Forck - Systematic Methods to Address Root and Contributing Causes.pptx
Transcript of Forck - Systematic Methods to Address Root and Contributing Causes.pptx
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Systematic Methods To
Address Root AndContributing Causes
Expectations inNRC Inspection Procedures 95! and95"
#rederic$ %& #orc$4' onsu(ting) **C
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+sing Too(s
+SE A T,,* +SE A T,,* T, -+I*.
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+sing Cause Ana(ysis Too(s
CA+SE ANA*/SIS T,,*S +SE T,,*S T, REC,NSTR+CT
!& #au(t tree ana(ysis"& Critica( incident techni0ues1& E2ents 3 causa( 4actors
ana(ysis& Pareto Ana(ysis5& Change ana(ysis6& -arrier ana(ysis7& Management ,2ersight 3
Ris$ Tree 8M,RT ana(ysis:& ;hy Staircase
NRC IP 95!
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Systematic E2a(uation Norma((yInc(udes<
Clearly identify problem State assumptions Data
Timely collection
Verification Preserve evidence Document analysis so
•Progression of the problem
is clearly understood
•
Any missing information orinconsistencies are identified
•Problem can be easily explained
and/or
understood by others
Determine cause & effect
relationships resulting in dentification of root and contributing
causes that
Consider the follo!ing typesof issues"• #ard!are" design$ materials$ systems aging$
and environmental conditions%
• Process" procedures$ !or practices$
operational policies$ supervision and oversight$
preventive and corrective maintenanceprograms$ and 'uality control methods% and
• #uman performance" training$ communications$
human(system interface$ and fitness for duty
)!hich includes managing fatigue*+
NRC IP 95!
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-asic In2estigation Steps
Recommend correcti2e actions
.isco2er causes&
Reconstruct the incident&
=ather in4ormation
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Continuous PerformanceImprovement
ProblemPrevention
Symptom/Eect Analysis
CauseAnalysis
SolutionAnalysis
Follow UpAnalysis
A2atar Internationa( Inc&) !9:5
I n c i d e n t
ProblemPrevention
Symptom/EffectAnalysis
CauseAnalysis
SolutionAnalysis
Follow UpAnalysis
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=enera( %ob>Tas$ Ana(ysis
.eri2ed 4rom!& INP, 9?"& N+RE=>CR?555) NRC @PIP1& Entergy Root Cause Analysis
Process
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Instructions, Proceures, ! "rawin#sCriterion $ of Appeni% & to '(CF)*(
;ritten #o((oed
Inclue AcceptanceCriteria
!C#R5) App& -Ca((aay P(ant Lead Auditor
Training
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,2era(( Method Steps & Techni0ues
.eri2ed 4rom!& INP, 9?
"& N+RE=>CR?555) NRC @PIP1& Entergy Root Cause Analysis
Process
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SC+PE -E P)+&.E0Step '1
.eri2ed 4rom!& INP, 9?"& N+RE=>CR?555) NRC @PIP1& Entergy Root Cause Analysis
Process
Techni0ues•Deviation Statement •Diference Mapping•Problem Description•Extent o ConditionRevie!
