Five types of factor building blocks with case study 2014.05.05.0730

Factor Building Blocks (The DNA of the Problem)

Factor Trees are made up of linked Factor Building Blocks (FBBs)

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

© 2014, William R. Corcoran, 860-285-8779, [email protected]

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Notices• This is part of The Phoenix Approach©.• It also applies to all other approaches to issue

investigation (root cause analysis).• If your organization is licensed to use The Phoenix

Approach© you may use this in accordance with the license.

• If your organization is not licensed to use The Phoenix Approach© please call for permission. In the meanwhile you have permission to give this seminar once in-house, if you send me the workshop comments.


3

Who Can Benefit

• Investigators• Investigation Team Leaders• Investigation Team Sponsors• Investigation Report Reviewers/ Approvers• Investigation Report Inspectors• Managers whose success can be affected by

Investigation Team Results


4

FBB Seminar Objectives

1. To explain a Factor Tree.2. To explain a Factor Building Block (FBB).3. To show how FBBs make up a Factor Tree.4. To explain the five known types of FBBs.5. To show that three of the five are rigorously capable of

explaining the key attributes of the FBB’s “effect.”6. To show that one can provide input for any of the first three.7. To show that one can be convenient in some common

situations.8. To show how this fits into issue investigation in general.


5

• State your name• State your position and affiliation• State (very briefly) your most memorable

involvement with an event or an investigation• Tell us one or two things you would like to get

out of this seminar.


Exercise

6

DNA?

• DNA shows up in every cell of life.• The FBB shows up in every part of that which

results in every harmful outcome.• DNA testing helps assure that you’re

electrocuting the right suspect.• Using FBBs helps assure that you’re fixing the

right problem right.


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Usual Investigation Objective

To identify the factors that resulted in the adverse outcomes that are being investigated so that actions can be taken to avoid such outcomes in the future.

1. To have confidence in the above, the factors should explain the nature, the magnitude, the location, and the timing of the adverse outcome.

2. This involves tightly linked, evidence-based chains of factors from the adverse outcome to the deepest identified factors.


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Corrective Actions

• The corrective actions for an adverse outcome address/ respond to/ relate to the factors that resulted in the adverse outcome.

• If the factors do not explain the nature, the magnitude, the location, and the timing of the adverse outcome there must be one or more missing or erroneous factors.

• Thus there can be a serious lack of confidence that the corrective actions are sufficient and appropriate.


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Causal Factor Analysis (Root Cause Analysis) Report Production/ Evaluation

CorrectiveActions

Extent of Conditions &Causes

Factors Extraneous CAQs

Lessons-To-Be-Learned

Consequences

Evidence(data)

© Drs. William Corcoran and Richard Hartley 8-21-07

EventRecognition

Investigation (collect & organizeevidence (data ))

CultureInsight

Convert Evidence (data) toInformation

SignificanceCharacterization

HumanBehavior

Technology

Use AppropriateRCA Tools

Lines of Inquiry

The Fixes

To BeFixed

To BePrevented

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Corrective Action Must Relate to Consequence Through Factor


Corrective Action

Factor

Consequence

What factor does it address?

What consequence did it affect?

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This Seminar Begins to Address

• The shape labeled “Consequences”• The shape labeled “Factors”• The shape labeled “Use Appropriate RCA

Tools”• (The Big Picture Slide includes eleven other

shapes!)


12

Flash Card Front

• For confidence in the fixes, the items fixed must explain the _________.


13

Flash Card Back

•Effect(s) to be prevented, ie., the consequences.


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Affect and Effect

• Affect (verb): to influence, change, modify…, e.g., The angle of the sun affects the length of shadows.

• Effect (noun): A phenomenon. Something that happens, e.g., Einstein got his first Nobel Prize for the Photoelectric Effect. The Domino Effect was a Vietnam Era discussion topic. When one employee quits HR worries about the Bandwagon Effect.


15

Drag is

an effect.

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Affect/Effect Hint

1. Use “affect” only as a verb. 2. Use “effect” only as a noun.


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Terminology

• Factor-A factor of an effect is an item that affected the effect.

• Effect-An identifiable phenomenon• Factor Tree-A linked structure that looks like

an organization chart and represents the chains of factors that resulted in a defined adverse effect.

• Factor Building Block-An effect linked to the factors that directly resulted in it.


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Aliases

• There is great variation in investigative terminology.• Bad Factors (Harmful Factors) are often called

“Causal Factors.”• Good Factors (Beneficial Factors) are often called

“Mitigating Factors” and, in the case of a near miss, “Preventive Factors.”

• Bad Effects (Adverse Outcomes) are often called “Consequences” when they are where an investigation starts.


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A Factor Can Be:

• Condition, e.g., Bearing installed backwards• Behavior, e.g., Worker installs bearing

backwards• Action, e.g., Pump starts automatically• Inaction, e.g., Plant staff does not sample lube

oil• Note: The reality of a factor can often be

expressed in more than one way.


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Not Wearing a Hard Hat Can Be:

• Condition, e.g., Hard hat was not being worn. (Head exposed to impacts)

• Behavior, e.g., Worker did not put hard hat on.• Action, e.g., Worker left hard hat in break

room.• Inaction, e.g., Worker did not put hard hat on.• Note: The reality of a factor can often be

expressed in more than one way.


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Direct Factor

• A direct factor of an effect is a factor that affects the effect without any intermediate, or intervening, factors.

• Aliases: Direct Cause, Immediate Cause, Proximate Cause…

• Example: A direct factor of the Hartford Civic Center Roof Collapse was the snow load.

• There are always more than one direct factor for an effect.


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Direct Factor Exercise

• Conduct a thought experiment:– Wait until the hole tray in your three-hole puncher is

almost full– Remove it from the three-hole puncher– Take it to an vacant room– Empty the hole tray on the floor– View the pattern of paper discs.

• What are the factors that directly resulted in the nature, the magnitude, the location, and the timing of the pattern of paper discs?


