from Incident Investigation Training, Callaway Plant
Correctable root and
contributing causes
Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis Process
Plan
Techniques
Corrective
•Action Plan
Actions
•Solution Selection Tree
•Solution Selection Matrix
•Change Management
•Active Coaching Plan
•S.M.A.R.T.E.R.
•Effectiveness Review
•Contingency Plan
•Communication Plan
What next?
Intervention(s) that
improve design or
change behavior
Develop alternative actions which address the underlying factors
[i.e. the root cause(s)].
Evaluate alternative courses of action.
Ensure corrective actions address the underlying factors [i.e. the root
cause(s)].
Decide which alternatives will be recommended to management.
Map out implementation of interventions/actions
that will prevent or mitigate recurrence.
Plan for contingencies.
Institutionalizing
Corrective Actions*
Do it
(implementation & use)
Check
Monitor
(management & peers)
Write it down
(Procedure)
Feedback
(observation & mentoring)
Agree
Check
Adjust
Start Here
Agree
Agree
Communicate it
(Training)
Vision,
Values, &
Beliefs
Mental Model
(Expectation = Standard)
Ownership of Expectation
(Organization; incl.
management & peers)
Vision,
Values, &
Beliefs
© 2009 4Konsulting, LLC
Adjust
* Could be called
-Alignment Model
-Behavior Anchoring Model
-Accountability* Model for Organizations
-Gap Closure Plan
Institutionalization Plan
Factor/Cause
Being Addressed
© 2009 4Konsulting, LLC
Corrective
Action Step
1. Right
Picture
2. Communicate
3. Monitor
4. Feedback
Who
When
Owner
Due Date
Specific
• What exactly needs to be done? Focus on results.
• WHO does WHAT by WHEN
Measurable
• Describes desired behaviors so an observer can compare
observed behavior to a desired behavior
Attainable
• Doable? Feasible? Realistic? Cost/Benefit?
• Agreed to by Stakeholder? Good business?
Related
• Logical tie between the problem and cause(s)
• Logical tie between cause(s) and corrective actions
Time-sensitive
• Should be completed before next “shot on goal”
• If not, interim corrective actions are needed
Effective
• Degree of Dependability/Reliability
• Leveraged solution w. Behavior Engineering Model
Reviewed
• By Stakeholders? By Subject Matter Experts?
• For Unintended Consequences?
www.hanford.gov
Institutionalization
Plan
Cause/Factor
Being
Addressed
Corrective Action Plan
To Prevent Recurrence
1. Right Picture
2. Communicate
3. Monitor
4. Feedback
S.M.A.R.T.E.R.
Specific
Measurable
Attainable
Related
Timely
WHO
Effective
Reviewed
Owner
WHEN
Due
Date
Design Activity
Risk at
acceptable
level?
NO
Document any relative
policies or guidelines
to ensure
management strategy
Redesign to
reduce risk
Risk at
acceptable
level?
NO
Incorporate
safety
devices
MIL-STD-882D
SAFETY DEVICES:
YES
YES
Risk at
acceptable
level?
Provide risk
analysis package
to management
YES
YES
YES
www.safeoutside.org/risk/Proceedings/Inc_Accpresentation.ppt
NO
Risk at
acceptable
level?
Provide
warning
devices
NO
WARNING DEVICES:
Develop special
procedures and
training
Risk at
acceptable
level?
NO
SPECIAL PROCEDURES
Document policy
or guideline
excluding activity
Repair activity
1
Develop corrective
actions
DEVELOP an
Effectiveness
Review Plan
Implement
intervention(s) that
improve design or
change behavior
UPDATE
management
2
PERFORM
Effectiveness Review
(Assessor Actions)
3
DOCUMENT
Effectiveness Review
(Assessor Actions)
4
APPROVE
Effectiveness Review
(QRB actions)
METHOD
• Describe the means that will be used to verify
that the actions taken had the desired outcome.
ATTRIBUTES
• Describe the process characteristics
to be monitored or evaluated.
SUCCESS
• Establish the acceptance criteria for the
attributes to be monitored or evaluated.