•Met"odology Selection
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EBecti2e Prob(em .escription
dentify the GAP" 1hat is the Problem2
Metod !" Deviation Statement )noun/verb*
#$%EC&" What is te item tat is affected'
(EFEC&" Identify te )(E*IA&I#+, from te )E-PEC&E(, or ).EUI.E( S&A+(A.( of PE.F#.MA+CE0,
E1ample" Five 2allons of oil spilled 3defect4
on te )$, Emer2ency (iesel Generator room floor 3ob5ect4 0
#. Use"
Metod 6" .xpected vs+ Actual Statement
Compare )78A& S8#U9( $E,:" .e;uirement< Standard< +orm< or E1pectation
!ith
)78A& IS," &e e1istin2< as=found condition,
3Sometimes the 41hat Should 5e6 is implied+
-PI Problem Solving#Decision Ma$ing#Planning
'epner?Tregoe)T"e %e! Rational Manager
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@,;< Extent o4 2Averse3Condition E2a(uate ,N*/ 4rom Prob(em .escription
Perspecti2e
Then e2a(uate 2arious combinations• Same Same Same• Same Same Simi(ar
• Simi(ar
Same
Same• Simi(ar Simi(ar Same• etc&
.ocument the basis 4or bounding iththe associated ris$ and conse0uence
.e2iation Statement< &b'ect Deect Application
SameSameSame
An Identica( &b'ect
in an E0ui2a(ent Application
ith a Matching Deect
SameSameSimilar
An Identica( &b'ect in an E0ui2a(ent Application
ith a Re(ated Deect
SimilarSameSame
A Comparab(e &b'ect
in an E0ui2a(ent Application
ith a Matching Deect *eis A((en ) STP) !5th Annua( @PRCT
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-ow to o an E%tent of Conition )eview
@uman Per4ormance Too(
Peer Chec$
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In4ormation =athering Strategy
'8 "etermine 9ow best to :ll your information nees88In4ormation you ha2e 2s& In4ormation you sti(( need• re2ie o4 (ogsheets) charts) draings) etc&
• area a($dons
• inter2ies
•.ecide ho to inter2ie and hat you hope to (earn 4rom them&
78 "etermine w9ic9 information to pursue :rst8
Considerations
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@o is Interviewin# done
Close
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woPron#e
Approac9 toIncient
Prevention
)e
Adapted 4rom INP, 6?
1
@uman #actors ProngSystem ,actors Prong
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Factor ree
P"oenix ,andboo$ ) Corcoran.ana Coo(ey
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)EC+5S)UC -E S+)= 0Step ;1
Techni0ues•0ault Tree•Tas$ Analysis•Critical ActivityC"arting• Actions + 0actors C"art
.eri2ed 4rom!& INP, 9?"& N+RE=>CR?555) NRC @PIP1& Entergy Root Cause Analysis
Process
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Adapted 4rom Ca((aay P(ant F#au(t Tree Ana(ysisG Training
-umanac9ine Interface
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: Steps o4 #au(t TreeAna(ysis
Step 1:
Identify the
Undesirable
Incident
Step 2:
Identify
1st Level
Inputs
Step 7:
InvestigateRemaining
Inputs
Step 6:
DevelpRemaining
Inputs
Step !:
"valuate
Inputs
Step #:
Lin$ Using
Lgic %ates
Step &:
Identify
2nd Level
Inputs
Step ':Determine
(ntributing)actrs
*+hysical
Rts,
0ault Tree Analysis) C(emensCa((aay P(ant F#au(t Tree Ana(ysisG Training
ac or
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E;uipment
8uman=Macine
Interface
Pysical
.oots
8uman
.oots
.esponse
&in> 3#peration4
Stimulus
(efense=In=(ept
9atent
#r2ani?ational
7ea>nesses
9atent
.oots
ac orFlow
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@o is Tas$ Ana(ysis done
Step 1:Obtain
Preliminary
Information
Step 2:Select
Task(s) of
Interest
Step 3:Obtain
Backgron!
Information
Step ":Prepare a Task
Performance
#i!e
Step $:
%&alate '
Integrate
in!ings
Step :
*eenact
Task
Performance
Step +:
Select
Personnel
Step ,:
#et amiliar
-it. t.e
#i!e
Step /:Inter&ie0
Personnel
(/lternate
et.o!)