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Direct Factor Exercise

Pattern of Paper Discs (NMLT) _________________________Direct

Factor 1: ________

_____

DirectFactor 2:

_____________

DirectFactor 3:

__________

DirectFactor 4:

_____________

Add others as needed.


Write on or near objects.

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Direct Factor Exercise Potential Answer #1

Pattern of Paper Discs (NMLT) _________________________Direct

Factor 1: Number of

Discs

DirectFactor 2: Height of

Drop

DirectFactor 3: Air Movement

DirectFactor 4: Stickiness of Discs


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Effect

• Death, Damage, Dose, Delay….• Note: An effect can have an impact on a

downstream effect, e.g., damage can result in delay.

• Note: A factor is an effect of the deeper factors that resulted in it.

• Note: The reality of an effect can often be expressed in more than one way.


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Factors and Effects

Effect

Factor / Effect

Factor / Effect Factor / EffectFactor / Effect

Factor / Effect

Factor / Effect

Factor / Effect

Factor / Effect


An effect is the result of factors, which in turn are the effects that resulted from deeper factors……. (it ends when we decide to stop)

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Flash Card Front

• In Factor Trees (and Factor Building Blocks) the factors connected directly below an effect are always _________ factors of the effect.


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Flash Card Back

•DIRECT


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Block and Tree Legend

Effect

Direct Factor Direct Factor Direct Factor


The connecting lines always mean that the upper itemis/was a result of the lower connected items.

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A Factor Tree is

• A graphic representation of the factors that resulted in an adverse effect.

• A structure that has an adverse effect at the top and the terminal factors at the bottom.

• An evidence-based unbroken logical set of chains of results from the top effect to the deepest factors.


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Factor Tree Example FT1

HarmfulEffect: Factory Fire

DirectFactor 1: Fuel

Supply

DirectFactor 2: Oxygen supply

DirectFactor 3: Ignition

DirectFactor 4:Suppression

All Factor Trees are like this.


The direct factors of an effect will explain the nature, the magnitude, the location, and the timing of the effect.

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Factor Tree Example FT1.1

HarmfulEffect: Factory Fire

DirectFactor 1: Fuel

SupplyFactors

Affecting NMLT of FS

DirectFactor 2: Oxygen

supplyFactors

Affecting NMLT of OS

DirectFactor 3: Ignition

Factors Affecting NMLT of Ignition


Factors Affecting NMLT of suppression



The direct factors of an effect will explain the nature, the magnitude, the location, and the timing (NMLT) of the effect.

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Factor Tree Example FT1.4


NMLT of Installed Suppression Systems Performance

Deeper Factors

NMLT of External Fire Company Performance

Deeper Factors



The direct factors of an effect will explain the nature, the magnitude, the location, and the timing (NMLT) of the effect.

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Factor Tree Example FT2

HarmfulEffect: Radiation DoseDirect

Factor 1: Source

Strength

DirectFactor 2: Time

of Exposure

DirectFactor 3:

Distance to Source

DirectFactor 4:Shielding




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Flash Card Front

• The nature, the magnitude, the location, and the timing of an effect are explained by the _________ of the effect.


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Flash Card Back

•DIRECT FACTORS


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Factor Tree Exercise I

• Draw a one level Factor Tree for one of the following:– Fatigue Cracking– Stress Corrosion Cracking– Burned Out Lighting Device– Weak Vehicle Battery– Specific Procedure Defect– Unintended Contact with Live Conductor– Running Low on Fuel for Vehicle


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Factor Tree Exercise II

• Draw a one level Factor Tree for one of the following:– Foreign Material in Critical Component– Near Miss Asphyxiation– Hospital Drug Overdose – Checking Account Overdraft– Radioactive Material Uptake– Hole in Reactor Vessel Head– Crane Toppling


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One Level Factor Tree Exercise

Consequence (NMLT) _________________________Direct

Factor 1: ________

_____

DirectFactor 2:

_____________

DirectFactor 3:

__________

DirectFactor 4:

_____________

Add others as needed.


Write on or near objects.

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Stopping Fact

• All factor tree branches must stop somewhere.• There is a stopping decision on each branch.• We’re not addressing that now.


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Flash Card Front

Multiple Choice:• Every factor tree branch ends in

A. The Root CauseB. A Root CauseC. A terminal (ending/last) factor D. None of the above


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Flash Card Back

• Every factor tree branch ends inC. A terminal (ending/last)

factor (But some terminal factors can be “root causes.”)


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A Factor Building Block is

• An effect connected to the factors that directly resulted in the effect.

• A component/node/cell/module of a factor tree.

• An evidence-based one-level explanation of the attributes of an effect.

• A top, intermediate, or bottom part of a factor tree.


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Generic Factor Building Block (FBB)(Generic Direct Factors)

HarmfulEffect

DirectFactor 1

DirectFactor 2

DirectFactor…

DirectFactor…

DirectFactor…

All Factor Building Blocks are like this.



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Caution

• “Block” is just a metaphor.• A Factor Building Block would be the same

even if it were called:– A Factor Building Component – A Factor Building Cell– A Factor Building Module– A Factor Building Node– A Factor Building “Whatever”


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Generic Factor Building BlockNotes

• A harmful effect can be– A “consequence” (harmful outcome, harmful

effect)– A factor of a harmful outcome

• There is no upper limit on the number of direct factors. (There are seldom more than eight.)


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Five Known Types of FBBs• There could be more than five.1. Four Factor Types: Set-up, Trigger, Exacerbation,

Mitigation (STEM)2. Four Key Attributes: Nature, Magnitude, Location,

Timing (NMLT)3. Five Barrier Analysis Elements: Target, Hazard, Co-

location, Simultaneity, Lack of Barrier, Limiting Barrier (THCSLL)

4. Existence: Creation, Persistence (CP)5. Rollup/Breakdown: A greater effect can be the

result of smaller effects.© 2014, William R. Corcoran, 860-285-8779, [email protected]

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What About an Effect Needs Explaining?