TIMELINESS
• Define the optimum time to
perform the effectiveness review.
Grand Gulf Nuclear Station
General Performance Measure Development
The following table is useful when developing Performance Indicators.
Organizational Outcome/Output: Step 1
Process Outcome/Output:
Step 2
Process Purpose:
Step 3
Operational Excellence
Critical
Outcome/Output
Dimensions
Step 4
Step 5
Measures
Standards
(Goals)
Annunciator
Definitions
Step 6
Step 7
Step 8
Improving Performance: How to Manage the White Space on the Organization Chart, Rummler & Brache
Intervention(s) that
improve design or
change behavior
Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis Process
Report
Learning
Forms
•Report Template
•Grade Cards/Scoresheets
An auditable,
defensible record
The investigation will have determined the following:
 What was expected
(anticipated consequences);
 What has happened
(real consequences);
 What could have happened
(potential consequences);
 Cause-effect relations;
 Faulty/failed technical elements
(structures, systems, or components);
 Inappropriate actions (human, management, organizational);
 Failed or missing defenses
(barriers, controls).
IAEA-TECDOC-1600
 What
was the Job Performer focused on?
 Could they do the Job if their lives depended on it?
 Equally qualified person likely to make same error?
 What were the factors that directly resulted in
the nature, the magnitude, the location, and
the timing of the key consequences?
 What happens to them when they do what they do?
Mager & Pipe, Analyzing Performance Problems
Corcoran , Phoenix Handbook
Daniels, Performance Management












Who identified issue (licensee? regulator? self-revealing?) under what conditions?
How long did issue exist? prior opportunities to identify?
Plant-specific risk consequences? individual & collective compliance concerns?
Systematic method used to identify underlying factors?
Evaluation detail commensurate with significance of the problem?
Evaluation considered prior occurrences? operating experience?
Extent of condition addressed? extent of cause?
Corrective actions for each underlying factor?
or adequate evaluation why no corrective actions are necessary?
Corrective action priority considers risk significance & regulatory compliance?
Schedule established for implementing and completing corrective actions?
Quantitative/qualitative effectiveness measures of actions to prevent recurrence?
Corrective actions adequately address Notice of Violation, if applicable?
NRC IP 95001
NRC IP 95002
 Later
Frederick J. Forck, CPT*
4Konsulting, LLC
2320 Knight Valley Drive
Jefferson City, Mo 65101-2253
Phone: 573-645-8854
Fax: 573-636-7734
Email: [email protected]
www.4konsulting.com
*International Society for Performance Improvement (ISPI) Certified Performance Technologist (CPT)
Extent of Condition
Review Criteria
Deviation Statement
Same-Same-Same
An Identical Object
in an Equivalent Application
with a Matching Defect.
Same-Same-Similar
An Identical Object
in an Equivalent Application
with a Related Defect.
Similar-Same-Same
A Comparable Object
in an Equivalent Application
with a Matching Defect.
Similar-Same-Similar
A Comparable Object
in an Equivalent Application
with a Related Defect.
Same-Similar-Same
An Identical Object
in a Corresponding Application
with a Matching Defect.
Similar-Similar-Same
A Comparable Object
in a Corresponding Application
with a Matching Defect.
Same-Similar-Similar
An Identical Object
in a Corresponding Application
with a Related Defect.
Object
(Person, Place, Thing)
Application
(Activity, Form, Fit, Function)
Defect
(Flaw, Failing, Deficiency)
Driver’s
side front tire
of rental car
parked
in my driveway
is flat
Object
Extent of Condition
(Person,
Place, Thing)
Review Criteria
Deviation Statement Driver’s Side Front Tire on
Same-Same-Same
An Identical Object
in an Equivalent Application
with a Matching Defect.
Same-Same-Similar
An Identical Object
in an Equivalent Application
with a Related Defect.
Similar-Same-Same
A Comparable Object
in an Equivalent Application
with a Matching Defect.
