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Systematic Methods To

Address Root And
Contributing Causes
Expectations in
NRC Inspection Procedures 95001 and
95002
Frederick J. Forck
4Konsulting, LLC

Using Tools
USE A TOOL

USE A TOOL TO BUILD

Using Cause Analysis Tools
CAUSE ANALYSIS TOOLS
1. 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
NRC IP 95001

USE TOOLS TO RECONSTRUCT

systems aging. supervision and oversight. and • Human performance: training. work practices. communications. preventive and corrective maintenance programs. human-system interface. operational policies. and environmental conditions.Systematic Evaluation Normally Includes:    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. • Process: procedures. and quality control methods. and fitness for duty (which includes managing fatigue). . materials.

Recommend corrective actions .Basic Investigation Steps Gather information Reconstruct the incident. Discover causes.

1985 ..Continuous Performance Improvement Problem Prevention Symptom/Effect Analysis Cause Analysis Solution Analysis Problem Prevention Follow Up Analysis Solution Analysis I n c i d e Follow Up Analysis n t Symptom/Effe ct Analysis Cause Analysis Avatar International Inc.

INPO 90-004 2. NRC HPIP 3.General Job/Task Analysis Derived from 1. Entergy Root Cause Analysis Process . NUREG/CR-5455.

Procedures. & Drawings Criterion V of Appendix B to 10CFR50  Written  Followed  Include Acceptance Criteria 10CFR50. App. B Callaway Plant Lead Auditor Training .Instructions.

or allowed the incident Accurate. defensible record Correctable root and contributing causes . 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.Steps with Acceptance Criteria Issues that drove. influenced. bounded problem statement Plan Corrective Actions Report Learnings Auditable.

NUREG/CR-5455.Overall Method Steps w. Techniques Derived from 1. NRC HPIP 3. INPO 90-004 2. Entergy Root Cause Analysis Process .

SCOPE THE PROBLEM (Step 1) Derived from 1. NRC HPIP 3. INPO 90-004 2. Entergy Root Cause Analysis Process Techniques •Deviation Statement •Difference Mapping •Problem Description •Extent of Condition Review •Methodology Selection . NUREG/CR-5455.

Norm.” Example: Five gallons of oil spilled (defect) on the “B” Emergency Diesel Generator room floor (object) . The New Rational Manager BPI Problem Solving-Decision Making-Planning . Standard. or Expectation with  “WHAT IS”: The existing. as-found condition” *Sometimes the “What Should Be” is implied.Effective Problem Description 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. Kepner-Tregoe. Actual Statement  Compare “WHAT SHOULD BE”*: Requirement. OR Use: Method 2: Expected vs.

15th Annual HPRCT Defect 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 .HOW: Extent of [Adverse] Condition Evaluate ONLY from Problem Description Perspective Deviation Statement: Object Application   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.

How to do an Extent of Condition Review Human Performance Tool Peer Check .

Entergy Root Cause Analysis Process Techniques •Evidence Preservation •Interviewing (What & How) •Performance Analysis Worksheet •Culpability Decision Tree •Substitution Test/Survey •SORTM questions . NUREG/CR-5455. INPO 90-004 2. NRC HPIP 3.INVESTIGATE THE FACTORS (Step 2) Derived from 1.

(Information you have vs.g. • Divide responsibilities among team members • If no team.Information Gathering Strategy 1. • area walkdowns • interviews • Decide who to interview and what you hope to learn from them. charts. drawings. Considerations: • Focus on issues that appear to be key. restart issues). Information you still need) • review of logsheets. • Interviewee availability may pose an impact. system engineer can research material history Adapted from Incident Investigation Training. Determine who will obtain the information.g. etc. • Management Sponsor may need certain information first (e. you can still seek assistance from cognizant parties e. Determine how best to fill your information needs. Callaway Plant . 3. 2. Determine which information to pursue first.

How is Interviewing done? Prepare Open Question Close IAEA-TECDOC-1600 .

TwoPronged Approach to Incident Prevention Md System Factors Prong Re Human Factors Prong Adapted from INPO 06003 .

Factor Tree Phoenix Handbook. Corcoran Dana Cooley .

NUREG/CR-5455.RECONSTRUCT THE STORY (Step 3) Derived from 1. Entergy Root Cause Analysis Process Techniques •Fault Tree •Task Analysis •Critical Activity Charting •Actions & Factors Chart . INPO 90-004 2. NRC HPIP 3.

Human-Machine Interface Adapted from Callaway Plant “Fault Tree Analysis” Training .

8 Steps of Fault Tree Analysis 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 .

Factor Flow Equipment Physical Roots Human-Machine Interface Response Think (Operation) Human Stimulus Roots Defense-In-Depth Latent Organizational Weaknesses Latent Roots .