Perspective Needs Explaining

Needs Explaining

Needs Explaining

Needs Explaining

Needs Explaining

Needs Explaining

1. Factor Involvement

Set-up Trigger Exacerbation Mitigation

2. Key Attributes Nature Magnitude Location Timing

3. Barrier Analysis Elements

Vulnerable Target

HarmfulHazard

Co-location Simultaneity Lack of Effective Barrier

Limiting Barrier

4. Existence Creation Persistence

5. Rollup/ Breakdown

Constituent Items


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How FBBs make up a Factor Tree

Harmful Effect

FBB1FBB1.1

FBB 1.1.1

FBB 1.1.3

FBB1.2

FBB1…..

FBB2

FBB2.1

FBB2.2

FBB2...

FBB… FBB… FBB…



FBB=Factor Building Block

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Freedom

• An analyst can use any of the five types of factor building blocks at any stage of the construction of a factor tree.

• It is not necessary to pick one type of FBB and stick to it.

• The circumstances of the investigation will often suggest one type of FBB rather than others.


Factor Building Block #1(Four Factor Types-STEM)

Set-up: Trigger: Exacerbation: Mitigation


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Factor Building Block #1(Four Factor Types-STEM)

HarmfulEffect

DirectSet-up Factors

DirectTriggering

Factors

DirectExacerbating

Factors

DirectMitigating

Factors

The direct factors will explain the nature, the magnitude, the location, and the timing of the effect.


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FBB #1 (STEM) Notes

• If there had not been a set-up the effect could not have happened.

• If there had not been a trigger the set-up would have remained latent.

• If there had not been exacerbation the effect would have been less severe.

• If there had not been mitigation the effect would have been more severe.


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FBB #1 (STEM) Management Notes

• If the investigation report does not give you the set-up it is probably missing important corrective actions.

• If the investigation report does not give you the triggering it is probably missing important corrective actions.

• If the investigation report does not give you the exacerbation it is probably missing important corrective actions.

• If the investigation report does not give you the mitigation it is probably missing important corrective actions to make the fragile mitigators more robust.


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Factor Building Block Example STEM1(Four Factor Types-STEM)

HarmfulEffect is One House Burned Down

Direct Set-up Factors WereCombustible Construction,

etc.

DirectTriggering

FactorWas

Lightning Strike

DirectExacerbatingFactor Was

Time for Fire Fighters to

Arrive

DirectMitigating

FactorWas

Distance to Other

Combustibles


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Notes for House Fire Example

• If the house had been only partially destroyed the fire fighter involvement would be both exacerbating and mitigating.

• This type of situation arises frequently in events whose consequences do not go to completion/exhaustion/annihilation.


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HarmfulEffect is 1/3

Core Overheated(TMI)Direct Set-up

Factors areDecay Heatand Other

Core Conditions

DirectTriggering

FactorWas

Interruption of Injection

DirectExacerbatingFactor was

Time toDiagnose

DirectMitigating

FactorWas

RestorationOf Injection


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HPCI Inoperable for DD Days

Bearing can go in

Backwards

Worker put

Bearing in Backwards

Bearing Damages

Pump While

Operating

Damage Undiscovered Until

Pump Inoperabl

e

Damage Undiscovered for DD

More Days

Damage Discovere

d

Pump Restored

to Operabilit

y


Set-up

Trigger ExacerbationMitigation

MitigationExacerbation

Exacerbation

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Factors-consequences Matrix: STEM

Actual Case 1 Case 2 Case 3 Case 4

FACTORS

Set-up Yes No Yes Yes Yes

Trigger Yes Yes No Yes Yes

Exacerbating Yes Yes Yes No Yes

Mitigating Yes Yes Yes Yes No

CONSEQUENCES

As they were

None None Lesser Consequences

Worse Consequences


60

Flash Card Front

• A Factors-consequences Matrix shows how a change in a factor results in a change in the _________.


61

Flash Card Back

•Consequence(s) /harmful effect(s)


62

Factor Building Block Exercise-STEM

• Draw a one level FBB for one of the direct factors of one of the following effects or an effect of your own choosing:– Fatigue Cracking– Stress Corrosion Cracking– Burned Out Lighting Device– Weak Car Battery– Specific Procedure Defect– Unintended Contact with Live Conductor– Running Low on Fuel for Vehicle


63

STEM FBB Exercise

Factor_________________________Direct

Factor(s) S: ___________

__

DirectFactor(s) T:

_____________

DirectFactor(s) E:

__________Direct

Factor(s) M: _____________


Write on or near objects. From Previous Exercise

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The STEM FBB is good for

• All types of consequences• All types of factors


Factor Building Block #2(Attributes of Consequence-

NMLT)Nature: Magnitude: Location: Timing


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Factor Building Block #2(Attributes of Consequence-NMLT)

HarmfulEffectDirect

Factors Affecting Nature

DirectFactors

Affecting Magnitude

DirectFactors

Affecting Location

DirectFactors

Affecting Timing



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Factor Building Block Example NMLT1(Attributes of Consequence-NMLT)

HarmfulEffect: Glass Shards and Wine on Floor

DirectFactors

Affecting Nature:

Fragility of Bottle,

Hardness of floor, etc.

DirectFactors

Affecting Magnitude:

Size of Bottle , Amount of Contents

DirectFactors

Affecting Location:

Location of Fumbler

DirectFactors

Affecting Timing: Time

of Being Startled, etc.



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HarmfulEffect: 856 DeathsDirect

Factors Affecting Nature:

Collision of Two 747s

DirectFactors

Affecting Magnitude: # of Occupants,

etc.

DirectFactors

Affecting Location:

Location of Stationary

747

DirectFactors

Affecting Timing: Time of Other 747 Takeoff, etc.



