A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety...

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A Foundation for Root Cause Analysis- (2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation W. R. Corcoran, NSRC Corporation, [email protected]

Transcript of A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety...

Page 1: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

A Foundation for Root Cause Analysis-(2011.05.27)

William R. Corcoran, Ph.D., P.E.

Nuclear Safety Review Concepts Corporation

© 2011 W. R. Corcoran, NSRC Corporation, [email protected]

Page 2: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

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Anyone who obtains this may:

• Use this slideshow in whole or in part in any training activity in their organization.

• Adapt this slideshow for use in their organization

Provided that:

• It does not go outside their organization without the permission of NSRC Corporation.

• The source of the material is always indicated.• Any changes to it are shared with Bill Corcoran.

© 2011 W. R. Corcoran, NSRC Corporation, [email protected]

Page 4: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

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YMP

Bill CorcoranAssisted Facilities

Designated by This Logo and Some

Others.

DNFSB

PORTSMOUTH

METROPOLIS

CHALK RIVER

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Bill CorcoranAssisted Units

Designated by This Logo and Some

Others.

Page 6: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

Topics

• Background

• Facts

• Suggestion

© 2011 W. R. Corcoran, NSRC Corporation, [email protected]

Page 7: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

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Root Cause Analysis?Root Cause Analysis is any structured approach toidentifying the factors that resulted in the nature, the magnitude, the location, and the timing of the consequences of one or more past events in order to identify what conditions, behaviors, actions, and/or inactions, need to be changed to prevent/reduce recurrence of similar consequences, when adverse, and to identify the lessons to be learned to promote the achievement of better consequences.

COMMENT: A given root cause analysis can be successful orunsuccessful. It can be superficial or insightful. It can be honestor dishonest. As long as it is a structured approach with the intent given above it would be fairly classed with other root causeanalyses.

© 2011 W. R. Corcoran, NSRC Corporation, [email protected]

Page 8: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

A Purpose of RCA

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Page 9: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

What’s a Problem?

A gap between what ought to beand what is.

Page 10: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

Some Examples of “What is.”

Nickname Nature Magnitude Location Timing

Chernobyl

Bhopal

Hindenburg

BP Deepwater

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Page 11: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

“What is” Puzzlers

• What are the relevant statements of “what is” for a given event?

• Which statements of “what is” should be investigated?

• Which “what is” should be investigated first?

© 2011 W. R. Corcoran, NSRC Corporation, [email protected]

Page 12: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

Fact One: The “What is” resulted from factors

• The “What is” is an effect.• A synonym for “effect” is “phenomenon.”• A factor is something that affected an effect.• Factors include conditions, behaviors, actions,

and/or inactions. • If a condition, behavior, action, or inaction did

not affect any property of the effect, e.g., the “what is”, then it wasn’t a factor of the effect.

© 2011 W. R. Corcoran, NSRC Corporation, [email protected]

Page 13: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

Harmful Effects (Four Factor Essences)

Harmful Effect

ConditionDirect Factor(s)

BehaviorDirect Factor(s)

ActionDirect Factor(s)

InactionDirect Factor(s)

© 2011 W. R. Corcoran, NSRC Corp., [email protected]

Factor essences are not mutually exclusive.

Page 14: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

Fact One-Elaboration

• “The “ought to be” resulted from factors as well.

• One strategy for solving the problem, i.e., closing the gap, is to change the “ought to be.”

© 2011 W. R. Corcoran, NSRC Corporation, [email protected]

Page 15: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

Fact Two: The “What is” has properties

• A “property” is a condition of reality.

• “Attribute” is a synonym for “property.”

• The properties of an effect include:– Nature– Magnitude (bigness, badness, spread…)– Location– Timing (beginning, end…)

© 2011 W. R. Corcoran, NSRC Corporation, [email protected]

Page 16: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

Fact Three: The “What is” directly resulted from direct factors.

• A “direct factor” is a factor that affected the effect without any intervening factors.

• “Proximate” and “immediate” are synonyms for “direct.”

• “Intermediate Factor” is a synonym for “intervening factor.”

© 2011 W. R. Corcoran, NSRC Corporation, [email protected]

Page 17: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

Harmful Effects(Factor Building Block)

Harmful Effect

(Consequence or Factor)

Direct Factor 1

Direct Factor 2

Direct Factor …

Direct Factor 3

Direct Factor …

© 2011 W. R. Corcoran, NSRC Corp., [email protected]

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Fact Four: The direct factors explain all of the properties.

• The properties explained by the direct factors include the:– Nature– Magnitude (number, bigness, badness, intensity,

seriousness…)– Location– Timing (beginning, end…)

• If the identified direct factors do not explain the properties, then one or more direct factors are missing.