Similar-Same-Similar
A Comparable Object
in an Equivalent Application
with a Related Defect.
Same-Similar-Same
An Identical Object
in a Corresponding Application
with a Matching Defect.
Similar-Similar-Same
A Comparable Object
in a Corresponding Application
with a Matching Defect.
Same-Similar-Similar
An Identical Object
in a Corresponding Application
with a Related Defect.
Application
(Activity, Form, Fit, Function)
Defect
(Flaw, Failing, Deficiency)
Parked in My Driveway
Flat
Rental Car
1. Other Tires on Rental Car
2. Tires on Pickup Truck
1. Parked in My Driveway
2. Parked in My Driveway
1. Flat
2. Flat
1. Other Tires on Rental Car
2. Tires on Pickup Truck
1. Parked in My Driveway
2. Parked in My Driveway
1. Low on Air
2. Low on Air
1. Tires on Boat Trailer
2. Tires on Bicycle
1. Parked in My Driveway
2. Parked in My Driveway
1. Flat
2. Flat
1. Tires on Boat Trailer
2. Tires on Bicycle
1. Parked in My Driveway
2. Parked in My Driveway
1. Low on Air
2. Low on Air
1.
2.
3.
1.
1.
2.
3.
1.
1.
2.
3.
1.
Car Spare Tire
Tires on Son’s Vehicle
Tires on Spouse’s Vehicle
Garden Tractor
1. Car Spare Tire
2. Tires on Son’s Vehicle
3. Tires on Spouse’s Vehicle
In Trunk as a Spare
Parked on the Street
Parked in the Garage
Parked Behind My House
1. In Trunk as a Spare
2. Parked on Street
3. Parked in the Garage
Flat
Flat
Flat
Flat
1. Low on Air
2. Low on Air
3. Low on Air
OR
OR
OR
OR
OR
Adapted from Callaway Plant “Fault Tree Analysis” Training
(1)
Paper & Pencil Input
Steps in
Procedure
or Practice
(2)
Walk Through
by Analyst
or trained
individual.
(3)
Questions/
Conclusions about
how task
was/should be
performed.
(1)
Paper & Pencil Input
Steps in
Procedure
or Practice
1. Locate proper “pig trap”.
2. De-pressurize line pressure.
3. Verify that the line has been
de-pressurized.
4. Open line.
5. Insert pig.
6. Close line.
7. Re-pressurize line.
(2)
Walk Through
by Analyst
or trained
individual.
Pig trap is not labeled.
Nearest pressure gauge is
up 2 flights of stairs about
50’ away.
Other pig traps all have
pressure gauges near
opening.
(3)
Questions/
Conclusions about
how task
was/should be
performed.
Is there a requirement to label?
Why is the location without a
pressure gauge?
Has it been modified?
Steps are all very general.
How does the operator know how
to do them?
Chlorine Plant
Explosion Kills
3, Injures 1
Prepare
tanker for
filling
Verify
tanker is
empty
Check
weight of
tanker
Enter
tanker target
weight
Prepare fill
line
Connect
main fill line
Error Type: Wrong Information Obtained
Error Description: Wrong Weight Entered
Consequence: Alarm does not sound before tanker overfills
Monitor
tanker filling
operation
Remain
within
earshot
while tanker
is fillin
Check road
tanker
Attend
tanker
during last
2-3 ton
filling
Error Type: Check Omitted
Error Description: Tanker not monitored while filling
Consequence: Leaks not detected early
Guidelines for Preventing Human Error in Process Safety, Center for Chemical Process Safety of the American Institute of Chemical Engineers
1977
Company installed
fixed ladder on
building.
Ladder was not
compliant with OSHA
requirements.
Employee
climbed
ladder.
Employee
slipped on
ladder rung.
Employee
fell from
ladder.
Rungs were wet.
Employee
broke
back.
Employee
transported
to hospital.
www.sandia.gov
A.
B.
C.
D.
E.
Factors
that Influence
Performance
Failed
Performance
Past
Successful
Performance
Difference
or Change
Contributing
Factor?