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HarmfulEffect: HPCI Inop for DD DaysDirect

Factors Affecting Nature: Internal

Booster Pump Damage

DirectFactors

Affecting Magnitude: Severity of Damage,

Persistence Time

DirectFactors

Affecting Location:

Location of Bearing

DirectFactors

Affecting Timing: Times

of Error, Damage,

Discovery, Restoration.



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Factor Building Block Example NMLT3.1(Attributes of Consequence-NMLT)

HarmfulEffect: HPCI Inop for DD Days

DirectFactors Affecting Nature: Internal Booster Pump

Damage

Deeper FBBs

DirectFactors Affecting

Magnitude: Severity of Damage,

Persistence TimeDeeper FBBs

DirectFactors Affecting Location: Location

of Bearing

Deeper FBBs

DirectFactors Affecting Timing: Times of Error, Damage,

Discovery, Restoration.Deeper FBBs



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Factors-consequences Matrix: NMLT

Actual Case 1 Case 2 Case 3 Case 4

FACTORS

Affecting Nature of Effect

Yes Different Same Same Same

Affecting Magnitude of Effect

Yes Same Different Same Same

Affecting Location of Effect

Yes Same Same Different Same

Affecting Timing of Effect

Yes Same Same Same Different

CONSEQUENCES

As they were

Different Nature

Different Magnitude

Different Location

Different Timing


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Direct Factors Matrix (DFM)-NMLT&STEM(This applies to factors as well as consequences.)

[Example for TMI-2 Accident: 1/3 Core Melt]

Every EFFECT is the resultant of vulnerability factors, triggering factors, exacerbating factors, and mitigating factors.

Set-up (Vulnerability)

Trigger(Initiator)

Exacerbator Mitigator

Every EFFECT is the resultant of factors that resulted in its nature, its magnitude/ intensity, its location, and its timing.

Nature(Core Melt)

1) Properties of fuel 2) Decay Heat

Magnitude(One-third)

Magnitude of Decay Heat

Interruption of Cooling

Amount of Time to Restore Cooling

Cooling Restored

Location(In reactor)

Core located in reactor

No melt-through

Timing(3-29-79)

Interruption of Cooling when it happened.

Cooling Restored when it was.

Every EFFECT will have at least one direct factor in each column and at least one in each row. (This applies to factors as well as consequences.)


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Factor Building Block Exercise-NMLT



74

NMLT FBB Exercise

Factor_________________________Direct

Factor(s) of N: ___________

__

DirectFactor(s) of

M: ___________

__

DirectFactor(s) of L: __________

DirectFactor(s) of T: _____________



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The NMLT FBB is good for



Factor Building Block #3(Barrier Analysis Elements-

THCSLL)Target: Hazard: Co-location:

Simultaneity: Lack of (Effective) Barrier: Limiting Barrier


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Barrier

THE BASICS OF BARRIER ANALYSIS

THREAT/ HAZARDTARGET

BARRIER:Anything that has the effect of (or is intended to) reduce the probability and/or consequences of the effect of a threat on a target.

© 2014 W. R. Corcoran, [email protected]

78

Factor Building Block #3(Barrier Analysis Elements-THCSLL)

HarmfulEffect

Vulnerable

Item (Target)

Hazard That

CouldHarm Target

Co-location

of Target

and Hazard

Simultaneityof Target

and Hazard

Lack of EffectiveBarrier

Between Targetand Hazard

Barrier That Limits the

Harm



79

Flash Card Front

• If there had been an effective barrier the target would _________ have been harmed as it was.


80

Flash Card Back

•Not


81

Failed, Missing, Ineffective Barriers

• If the target was harmed there was no effective barrier protecting the target from the harm that did occur.

• There is no upper limit on the number of failed, missing, and otherwise ineffective barriers.


82

Flash Card Front

• If there had not been an effective barrier that limited the harm the harm would have been _________ it was.


83

Flash Card Back

•Worse


84

Barriers That Limit

• The harm is always finite, i.e., limited.• Something resulted in the limitation.• Sometimes it is an active barrier, e.g., fire

fighters, well cappers, or rescuers.• Sometimes it is the lack of more victims or

more harmful agent.


85

Negative Factors

• A positive factor consists of the presence or excess of something.

• A negative factor consists of the absence or insufficiency of something.

• A failed, missing, or ineffective barrier can be a negative factor.

• Problem: There is no limit to the number of negative factors resulting in one adverse effect!!

• Problem: A negative factor can be described positively and vice versa!!


86

Factor Building Block Example THCSLL1(Barrier Analysis Elements-THCSLL)

HarmfulEffect was

Was Interruption of Injection for Some HoursVulnerable

Item (Target)

Was Injectio

nFlow

Hazard That

CouldHarm Target

was Operato

rAction

Co-location

of Target

and Hazard

was Operato

rAccess

toControls

They were there at the same time.



Next Shift Restored Injection


87


HarmfulEffect was

Was Bearing BackwardsVulnera

bleItem

(Target)Was

Bearing Would go in

Backwards

Hazard That

CouldHarm Target

was Worker

Error

Co-location

of Target

and Hazard

was WorkerAccess

toPump




There was only one

pump involved


88

Factor Building Block Example THCSLL2.1(Barrier Analysis Elements-THCSLL)

HarmfulEffect was

Was Lack of BarrierVulnerable

Item (Target)

Was Barrier Control

Hazard That

CouldHarm Target

was No Requirement for Barriers

Co-location

of Target

and Hazard

was Work

Control Informal

ity

They were

there at the

same time.