Paper & Pencil P.ase
Walk-Through Phase
.,E?NE?ST.?!?9"
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Critica( @uman Action Concept
Note< Not a(( steps o4 a or$ acti2ity
are e0ua((y important&
Critica( @uman Actions 8steps inc(ude<• Actions aimed at changing the state o4
4aci(ity structures) systems) or components
• Steps that are irreco2erab(e or
actions that cannot be re2ersed• Steps here the outcome o4 an error
is into(erab(e 4or personne( or 4aci(ity sa4ety
&hano2er&go2
NRC N+RE=>CR?555) %RC ,P(P
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A >Critical> -uman Action IS<
A step in the acti2ity that caused or cou(d ha2emade the incident (ess se2ere&It is a C@A i4 the step<
Might cause an incident i4 the step is not done Might cause an incident i4 an error is made
Might cause an incident i4 done some other ay
Ma$es incident (ess se2ere i4 done the right ay&
Cou(d be a FCritica( StepG re(ated to the incident
NRC N+RE=>CR?555) %RC ,P(P
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=enera( Systems Ana(ysisE2ents 3 Causa( #actors Charting
Action Action Action Action
Adapted 4rom .,E Accident In2estigation Program
@o did the 4actors originate
Incident
Institutional
Causes
;hat systems a((oed The Conditions toexist
Factor
Process
Causes
?or@ActivityCauses
Factor
Contributin2
Factor
;hy did thisIncidenthappen
Contributin2Factor
Contributin2
Factor
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6eneral Format
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ESA&.IS- C+5)I&UI56FAC+)S 0Step 41
Techni0ues•C"ange Analysis•1arrier Analysis•Production.ProtectionStrategy )Deense#(n#Dept"- Analysis
•0actor Tree
.eri2ed 4rom!& INP, 9?"& N+RE=>CR?555) NRC @PIP1& Entergy Root Cause Analysis Process
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-ow is C9an#e Analysisone
'
7
; 4 * B
E2a(uate by as$ing these 0uestions<• ;hat as diBerent about this time 4rom a((
the other times the same hardare
operated ithout a prob(em or the sametas$ or acti2ity as carried out ithouterror
• ;hy no and not be4ore• ;hy here and not there
Root Cause Ana(ysis Training Course CAP?") Pa(o Jerde Nuc(ear =enerating Station
Ammerman) T"e Root Cause Analysis ,andboo$
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Ientify )is@ "efenses0&arriers ! Controls1
.ocalFactorControl
En#ineere
&arriers
AminControl
s
+versi#9t
ControlsCulturalControls
.liminate tas+
Prevent error+
Catch error+
Detect defect+
7itigate harm+
Accept ris>0
)Carelessness and overconfidence are more dan2erous tan deliberately accepted ris>0,
Wilbur Wright, 1901 )&4aa&go2Muschara) Managing Critical Steps) @PRCT"9
Muschara) Managing Deenses2 @PRCT ":
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Systematic &arrier Analysis
Identi4y each Target o4 haDards>threats& Identi4y each @aDard 8ad2erse eBect>conse0uence Identi4y -arriers that shou(d ha2e contro((ed @aDard
• Pre2ented contact beteen @aDard and Target ,R• Mitigated conse0uences o4 @aDard>Target contact
Assign a Sa4ety Precedence Se0uence K to each-arrier
Assess -+? -arrier 4ai(ed• not pro2ided>missing 8not in p(ace• not used>circum2ented 8but ere in p(ace• ineBecti2e
.etermine ?-= -arrier 4ai(ed 8Step 5 Ja(idate ana(ysis resu(ts Integrate this in4ormation in E 3 C# Chart
Ammerman) T"e Root Cause Analysis ,andboo$
AS
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System Safety "esi#n +rer +fPreceence
!& E(iminate haDards through design se(ection
"& Incorporate Sa4ety .e2ices
1& Pro2ide ;arning .e2ices
& +se Procedures 3 Administrati2e Contro(s
5& Se(ect) train) super2ise) and moti2ate to or$
sa4e(y6& Accept ris$s at appropriate management (e2e(
MI*?ST.?
::".
M,STE##ECTIJE
*EASTE##ECTIJE
*,; @+MANINTER#ACE
@I=@ @+MANINTER#ACE
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"efense Analysis Form
Ammerman) T"e Root Cause Analysis
,andboo$ AS
.,,.CT/C89S.:.9C.S
)1hat #appened*
0ist one at time(
se'uential order
not re'uired
5A--.-/C89T-80 T#ATS#80D #AV. P-.C0D.D
T#. 9CD.9T
list all applicable physical and
administrative defenses for each
conse'uence
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Examp(e
&sandia&go2
&sandia&go2
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on r u n# ausa ac or
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on r u n# ausa ac orestIentify Contributin# InDuences
Evaluate factors 3ovals4 and flawed defense 3bro>en barriers4 on te Actions @ Factors Cart by as>in2"• If tis factor ad not e1isted< could tis incident ave occurred'• If te answer is no< ten youre on your way toward findin2 a )Contributin2 Factor,B
NRC Inspection Procedure 95!