How is Task Analysis done? Step 1: Obtain Preliminary Information Step 2: Select Task(s) of Interest Step 3: Obtain Background Information Step 4: Prepare a Task Performance Guide Paper & Pencil Phase Step 8: Evaluate & Integrate Findings Step 7: Reenact Task Performance Step 7A: Interview Personnel (Alternate Method) DOE-NE-STD-1004-92 Step 6: Select Personnel Step 5: Get Familiar With the Guide Walk-Through Phase .

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. systems.Critical Human Action Concept Note: Not all steps of a work activity are equally important.gov NRC NUREG/CR-5455.hanover. NRC HPIP . Critical Human Actions (steps) include: • Actions aimed at changing the state of facility structures.

NRC HPIP . Could be a “Critical Step” related to the incident NRC NUREG/CR-5455. 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.A "Critical" Human Action IS: A step in the activity that caused or could have made the incident less severe.

NRC HPIP 2. could have prevented the incident or made the incident less severe (Critical Human Actions or CHAs).) 2. (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. Identify the human actions to be analyzed. Derived from: 1. Decide which human actions caused the incident or. NRC NUREG/CR-5455. 3.How is a Critical Human Activity Table done? 1. if they had been performed correctly. Collect and record information about the CHAs. UE QIP .

General Systems Analysis Events & Causal Factors Charting Action Action Action How did the factors originate? Action Inciden t Factor Factor Why did this Incident happen? What systems allowed The Conditions to exist? Adapted from DOE Accident Investigation Program Contributing Factor Contributing Factor Contributing Factor Work Activity Causes Proces s Causes Institution al Causes .

General Format .

Entergy Root Cause Analysis Process Techniques •Change Analysis •Barrier Analysis •Production/Protection Strategy (Defense-In-Depth) Analysis •Factor Tree . INPO 90-004 2.ESTABLISH CONTRIBUTING FACTORS (Step 4) Derived from 1. NUREG/CR-5455. NRC HPIP 3.

The Root Cause Analysis Handbook . Palo Verde Nuclear Generating Station Ammerman.How is Change Analysis done? 1 2 3 4 5 6 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? Root Cause Analysis Training Course CAP-02.

” Wilbur Wright. Accept risk.Identify Risk Defenses (Barriers & Controls) Local Factor Control Engineere d Barriers Admin Control s Oversigh t Controls Cultural Controls Eliminate task.gov) Muschara. Prevent error. HPRCT 2009 Muschara. 1901 (www. Managing Defenses. Catch error. HPRCT 2008 . Managing Critical Steps. Detect defect. “Carelessness and overconfidence are more dangerous than deliberately accepted risk.faa. Mitigate harm.

Systematic Barrier Analysis    Identify each Target of hazards/threats. The Root Cause Analysis Handbook ASQ . 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.

Eliminate hazards through design selection 2.System Safety Design Order Of Precedence MOST EFFECTIVE LOW HUMAN INTERFACE 1. and motivate to work safely 6. Use Procedures & Administrative Controls 5. Incorporate Safety Devices 3. Select. Provide Warning Devices $ 4. supervise. Accept risks at appropriate management level LEAST EFFECTIVE MIL-STD882D HIGH HUMAN INTERFACE . train.

Defense Analysis Form EFFECT/ CONSEQUENCES (What Happened) List one at timesequential order not required BARRIER/CONTROL THAT SHOULD HAVE PRECLUDED THE INCIDENT list all applicable physical and administrative defenses for each consequence Ammerman. The Root Cause Analysis Handbook ASQ .

sandia.gov www.Exampl e www.sandia.gov .

Contributing [Causal] Factor
Test
Identify Contributing Influences
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 Inspection Procedure 95001

VALIDATE UNDERLYING FACTORS
(Step 5)
Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis
Process

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

HPRCT 2006 Capabilities/Limitations Task Demands/Environment  .The WHY Factor Staircase  Incident  Execution Preparation Feedback      Outcomes Methods Resources  Plan/Do/Check/Act  Vision Beliefs Values    Phoenix Handbook. Martin. Corcoran Root Cause.

Culture .

Re Active Error Analysis Job Performer TW IN Analysis Goals & Values Task Preview Pre-Job Brief Post-Job Review Behavio r Business Result s I n c i d e n t INPO Human Performance Fundamentals Course .

Performance Management. Daniels . Foundations of Behavioral Accident Prevention: Eagles Management Support Course. Inc.The “A-B-C’s”: 1st Occurrence 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. BST.

Inc. Foundations of Behavioral Accident Prevention: Eagles Management Support Course. Performance Management. Daniels . BST.The “A-B-C’s”: Subsequent Occurrence 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.