Between Targetand Hazard (Ineffective Oversight)

Other Items not Involved


89

Factor Building Block Example THCSLL2.1.1 (Ineffective Barriers)

• Use of Instructions, Procedures, and Drawings• Worker Performance

– Experience– Training

• Supervision• Pre-job Briefing• Work Planning• Prior QA Performance• Use of Operating Experience• Others


90

Factors-consequences Matrix: Barrier Analysis (THCSL)Actual Case 1 Case 2 Case 3 Case 4 Case 5 Case 6

FACTORS Yes Yes

Vulnerable Target

Yes Invulnerable or No Target

Yes Yes Yes Yes Yes

Harmful Hazard Yes Yes No Hazard Yes Yes Yes Yes

Co-location of Target & Hazard

Yes Yes Yes Different Places

Yes Yes Yes

Simultaneity of Target & Hazard

Yes Yes Yes Yes Different Times

Yes Yes

Lack of an Effective Barrier between Target & Hazard

Yes Yes Yes Yes Yes Effective Barrier

Yes

Limiting Barrier

Yes Yes Yes Yes Yes Yes Less Limiting Barrier

CONSEQUENCES

As they were

No Harm No Harm No Harm No Harm No Harm Worse Harm


91

Direct Factors Matrix of Barrier Analysis and Factor Type (THCSLL)

(This applies to harmful factors as well as harmful consequences.)[Example for TMI-2 Accident: 1/3 Core Melt]

Every harmful EFFECT is the resultant of a hazard, a vulnerable target, co-location, simultaneity, lack of an effective barrier to the harm, and an effective barrier that limited the harm..

Hazard Target Co-location

Simultaneity

Lacking Barrier

Limiting Barrier

Every harmful EFFECT is the resultant of factors that resulted in its nature, its magnitude/ intensity, its location, and its timing, including set-up, triggering, exacerbation, and mitigation.

(Set-up) Decay Heat Ceramic pellet and Zr clad

Decay heat within fuel

Decay heat within fuel

Trigger(Initiator)

Interruption of Cooling

Exacerba-tion

Magnitude of decay heat

Properties of pellet and clad

How long the cooling was off

Mitigation . . Cooling Restored when it was (next shift)

Every harmful EFFECT will have at least one direct factor in each column and at least one in each row. (This applies to harmful factors as well as harmful consequences.)©

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92

Flash Card Front

• If a worker is injured you know that all of the barriers to that exact injury were _________ or _______.


93

Flash Card Back

•Missing or ineffective


94

Flash Card Front

• If a worker is injured you know that some barrier(s) limited the exact injury so it wasn’t even _________ .


95

Flash Card Back

•Worse


96

Factor Building Block Exercise-THCSLL



97

THCSLL FBB Exercise

Factor_________________________Direct

Factor(s) related

to T: _______

_____

DirectFactor(s) related

to H: _______

___

DirectFactor(s) related

to S: _______

__

DirectFactor(s) related to C: _____________

DirectFactor(s) related to L: _____________

Direct Factor(s) related to Limiting

Barrier __________



98

The THCSLL FBB is good for



Factor Building Block #4(Existence of Effect: [CP])

Creation & Persistence


100

Existence

• If something existed at a given time– It must have been created and– It must have persisted up to that time.

• Examples– Apollo XIII-Defective O2 Tank wiring– Columbia-Damaged wing tile– Challenger-Hardened O-ring– Davis-Besse-Crack in CRDM nozzle


101

Factor Building Block #4(Existence of Effect: Creation & Persistence [CP])

HarmfulEffect

DirectFactors

of Creation

Direct Factors

of Persistence


102

Factor Building Block Example CP1.0(Existence of Effect: Creation & Persistence [CP])

HarmfulEffect : Bearing Backward 1.0DirectFactors

of Creation : Worker Installed the Bearing

Backward 1.1

Direct Factors

of Persistence: Not noticed, effects not addressed, etc. 1.2


103

Flash Card Front

• The only harmful effects involved in the event being investigated are those that both were ______ at some time in the past and ______ until the event.


104

Flash Card Back

•Created, persisted


105


HarmfulEffect : Bearing Backwards 2011 (1.0)

Worker Installed the Bearing Backward in 2005 (1.1)

Pump designed such that bearing can go in backwards 1.1.1

Ineffective training 1.1.2

Insufficient experience 1.1.3

Ineffective supervision 1.1.4

Ineffective use of instructions, procedures, drawings 1.1.5

Bearing Left Backwards Until 2011 (1.2)

Deeper FBBs


106



Worker Installed the Bearing Backward in 2005 (1.1)Pump

designed

such that

bearing can go in

backwards 1.1.1Deeper FBB

s

Ineffective traini

ng 1.1.2

Deeper FBB

s

Insufficient

experience 1.1.3

Deeper FBB

s

Ineffective supervision 1.1.4

Deeper FBB

s

Ineffective

use of instructions

, procedures, drawi

ngs 1.1.5Deeper FBB

s


Deeper FBBs


107




Deeper FBBs


Record reviews do not reveal error 1.2.1

Pump runs with bearing backwards 1.2.2

Lube oil sampling not done 1.2.3

Vibration monitoring not effective 1.2.4

Damage insufficient to cause severe failure 1.2.5

Damage insufficient to cause severe vibration until 2011 (1.2.6)


108




Deeper FBBs

Bearing Left Backwards Until 2011 (1.2)Record

reviews do not reve

al erro

r 1.2.

1

Deeper FBBs

Pump

runs with bearing backwards

1.2.2

Deeper FBBs

Lube oil

samplin

g not don

e 1.2.

3Deeper FBBs

Vibratio

n monitoring not

effective 1.2.

4

Deeper FBBs

Damage

insufficient to caus

e seve

re failu

re 1.2.

5

Deeper FBBs

Damage


e seve

re vibratio

n until 201

1 (1.2.

6)

Deeper FBBs


109

Factors-consequences Matrix: Creation & Persistence

Actual Case 1 Case 2

FACTORS

Factors Resulting in Creation of Effect

Yes No creation factors Same

Factors Resulting in Persistence of Effect

Yes Yes No Persistence Factors

CONSEQUENCES

Effect as it was when it was

No creation, thus no existence

No Current Existence


110

Direct Factors Matrix (DFM) for CP FBB(This applies to factors as well as consequences.)