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$A.I"AE U5"E).=I56 FAC+)S0Step *1
Techni0ues•*,3 0actor Staircase• A#1#C Analysis•,&*#To#*,3 Matrix
•Cause + Efect Tree•Root Cause Test •Root Cause Evaluation•Extent o CauseRevie!•Common 0actor Analysis
.eri2ed 4rom!& INP, 9?"& N+RE=>CR?555) NRC @PIP1& Entergy Root Cause Analysis
Process
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9e ?-= Factor
Staircase
ncident
.xecution Preparation ,eedbac
Capabilities/0imitations Tas Demands/.nvironment
8utcomes 7ethods -esources
Plan/Do/Chec/Act
Vision 5eliefs Values
P"oenix ,andboo$ ) Corcoran
Root Cause2 Martin) @PRCT "6
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Culture
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Active Error Analysis
obPerformer
&e9avio
r
6oals !$alues
&usiness
)esults
INP, ,uman Perormance 0undamentalsCourse
Pre(;ob
5rief
T1 9
Analysis
Tas
Previe!
Post(;ob
-evie! I n c i d e n t
)e
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9e A&CGsH'st +ccurrence
.esired beha2ior< ;ear sa4ety g(asses
Consequences for current or past behaviors have
the strongest influence on our future behavior.
Perormance Management2.anie(s
0oundations o 1e"avioral Accident Prevention4 Eagles Management Support Course)
-ST) Inc&
A• Sa4ety po(icy
• Sa4ety signs• Sa4ety procedure• Sa4ety brieng• %ust?in?time
training
&• ;ear sa4ety
g(asses
C• Ears hurt
• CanLt seec(ear(y
• +ncom4ortab(e• #ee( odd
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The FA?-?CLsG<Subse0uent ,ccurrence
.esired beha2ior< ;ear sa4ety g(asses
A• Peers donLt ear• Super2isors
occasiona((y donLtear
• *ea2e at home• Embarrassed to as$
4or spare pair
&• ;or$ >o sa4ety
g(asses
C• Ears donLt hurt• Can see c(ear(y• *ess bother
Consequences for current or past behaviors have
the strongest influence on our future behavior.
Perormance Management2
.anie(s
0oundations o 1e"avioral Accident Prevention4 Eagles Management Support Course)-ST) Inc&
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"efense ana#ement Analysis
Processes/Practices
as@s/&e9aviors
6oals/$alues
Resu(ts>
Conse0uences
Self(Chec
Peer Chec
< Part Communication
:uestioning Attitude
Stop=1hen nsure
Procedure seProcedure Adherence
Place(eeping 8bservations
Conservative Decision(7aing
1al(do!ns
Tas Previe!Pre(;ob 5rief
Turnover
neasy Attitude1ritten nstruction :uality
;ob Performer Sill$ >no!ledge$ Proficiency#ouseeeping
7orale
1or(Arounds & 5urdens
,itness(,or(Duty
Tool :uality & Availability
.'uipment 0abeling & Condition
.'uipment .rgonomics
1al(do!ns
0ocout(Tagout
Tas 'ualifications
Tas assignment
Performance ,eedbac
Post(;ob Criti'ues-oot Cause Analysis
Tas assignmentPerformance ndicators
ndependent Verificationnterlocs
Alarms
Personal Protective
.'uipment
-edundant trains
Containment
.'uipment Protection Systems
5erms
.'uipment -eliability
Safeguards .'uipmentndependent 8versight
Continuous 0earning
Staffing
Problem(Solving
Accountability
5enchmaring
Clear .xpectations
Communication Practices -evie!s & Approvals
7anagement Practices
Change 7anagement
-e!ards & -einforcement
#andoffs
Simple$ .ffective Processes
INP, ,uman Perormance 0undamentalsCourse
I n c i d e n t
.e4ense In .epth*eadership
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"eeper Unerstanin#
a e y u ure enera
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a e y u ure eneraree
NRC IM Chapter 15 Areas
Sa4ety Cu(ture
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Sa4ety Cu(tureAna(ysis
NRC IMC 15
as@s/
&e9aviors
Processes/
Practices
6oals/$alues
Do Last!!!