(Yes/No)
When
Supervision
Job Performer Job Performer
came in early to started day the
avoid the heat. same time as coworkers.
Employee did
not meet with
supervisor the
morning of the
accident.
Employee met with
supervisor to
discuss the day’s
work activities.
No co-workers
Yes. Worker
were available to came to work
help with the job. early, so was
working alone,
carrying tools.
Work activities
Yes. Because
were not
worker came to
discussed.
work early, job
hazards were not
discussed.
CF
1977
Company installed
fixed ladder on
building.
Ladder not
compliant
with OSHA
requirements.
Employee
came to work
early
Employee
climbed
ladder.
Working
alone
Carrying tools
Job hazards
not discussed
Employee
slipped on
ladder rung.
Employee
fell from
ladder.
Employee
broke
back.
Employee
transported
to hospital.
CF
2nd hand
not available to
stop fall
Rungs were wet.
Rungs not
slip-resistant
CF
Defense
Not Used
Defense
Missing
www.sandia.gov
Develop corrective
actions
IMPLEMENT interim
actions to prevent a
repeat event pending
comprehensive
corrective actions.
COMPLETE the
investigation
IDENTIFY steps to
address the
cause(s).
ESTABLISH action
plan for each identified
cause or document
the basis for no
corrective action.
INCLUDE actions to
address Extent of
Condition findings.
INCLUDE actions to
address Extent of
Cause findings.
ASSURE actions
have addressed
Safety Culture
weaknesses
FOR root causes,
PLAN an intervention
that is sustainable
and that will be
institutionalized.
DETERMINE an
appropriate date for
completion of
Corrective Action.
EVALUATE the
potential
effectiveness of
proposed corrective
actions
VERIFY the
corrective action plan
meets Change
Management policy
requirements.
DEVELOP a
contingency plan
WRITE a
Communication Plan.
(with Lessons To Be
Learned)
DEVELOP an
Effectiveness
Review Plan
UPDATE
management
Implement
intervention(s) that
improve design or
change behavior
1
DEVELOP an
Effectiveness Review
Plan
2
PERFORM
Effectiveness Review
(Assessor Actions)
SEARCH for examples of
conditions/incidents that
demonstrate the actions
taken were ineffective at
preventing recurrence.
GENERATE a
trackable activity with
acceptance criteria to
evaluate long-term
effectiveness
DOCUMENT the
Effectiveness Review
plan and
Effectiveness Review
criteria.
REVIEW the
document(s) that
originated the
corrective actions.
FOLLOW the
Effectiveness Review
Plan in filling out the
Effectiveness Review
ChecklistIII
Attachment
SEARCH for precursor
incidents/conditions that
may indicate the actions
taken have not been
effective.
3
DOCUMENT
Effectiveness Review
(Assessor Actions)
Effectiveness
Criteria met?
Yes
No
Detailed Effectiveness Review Flowchart
LIST Causes/
Root Causes
that were
identified:
DETERMINE whether the issue(s) or
condition(s) identified in the Problem Report
have been eliminated and whether the
measures taken to correct the issue(s) or
condition(s) are being managed.
GENERATE a
new Problem
Report
ATTACH a new
Effectiveness
Review Plan
DETERMINE whether the
actual corrective action(s)
address each cause or root
cause documented in the
Problem Report.
LIST Corrective
Actions that
were planned:
DETERMINE whether a
repeat occurrence or
condition took place.
DOCUMENT
what was
performed to
validate
findings.
4
DETERMINE whether all the
corrective action assignments
are implemented AND remain
active as stated in the
corrective action plan.
IF the actions to prevent
recurrence were not
effective, IDENTIFY any
additional corrective actions
needed to resolve the issue.
APPROVE
Effectiveness Review
(QRB actions)
DETERMINE whether the
corrective actions have been in
place long enough to
successfully challenge the
effectiveness of the actions.
DISCUSS corrective actions
with cognizant personnel to
identify any noteworthy
weaknesses in the
corrective actions.
ENSURE corrective
action taken did
NOT result in a
negative impact.

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