[Example for TMI-2 Accident: Defective Operator Mental Model ]

The current EXISTENCE of every EFFECT is the resultant of the factors that resulted in its creation and the factors that resulted in its persistence.

Creation Persistence

Every EFFECT is the resultant of factors that resulted in its nature, its magnitude/ intensity, its location, and its timing.

Nature(Relationship of Pzr Level to RCS Inventory)

Navy training on “Solid Operation-Brittle Fracture”

No training by plant to replace or clarify Navy training

Magnitude(One)

Not counteracted by training on sub-cooled margin.

Not counteracted by commercial nuclear training.

Location(In Operator’s Mind)

Operated was trained. Operator remembered.

Timing(Created during naval service. Persisted until 3-29-79.)

During naval service. Activated by high Pzr Level

Every EFFECT will have at least one direct factor in each column and at least one in each row. (This applies to factors as well as consequences.)


111

Flash Card Front

• If you know the factors that resulted in the creation of a harmful factor you may be able to prevent the creation of other harmful factors.

• True or False?


112

Flash Card Back

•True


113

Flash Card Front

• If you know the factors that resulted in the persistence of a harmful factor you may be able to find and address other harmful factors sooner.

• True or False?


114

Flash Card Back

•True


115

Factor Building Block Exercise-CP



116

CP FBB Exercise

Factor_________________________

DirectFactor(s) related to Creation:

_____________

DirectFactor(s) related to Persistence:

_____________



117

The CP FBB is good for



Factor Building Block #5 (Rollup/Breakdown-RB)

Greater effects can result from lesser effects.


5

119

Factor Building Block #5(Rollup/Breakdown-RB)

Greater HarmfulEffect

Lesser HarmfulEffect







120

Factor Building Block #5 Example RB1.0(Rollup/Breakdown-RB)

Greater HarmfulEffect: No Effective Barrier

No Effective Work

Control BarrierDeeper

FBBs

No Effective Supervision

BarrierDeeper

FBBs

No Effective Procedural

BarrierDeeper

FBBs

No Effective Experience

BarrierDeeper

FBBs

No Effective Training BarrierDeeper

FBBs



121



No Effective Barrier to Encourage

Appropriateness

Deeper FBBs

No Effective Barrier to

Discourage Inappropriatene

ssDeeper

FBBs

No Effective Barrier to Prevent

Inappropriateness

Deeper FBBs


Detect Inappropriatene

ssDeeper

FBBs


Compensate for Inappropriatene

ssDeeper

FBBs

When there is no effective barrier these aremissing or defective.


122

Barrier Exercise

Identify at least one barrier that would:1.Encourage putting the bearing in correctly.2.Discourage putting the bearing in backwards.3.Prevent putting the bearing in backwards.4.Detect that the bearing had been put in backwards.5.Compensate for the bearing being in backwards.


123

Flash Card Front

• Whenever there is no effective barrier you know that in concept that all ____ types of barriers were missing or defective.


124

Flash Card Back

•Five (5)!


125

Factor Building Block #5(Rollup/Breakdown-RB) Notes

• A formula for investigation team trouble is to attempt to explain a greater effect without first explaining the lesser effects.

• Sometimes the factors that resulted in various lesser effects are similar, if not identical.

126

Factor Building Block ExerciseRollup/Breakdown-RB

• Draw a one level FBB for one of the direct factors of one of the following effects or an effect of your own choosing:– Fatigue Cracking– Stress Corrosion Cracking– Burned Out Lighting Device– Weak Car Battery– Running Low on Fuel for Vehicle– Project Delay


127

RB FBB Exercise

Factor_________________________Compone

nt of Factor:

_____________

Component of

Factor: ________

_____

Component of

Factor: ________

__

Component of Factor: _____________

Component of Factor: _____________


Write on or near objects. Factor amenable to Rollup/Breakdown

From Previous Exercise

128

The RB FBB is good for

• Consequences and factors that – Are aggregations– Are combinations– Are divisible into chunks– Are made up of multiple factors


129

The RB FBB is NOT good for

• Consequences and factors that – Are unitary– Are singular– Are not aggregations– Are not divisible into chunks


130

Recommendations for Investigators

• Create a Factor Tree for your next investigation

• Use FBB#1-STEM on your next investigation• Make the Factor Tree explain NMLT level by

level.


131

Recommendations for Investigation Report Reviewers/ Inspectors/

Auditors• Ask: What is the nature, the magnitude, the

location, and the timing (NMLT) of the most important harmful effect?

• Ask: Does the report explain the NMLT?• Ask: Do the corrective actions address that

which explains the NMLT?• Ask: How does each corrective action affect

the NMLT?© 2014, William R. Corcoran, 860-285-8779, [email protected]

132

Conclusions 1.0

• There are at least five useful Factor Building Block models.• The following three are always useful:

– STEM– NMLT– Barrier Analysis Elements (TBCSL)

• The Existence (CP) FBB should be used as a check for missing Lines of Inquiry.

• The Rollup/ Breakdown (RB) FBB should be used for multiple similar consequences and for failed/missing/ineffective barriers.


133

Conclusions 2.0

• The FBB models provided can help in– Doing business issue investigations– Identifying weaknesses, shortfalls, and defects in

investigation reports• Each of the five can be used to find the flaws

in an analysis.


Frequently Asked Questions


135

FAQ Topics

• Root Cause• Compliance• Comparative TimeLine©• Missed Opportunity Matrix• The Investigation Report• Glossary• Corrective Action Matrix

• Extent• Lines of Inquiry• Stopping Rules• Extent• Charter• Barrier Analysis Matrix• Barrier Analysis Flow Chart

136

What about Root Causes? (1)

• The root causes will be at the bottom of the factor tree in the deepest factor building blocks.

• They will be basic fundamental underlying harmful conditions, behaviors, actions, and/or inactions.

• Their factors will be less important than they are.