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)oot Cause est
Adapted 4rom or$ o4 .r& ;i((iam R& Corcoran) NSRCCorp&
w % u
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w % u)eview
@uman Per4ormance Too(
Peer Chec$
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Common Factor Analysis Steps
Adapted 4rom (ncident (nvestigation Training) Ca((aay
P(ant
Step !
(etermine te
Scope of
te CFA
Step
(etermine 7ic
Information to
Evaluate
Step 6
Gater
(ata
Step D
Cate2ori?e
te (ata
Step
Identify Areas
for Furter
Analyses
Step Analy?e
Areas of
Interest
Step (evelop and
*alidate Causal
&eories
Step HPlan
Corrective
Actions
Step
.eport
9earnin2s
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P.A5 C+))ECI$E ACI+5S0Step B1
Techni0ues• Action Plan•Solution SelectionTree
•Solution SelectionMatrix •C"ange Management • Active Coac"ing Plan•S5M5A5R5T5E5R5•Efectiveness Revie!
•Contingency Plan•Communication Plan
.eri2ed 4rom!& INP, 9?"& N+RE=>CR?555) NRC @PIP1& Entergy Root Cause Analysis
Process
. ( i A C ti A ti P(
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.e2e(oping A Correcti2e Action P(an To Pre2ent Recurrence
P(an 4or contingencies&
Map out imp(ementation o4 inter2entions>actionsthat i(( pre2ent or mitigate recurrence&
.ecide hich a(ternati2es i(( be recommended to management&
Ensure correcti2e actions address the under(ying 4actors 6i5e5 t"eroot cause)s-75
E2a(uate a(ternati2e courses o4 action&
.e2e(op a(ternati2e actions hich address the under(ying 4actors6i5e5 t"e root cause)s-75
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The Success Cyc(e
& 9 i C9
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&e9avior C9an#eInstitutionaliJation Plan 7o 7en
,actor/Cause5eing Addressed
CorrectiveAction Step
?+ -ightPicture
@+ Communicate
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S88A8)88E8)8 Criteria
• 1 h a t e x a c t l y n e e d s t o b e d o n e 2 , o c u s o n r e s u l t s + • 1 # 8 d o e s 1 # A T b y 1 # . 9
Specic
• D e s c r i b e s d e s i r e d b e h a v i o r s s o a n o b s e r v e r c a n c o m p a r e o b s e r v e d b e h a v i o r t o a d e s i r e d b e h a v i o r
Measurab(e
•
D o a b l e 2 , e a s i b l e 2 - e a l i s t i c 2 C o s t / 5 e n e f i t 2
• A g r e e d t o b y S t a & e h o l d e r 2 B o o d b u s i n e s s 2
Attainab(e • 0 o g i c a l t i e b e t ! e e n t h e p r o b l e m a n d c a u s e ) s * • 0 o g i c a l t i e b e t ! e e n c a u s e ) s * a n d c o r r e c t i v e a c t i o n s
Re(ated
• S h o u l d b e c o m p l e t e d b e f o r e n e x t 4 s h o t o n g o a l 6 • f n o t $ i n t e r i m c o r r e c t i v e a c t i o n s a r e n e e d e d
Time?sensiti2e
• D e g r e e o f D e p e n d a b i l i t y / - e l i a b i l i t y • 0 e v e r a g e d s o l u t i o n ! + 5 e h a v i o r . n g i n e e r i n g 7 o d e l
EBecti2e
• 5 y S t a & e h o l d e r s 2 5 y S u b e c t 7 a t t e r . x p e r t s 2 • , o r n i n t e n d e d C o n s e ' u e n c e s 2
Re2ieed&han4ord&go2
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InstitutionaliJationPlan S88A8)88E8)8
1#8 1#.9
Cause>#actor-eing
Addressed
Correcti2e Action P(an To Pre2ent Recurrence
Specific Measurable Attainable .elated &imely Effective .eviewed,ne
r.ue.ate
'8 )i#9t Picture
78 Communicate
;8 onitor
48 Feebac@
Correcti2e Action
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MI*?ST.?::".