© 2011 W. R. Corcoran, NSRC Corporation, [email protected]

Page 19: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

Harmful Effects (Four Property-related Factors)

Harmful Effect

Direct Factor(s) AffectingNature of Effect

Direct Factor(s) Affecting

Magnitude of Effect

Direct Factor(s) AffectingLocation of Effect

Direct Factor(s) AffectingTiming of

Effect

© 2011 W. R. Corcoran, NSRC Corp., [email protected]

Factor types are not mutually exclusive, but they all must be there.

Page 20: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

Fact Five: The direct factors include four types of “involvement” factors.

• The situation for the effect was set-up.

• The creation of the effect was triggered.

• The effect was as bad as it was.

• The effect was not any worse than it was.

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Page 21: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

Harmful Effects (Four Factor Involvement Types)

Harmful Effect

Vulnerability(Set-up)

TriggerExacerbation Mitigation

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Page 22: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

A Barrier Model

Yet another legitimate perspective?

Page 23: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

THREAT BARRIER

THE BASICS OF BARRIER ANALYSIS

BARRIER:Anything that has the effect of (or is intended to ) reduce theprobability and/or consequences of the effect of a threat on a target. (Notice that a barrier is only defined with respect to both a threat and atarget.)

TARGET

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Page 24: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

Fact Six: The direct factors include the barrier analysis factors.

• There must have been something that could be harmed. (A “target.”)

• There must have been something that could harm the target. (A “hazard” aka “threat.”)

• The target and the hazard must have been in the same place.

• They must have been there at the same time.• There must have been no barrier that effectively

protected the target from the hazard.

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Page 25: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

Harmful Effects(Barrier Analysis Elements)

Harmful Effect

(Vulnerable) Target

Hazard/ Threat

No EffectiveBarriers

Co-location Simultaneity

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Page 26: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

“No Effective Barrier” Puzzlers

• How many missing and ineffective barriers make up the “no effective barrier?”

• Which missing and ineffective barriers should be included?

• Which missing and ineffective barriers should be investigated?

• Which missing and ineffective barriers should be investigated first?

© 2011 W. R. Corcoran, NSRC Corporation, [email protected]

Page 27: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

Fact Seven: As the investigation goes deeper each factor becomes a “what is” and the above apply.

• This implies a tightly linked, evidence-based, hierarchical factor-effect tree-like structure.

• That structure allows the deepest factors to be traced up to the highest “what is.”

© 2011 W. R. Corcoran, NSRC Corporation, [email protected]

Page 28: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

Factor X

DirectFactor

DirectFactor

DirectFactor

DirectFactor

IntermediateFactor

DeeperIntermediate

Factor

RootFactor

© 2011, William R. Corcoran, NSRC Corp., 860-285-8779, [email protected]

Page 29: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

Fact Eight: Favorably addressing any harmful factor favorably affects

everything above it.• “Favorably address” includes: ameliorate,

remove, improve, correct, contain, reduce, dilute, and the like.

• No matter how deep or shallow an investigation with this foundation goes it will reveal harmful factors that if favorably addressed will aid in preventing the recurrence of a problem and/or reducing the severity of its future recurrence.

© 2011 W. R. Corcoran, NSRC Corporation, [email protected]

Page 30: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

Fact Eight-Elaboration

• The deeper an investigation with this foundation goes the more harmful factors it will reveal-- that if effectively addressed will aid in preventing the recurrence of a problem and/or reducing the severity of its future recurrence.

• Allowing any harmful factor to go unaddressed is to predispose some future event.

© 2011 W. R. Corcoran, NSRC Corporation, [email protected]

Page 31: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

Fact Nine: Unfavorably addressing any mitigating factor allows adverse recurrence

of everything adverse above it.

• “Unfavorably address” includes: deteriorate, remove, weaken, de-institutionalize, release, reduce, dilute, and the like.

• Deeper investigations will reveal more mitigating factors that if preserved and/or improved will aid in preventing the recurrence of a problem and/or limiting the severity of its future recurrence.

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Page 32: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

Fact Nine-Elaboration

• Allowing any non-robust mitigating factor to go unfortified is to predispose some future event.

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Page 33: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.

Suggestion:

• Be the “building inspector” for your next root cause analysis.

• Check the foundation.

• If it is not sound the structure could collapse.

© 2011 W. R. Corcoran, NSRC Corporation, [email protected]

Page 34: A Foundation for Root Cause Analysis-(2011.05.27) William R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation © 2011 W. R. Corcoran, NSRC.
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Questions?

© 2011, William R. Corcoran, NSRC Corp., 860-285-8779, [email protected]