137

What about Root Causes? (2)If you have factors that are called root causes ask:1. What are the other harmful factors that have equal or better

claim to be called root causes?2. What are the factors that directly resulted in each root

cause?3. What is the evidence that supports the facts alleged in

statements of root cause?4. How did this root cause impact the top level harmful effect

(consequence)?5. What other factors are necessary to explain the nature, the

magnitude, the location, and the timing of the top level harmful effect (consequence)?


138138

Behavior orCondition

Make the EventHappen?

Make theConsequences

Worse?No

Is a Cause

Yes Yes

Is Something ElseNeeded to Explain

the Cause or Consequence?

ContributingCause Cause is

Self-sufficient

YES

NO

Is not a CauseNo

© 2014, William R. Corcoran,

139139

Behavior orCondition

Make the EventHappen?

Make theConsequences

Worse?No

Is a Cause

Yes Yes

Not a Root CauseRoot Cause

YESNO

Is Not a causeNo


Is this cause due to more important

[underlying] factors?

140

What about Extent? (1)

Every harmful effect, including those that are factors of higher level effects, have two types of extent: Magnitudinal Extent (E.g., vibration amplitude) Inferential Extent (E.g., other bearings with

similar issues) To appreciate the full importance of the issue

you need to understand both as well as their causation.


141


A credible job on extent must be based on a credible job on the basic investigation.

The inferential extent of X is the answer to the question, “If I see X what else should I expect to see?”

The X can be:1. A harmful effect2. A harmful factor (condition, behavior, action, or inaction)3. A beneficial, but fragile, factor


142


The What Else Besides X can be:1. The same item (X) existing

a. At a different timeb. In a different place

2. A similar item (Ξ)existing a. At a different timeb. In a different place

3. A factor affecting X4. A result of X


Ξ is a Greek letter “Xi”, a letter similar to the English letter X. It is pronounced “zigh” .

143

Systematic Approach to Extent

1. Do a good investigation.2. Select important conditions, both consequences

and factors.3. Select important factors, conditions, behaviors,

actions, and inactions.4. Specify your qualitative/quantitative acceptance

criteria for extent.5. Select or invent a tool for extent.6. Determine probable extent.7. Actually see if the extents are there.

© 2014 W. R. Corcoran, [email protected]

144

The Taxonomy of Extent 1.0

Extent of X (1.0)

Magnitudinal Extent of X (1.1)

See Taxonomy of Extent 1.1

Inferential Extent of X (1.2)

See Taxonomy of Extent 1.2

The connectors mean that the upper item is comprised of the lower items. The lower items are part of the upper item.


145


Magnitudinal Extent of X (1.1)

Size of X 1.1

Number of Xs 1.2

Intensity of X 1.3

Severity of X 1.4

Persistence of X

1.5

Other Magnitu

dinal Properties of X

1.6



146



More of X (1.2.1)

See Taxonomy of Extent

1.2.1

Items Similar to X (1.2.2)


1.2.2

Items that resulted in X

(1.2.3)See Taxonomy of Extent

1.2.3

Items resulting from X (1.2.4)


1.2.4



147

The 360 Degree Approach

• Is a nice way to comprehend inferential extent.

• Can be explained in down home common sense terms.


148

Roofing NailsIn Driveway

Nails inTires

Roofer ForeignMaterial Management

Roofing NailsIn Other Places

Other ForeignMaterial Problems


149149

Termite in Garage

Wood StructureDamage

Termite HabitatNearby

TermitesIn Other Places

Other Wood-eating

Insects


150

Problem ThatGot Noticed

DownstreamImpact

UpstreamCausation

More of the Same Item

More of the SameClass of Issue


151

What about Lines of Inquiry? (1)

• A Line of Inquiry (LOI) is an area, concept, issue, unanswered question or the like that the investigation team could consider.

• LOIs drive the investigation after the topics in the five types of FBBs have been worked.

• LOIs are very important to negative factors.


152

What about Lines of Inquiry(LOI)? (2)

• There are many pre-packaged LOI generating tools including picklist approaches, e.g., MORT, and assessment checklists.

• LOI selection is often a knowledge-based activity.


http://www.nri.eu.com/NRI1.pdf

153

What about Lines of Inquiry(LOIs)? (3)

• For transparency, the investigation report should include lists of LOIs including– LOIs pursued– LOIs considered and dismissed


154

What about Compliance? (1)

• In a compliance-involved situation every harmful factor that requirements were intended to prevent is due either to– Noncompliance with a requirement or– A defect in the requirement.


155

The Tree of (Non)Compliance 1.0

Harmful Effect that Compliance Should Prevent (1.0)

And/OrNoncompliance with Requirement(s) (1.1)See Tree of

(Non)Compliance 1.1

Defective Set of Requirements(1.2)See Tree of (Non)Compliance

1.2

The connectors mean that the upper item is a result of the lower items. The lower items are factors of the upper item.


156

Flash Card Front

• If something happened that requirements were intended to prevent and the requirements were OK then there must have been ______________.


157

Flash Card Back

•Noncompliance


158

What about the Barrier Analysis Matrix? (1)

• Use it in conjunction with the THCSLL FBB• Use it independently to generate LOIs• Use it in conjunction with the FCM• Use it as input into the CTL


159

Barrier Analysis Matrix (BAM) [HPCI Inop for DD Days] Sheet 1 of N

Barrier Target Protected

Threat Effectiveness in this case

Significance

Outsource QA Appendix B Compliance by

Contractor

Critical Noncompliance

Ineffective. Contractor not in compliance with

Criterion V and others,.

Failed Barrier. Allowed nonconforming

installation.

Work Package Quality of Work Critical Work Defect Ineffective. Work had critical defect.

Failed barrier. Defective installation.

Pre-job brief for Booster Pump Work

Work process integrity.

Inadequate work process

Did not identify critical step.

Failed barrier. Missed Opportunity.

Contractor Work Supervision



Did not identify critical step done wrong.