Correcti2e ActionEBecti2eness Sca(e
EBecti2eness Re2ie =enera(
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EBecti2eness Re2ie =enera(#(o
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8A8S88 Eectiveness Plan
• . e s c r i b e t h e m e a n s t h a t A i ( ( b e u s e d t o 2 e r i 4 y t h a t t h e a c t i o n s t a $ e n h a d t h e d e s i r e d o u t c o m e &
ET@,.
•
. e s c r i b e t h e p r o c e s s c h a r a c t e r i s t i c s
t o b e m o n i t o r e d o r e 2 a ( u a t e d &A TTRI-+TES
• E s t a b ( i s h t h e a c c e p t a n c e c r i t e r i a 4 o r t h e a t t r i b u t e s t o b e m o n i t o r e d o r e 2 a ( u a t e d &
S+CCESS
• . e C n e t h e o p t i m u m t i m e t o p e r 4 o r m t h e e B e c t i 2 e n e s s r e 2 i e A &
IME*INESS
=rand =u(4 Nuc(ear Station
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Performance Inicator "evelopment@o is it done
Improving Performance: How to Manage the White Space on the Organiation !hart, -ummler & 5rache
)EP+) .EA)5I56S
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)EP+) .EA)5I56S0Step L1
#orms•Report Template•8rade Cards.Scores"eets
.eri2ed 4rom!& INP, 9?"& N+RE=>CR?555) NRC @PIP1& Entergy Root Cause Analysis
Process
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Report Ansers =enera( uestions
The in2estigation i(( ha2e determined the4o((oing<
;hat as expected 8anticipatedconse0uences
;hat has happened 8rea(conse0uences
;hat cou(d ha2e happened 8potentia(conse0uences
Cause?eBect re(ations #au(ty>4ai(ed technica( e(ements8structures) systems) or
components Inappropriate actions 8human) management)
organiDationa(
IAEA?TEC.,C?!6
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Report Ansers Specic uestions
;hat as the %ob Per4ormer 4ocused onCou(d they do the %ob i4 their (i2es depended
on itE0ua((y 0ua(ied person (i$e(y to ma$e same
error;hat ere the 4actors that direct(y resu(ted in
the nature) the magnitude) the (ocation) andthe timing o4 the $ey conse0uences
;hat happens to them hen they do hatthey do
Mager 3 Pipe) Analy9ing Perormance ProblemsCorcoran ) P"oenix ,andboo$
.anie(s) Perormance Management
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Extent of Condition
Review Criteria
Obect
(Person Place T.ing)
!pplication
(/cti&ity orm it nction)
"efect
(la0 ailing eficiency)
Deviation Statement
Same=Same=SameAn dentical 8bect
in an .'uivalent Application !ith a 7atching Defect+
Same=Same=SimilarAn dentical 8bect
in an .'uivalent Application !ith a -elated Defect+
Similar=Same=SameA Comparable 8bect
in an .'uivalent Application
!ith a 7atching Defect+Similar=Same=Similar
A Comparable 8bectin an .'uivalent Application
!ith a -elated Defect+
Same=Similar=SameAn dentical 8bect
in a Corresponding Application !ith a 7atching Defect+
Similar=Similar=SameA Comparable 8bect
in a Corresponding Application !ith a 7atching Defect+
Same=Similar=SimilarAn dentical 8bect
in a Corresponding Application !ith a -elated Defect+
E t t f C diti Ob t ! li ti " f t
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Extent of Condition
Review Criteria
Obect
(Person Place T.ing)
!pplication
(/cti&ity orm it nction)
"efect
(la0 ailing eficiency)
Deviation Statement Driver’s Side Front Tire on