Md Defense Management Analysis Uneasy Attitude Morale Written Instruction Quality Job Performer Skill. Effective Processes Management Practices Accountability Rewards & Reinforcement Interlocks Independent Verification Personal Protective Equipment Alarms Results/ Consequence s Goals/ Values Handoffs Questioning Attitude Procedure Use Procedure Adherence Self-Check Place-keeping Observations Conservative Decision-Making 3 Part Communication Stop…When Unsure Peer Check I Post-Job Critiques Root Cause Analysis Independent Oversight Performance Indicators Task assignment n c i d e n t Berms Redundant trains Equipment Reliability Containment Equipment Protection Systems Safeguards Equipment INPO Human Performance Fundamentals Course . 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 Walk-downs Task qualifications Performance Feedback Task assignment Tasks/ Behaviors Leadership Defense In Depth Staffing Continuous Learning Clear Expectations Change Management Benchmarking Problem-Solving Reviews & Approvals Communication Practices Simple.

Deeper Understanding .

NRC: Safety Culture General Tree NRC IM Chapter 0305 Areas .

Safety Culture Analysis Do Last!!! Tasks/ Behavior s Processes / Practices Goals/ Values NRC IMC 0305 .

Corcoran. William R.Root Cause Test Adapted from work of Dr. NSRC Corp. .

How to do an Extent of Cause Review Human Performance Tool Peer Check .

Common Factor Analysis Steps 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 .

M.T.E.PLAN CORRECTIVE ACTIONS (Step 6) Derived from 1.R. INPO 90-004 2. NRC HPIP 3. Entergy Root Cause Analysis Process Techniques •Action Plan •Solution Selection Tree •Solution Selection Matrix •Change Management •Active Coaching Plan •S.A. •Effectiveness Review •Contingency Plan •Communication Plan .R. NUREG/CR-5455.

the root cause(s)]. . Evaluate alternative courses of action. Decide which alternatives will be recommended to management. Ensure corrective actions address the underlying factors [i.e. Plan for contingencies.e.Developing A Corrective Action Plan To Prevent Recurrence Develop alternative actions which address the underlying factors [i. Map out implementation of interventions/actions that will prevent or mitigate recurrence. the root cause(s)].

The Success Cycle .

Right Picture 2.Behavior Change Institutionalization Plan Factor/Cause Being Addressed © 2009 4Konsulting. Feedback Who Owner When Due Date . LLC Corrective Action Step 1. Communicate 3. Monitor 4.

E.hanford. Behavior Engineering Model • Should be completed before next “shot on goal” • If not.R.M.A. • WHO does WHAT by WHEN Reviewed Effective Time-sensitive Related Attainable Measurable Specific S.gov • By Stakeholders? By Subject Matter Experts? • For Unintended Consequences? • Degree of Dependability/Reliability • Leveraged solution w.T.www. Criteria . interim corrective actions are needed • Logical tie between the problem and cause(s) • Logical tie between cause(s) and corrective actions • Doable? Feasible? Realistic? Cost/Benefit? • Agreed to by Stakeholder? Good business? • Describes desired behaviors so an observer can compare observed behavior to a desired behavior • What exactly needs to be done? Focus on results.R.

T. Communicate 3.Institutionalization Plan Cause/Factor Being Addressed Corrective Action Plan To Prevent Recurrence 1.A. Specific Measurable Attainable Related Timely Effective WHO Reviewed Owne r WHEN Due Date .R.E. Monitor 4. Right Picture 2. Feedback S.R.M.

Corrective Action Effectiveness Scale MIL-STD-882D Md .

Effectiveness Review General Flow .

T.S. Effectiveness Plan . • Establish the acceptance criteria for the attributes to be monitored or evaluated. Grand Gulf Nuclear Station TIMELINESS SUCCESS S ATTRIBUTE METHOD M.• Define the optimum time to perform the effectiveness review.A. • Describe the means that will be used to verify that the actions taken had the desired outcome. • Describe the process characteristics to be monitored or evaluated.

Rummler & Brache .Performance Indicator Development How is it done? Improving Performance: How to Manage the White Space on the Organization Chart.

INPO 90-004 2. Entergy Root Cause Analysis Process Forms •Report Template •Grade Cards/Scoresheets . NUREG/CR-5455. NRC HPIP 3.REPORT LEARNINGS (Step 7) Derived from 1.

management.  What could have happened (potential consequences). or IAEA-TECDOC-1600 components). .  Cause-effect relations. organizational).  Inappropriate actions (human.  Faulty/failed technical elements (structures.Report Answers General Questions The investigation will have determined the following:  What was expected (anticipated consequences).  What has happened (real consequences). systems.

the magnitude. Performance Management . and the timing of the key consequences?  What happens to them when they do what they do? Mager & Pipe. the location.Report Answers Specific Questions  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. Analyzing Performance Problems Corcoran . Phoenix Handbook Daniels.

if applicable? NRC IP 95001 NRC IP 95002 .Report Answers Regulator Questions             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.

Forck.com *International Society for Performance Improvement (ISPI) Certified Performance Technologist (CPT) . CPT* 4Konsulting. LLC 2320 Knight Valley Drive Jefferson City.Questions?  Later Frederick J.4konsulting. Mo 65101-2253 Phone: 573-645-8854 Fax: 573-636-7734 Email: fforck@4konsulting.com www.

Same-Same-Similar An Identical Object in an Equivalent Application with a Related Defect. Place. Deficiency) . Object (Person.Extent of Condition Review Criteria Deviation Statement Same-Same-Same An Identical Object in an Equivalent Application with a Matching Defect. Similar-Same-Same A Comparable Object in an Equivalent Application with a Matching Defect. Similar-Similar-Same A Comparable Object in a Corresponding Application with a Matching Defect. Failing. 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. Form. Thing) Application (Activity. Function) Defect (Flaw. Same-Similar-Similar An Identical Object in a Corresponding Application with a Related Defect. Fit.

In Trunk as a Spare 2. Similar-Similar-Same A Comparable Object in a Corresponding Application with a Matching Defect. 1. Application (Activity. 1. Low on Air 1. Low on Air 2. Parked on Street 3. 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. Parked in My Driveway 2. Tires on Son’s Vehicle 3. Parked in My Driveway 1. Low on Air 2. 1. Car Spare Tire Tires on Son’s Vehicle Tires on Spouse’s Vehicle Garden Tractor 1. Other Tires on Rental Car 2. Flat 1. Failing. Similar-Same-Same A Comparable Object in an Equivalent Application with a Matching Defect. Tires on Boat Trailer 2. Similar-Same-Similar A Comparable Object in an Equivalent Application with a Related Defect. Form. Place. 3. Same-Same-Similar An Identical Object in an Equivalent Application with a Related Defect. 2. 3. 1. Low on Air 3. Deficiency) Parked in My Driveway Flat Rental Car 1. Parked in My Driveway 1. Tires on Pickup Truck 1. Other Tires on Rental Car 2. Tires on Bicycle 1. Low on Air 2. Same-Similar-Same An Identical Object in a Corresponding Application with a Matching Defect. Parked in My Driveway 1. Car Spare Tire 2.Object Extent of Condition (Person. Tires on Bicycle 1. Fit. 1. Parked in the Garage Flat Flat Flat Flat 1. Parked in My Driveway 2. Parked in My Driveway 2. Same-Similar-Similar An Identical Object in a Corresponding Application with a Related Defect. 2. Parked in My Driveway 2. Flat 2. 3. Flat 1. Low on Air . Tires on Boat Trailer 2. Flat 2. Function) Defect (Flaw. 2. Tires on Pickup Truck 1. Low on Air 1. Tires on Spouse’s Vehicle In Trunk as a Spare Parked on the Street Parked in the Garage Parked Behind My House 1. Parked in My Driveway 1.

Fault Tree Form O R O R O R O R O R Adapted from Callaway Plant “Fault Tree Analysis” Training .

Task Analysis Technique (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. WCNOC .

3.Example: Task Analysis Technique (1) Paper & Pencil Input Steps in Procedure or Practice 1. Re-pressurize line. Nearest pressure gauge is up 2 flights of stairs about 50’ away. How does the operator know how to do them? WCNOC . 2. Insert pig. Locate proper “pig trap”. Open line. De-pressurize line pressure. Verify that the line has been de-pressurized. (2) Walk Through by Analyst or trained individual. 4. 6. Pig trap is not labeled. 7. (3)  Questions/ Conclusions about how task was/should be performed. 5. Is there a requirement to label? Why is the location without a pressure gauge? Has it been modified? Steps are all very general. Close line. Other pig traps all have pressure gauges near opening.

Example: Chlorine Tanker Fill Critical Human Activity Error Type: Wrong Information Obtained Error Description: Wrong Weight Entered Consequence: Alarm does not sound before tanker overfills 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 .

gov A.Example www. early. carrying tools. Because were not worker came to discussed. C. same time as coworkers. . Employee met with supervisor to discuss the day’s work activities. No co-workers Yes. so was working alone. 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. Worker were available to came to work help with the job. Work activities Yes. job hazards were not discussed. E. D. Employee did not meet with supervisor the morning of the accident.sandia. work early. B.

gov .Events & Causal Factors Chart after Change & Barrier Analysis www.sandia.

Problem Correction Flowchart .

Effectiveness Review Detailed Flow .