Rental Car
Parked in My Driveway Flat
Same=Same=SameAn dentical 8bect
in an .'uivalent Application !ith a 7atching Defect+
?+ 8ther Tires on -ental Car
@+ Tires on Picup Truc
?+ Pared in 7y Drive!ay
@+ Pared in 7y Drive!ay
?+ ,lat
@+ ,lat
Same=Same=SimilarAn dentical 8bect
in an .'uivalent Application !ith a -elated Defect+
?+ 8ther Tires on -ental Car
@+ Tires on Picup Truc
?+ Pared in 7y Drive!ay
@+ Pared in 7y Drive!ay
?+ 0o! on Air
@+ 0o! on Air
Similar=Same=SameA Comparable 8bect
in an .'uivalent Application !ith a 7atching Defect+
?+ Tires on 5oat Trailer
@+ Tires on 5icycle
?+ Pared in 7y Drive!ay
@+ Pared in 7y Drive!ay
?+ ,lat
@+ ,lat
Similar=Same=SimilarA Comparable 8bect
in an .'uivalent Application !ith a -elated Defect+
?+ Tires on 5oat Trailer
@+ Tires on 5icycle
?+ Pared in 7y Drive!ay
@+ Pared in 7y Drive!ay
?+ 0o! on Air
@+ 0o! on Air
Same=Similar=SameAn dentical 8bect
in a Corresponding Application
!ith a 7atching Defect+
?+ Car Spare Tire
@+ Tires on Sons Vehicle
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Fault ree Form
,R
,R
,R
,R
,R
Adapted 4rom Ca((aay P(ant F#au(t Tree Ana(ysisG Training
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Tas$ Ana(ysis Techni0ue
(1)
Paper & Pencil Input
Steps in
Procedure
or Practice
(2)
Walk Through
by Analyst
or trained
individual
(!)
#uestions$
%onclusions about
ho task
as$should be
per'ored
;CN,C
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Examp(e< Tas$ Ana(ysis Techni0ue
(1)
Paper & Pencil Input
Steps in
Procedure
or Practice
(2)
Walk Through
by Analyst
or trained
individual
(!)
#uestions$
%onclusions about
ho task
as$should be
per'ored
?+ 0ocate proper 4pig trap6+
@+ De(pressuriEe line pressure+
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Examp(e< C9lorine an@erFill Critical -uman Activity
8uidelines or Preventing ,uman Error in Process Saety2 Center 4or Chemica( Process Sa4ety o4 the American Institute o4Chemica( Engineers
Error Type< ;rong In4ormation ,btainedError .escription< ;rong ;eight EnteredConse0uence< A(arm does not sound be4ore tan$ero2er((s
Error Type< Chec$ ,mittedError .escription< Tan$er not monitored hi(e((ingConse0uence< *ea$s not detected ear(y
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Examp(e
!# $# C# "# E#
Factorstat Influence
Performance
FailedPerformance
PastSuccessful
Performance
(ifferenceor Can2e
Contributin2Factor'
)Jes/9o*
7en ;ob Performercame in early toavoid the heat+
;ob Performerstarted day thesame time as co(
!orers+
9o co(!orers !ere available tohelp !ith the ob+
Jes+ 1orercame to !orearly$ so !as
!oring alone$carrying tools+
Supervision
.mployee didnot meet !ithsupervisor themorning of theaccident+
.mployee met !ithsupervisor todiscuss the days
!or activities+
1or activities !ere notdiscussed+
Jes+ 5ecause !orer came to !or early$ obhaEards !ere notdiscussed+
&sandia&go2
E2ents 3 Causa( #actors Chart
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E2ents 3 Causa( #actors Charta4ter Change 3 -arrier Ana(ysis
&sandia&go2
Prob(em Correction #(ochart
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Prob(em Correction #(ochart
EBecti2eness Re2ie .etai(ed
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EBecti2eness Re2ie .etai(ed#(o