Vendor Technical Manual

Work instructions Errors and omissions Not used.. Failed barrier. Missed Opportunity. Negative

factor.

In-house Operating Experience Program

This barrier and other barriers.

Repeat missing and ineffective barriers

Not used effectively Failed barrier. Missed Opportunity. Negative factor.

Industry Operating Experience Program





160

What about the Investigation Report?(1)

The report must be:• Trustworthy• Loyal to Principle• Helpful• (Reader) Friendly• Courteous• Kind to Victims

• Obedient to the Charter• Cheerful as Appropriate• Thrifty• Brave • Clean• Reverent

The Case Study Begins

Real Life Application of the Principles and Good Practices


HPCI Inoperable for DD Days(A case study using Factor Building Blocks

[FBBs])

For Training OnlyW. R. Corcoran, Ph.D., P.E.


DD

IS AB

OU

T 68

CONTAINS NO

INFO IDENTIFYING

INVOLVED PLANT

163

Notices• This is part of The Phoenix Approach©.• It also applies to all other approaches to issue

investigation (root cause analysis).• If your organization is licensed to use The Phoenix

Approach© you may use this in accordance with the license.

• If your organization is not licensed to use The Phoenix Approach© please call for permission. In the meanwhile you have permission to give this seminar once in-house, if you send me the workshop comments.


164

Generic Factor Tree with FBBs

Harmful Effect

FBB1FBB1.1

FBB 1.1.1

FBB 1.1.3

FBB1.2

FBB1…..

FBB2

FBB2.1

FBB2.2

FBB2...

FBB… FBB… FBB…



FBB=Factor Building Block

165



Bearing can go in

Backwards

Worker put


Bearing Damages

Pump While

Operating


Pump Inoperabl

e


More Days

Damage Discovere

d

Pump Restored

to Operabilit

y


166

The Comparative TimeLine©(CTL)

• The CTL organizes the evidence.• It works with the other tools.• The information of all of the tools should be

consistent (or explained).


167

Some Terminology

• QA=Quality Assurance• QAP=QA Program• App B=10CFR50,

Appendix B• VTM=Vendor Tech

Manual• OE=Operating

Experience• QC=Quality Control

• HPCI=High Pressure Coolant Injection

• BP=Booster Pump• Crit=Criterion, Criteria• Crit IV (1,2), e.g.=

Sentences 1 and 2 of Criterion IV

• PO=Purchase Order

168

Comparative TimeLine© [HPCI Inop for DD Days] Sheet n of N

When What(Actual) What(Should) Result of Δ Impact and Notes

Template for CTL Slides


169

Comparative TimeLine© [HPCI Inop for DD Days] Sheet 1 of N


Before 2005 Pump design allows thrust bearing to be put in backwards

OK Establishes vulnerability.

Triggering Factor unless controlled in Instructions, Procedures, Drawings.

Before 2005 Pump design allows pump to run with thrust bearing put in backwards

OK Vulnerability not detectable in short term test.

Set-up Factor unless controlled in Instructions, Procedures, Drawings.

Note: 10CFR50, Appendix B, provides one way of controlling vulnerabilities such as this one.


170



2005 or before HPCI BP needs rebuild and impeller mod

OK Work Process Starts

TriggerUpstream issues?

2005 No QAP required in PO

QAP required in PO

No App B QA applied

Crit IV (1, 2)

2005 No App B QA applied

App B QA applied

Many harmful effects

Crit I (2)

2005 or before VTM leaves out bearing orientation

VTM specifies bearing orientation

None: Not used ECAQCrit V (2)

2005 VTM not used Should have used VTM

None: It would not have helped

Separate ECAQCrit V (1)

2005 or before Defective VTM accepted for use

Defective VTM should have been rejected.

Defective VTM in document system

Separate ECAQCrit XVI (1)


171



2005 and before

OE on defective VTM not applied

OE on defective VTM applied

Defective VTMs persist. No compensation for defective VTM

Crit XVI (1)Programmatic Issue

2005 and before

Ineffective requirements for VTMs

Effective requirements for VTMs

Defective VTMs accepted for use.

Crit IV(1)Crit V (2)


172



2005 and/or before

QA Dept not effectively involved in work

QA Dept effectively involved in work

Above issues not identified

Crit I(1,3)Crit II(4)Crit XVI (1)

2005 and/or before

No Oversight Activity Notices any Programmatic Problems above

Many Oversight Activities Notice some Programmatic Problems above

Programmatic Issues remain

Crit II (9.10)Crit XVI (1)Crit XVIII (1)

2005 and/or before

Workers not qualified

Workers effectively qualified

Workers don’t know about bearings

Crit II(8)

2005 and/or before

Ineffective use of OE on worker qualification/trng

Effective use of OE

Missed Opportunity



173



2005 and/or before

Ineffective use of OE on bearing orientation

Effective use of OE

Missed Opportunity


2005.03.16 Bearing installed wrong

Bearing installed wrong

HPCI BP nonconforming

Tech Specs?Crit V(2)Physical TriggerBegins NC Time

2005.03.16 Error not found by QC

Error found by QC

HPCI BP stays nonconforming

Crit X (1, 2)Crit XVI (1)

2005.03.16 Error not found by Supervision

Error found by Supervision

HPCI BP stays nonconforming

Crit XVI (1)

2005.03.16 Orientation of bearing not recorded

Orientation of bearing recorded

Cannot ID prob by record review

Crit VII(2)Crit XVII (1)


174



2009.09.09 (about)

OE 29810 on Callaway TDAFP not applied

OE 29810 on Callaway TDAFP not applied

Misoriented bearing and defective LO Program not discovered.


2009.10.22 (About)

OE 30492 on Plant Hatch CRD Pump not applied

OE 30492 on Plant Hatch CRD Pump applied

Misoriented bearing and defective VTM not discovered.


2010.01.20 (About)

OE 30492 on different Plant Hatch CRD Pump not applied

OE 30492 on Plant Hatch CRD Pump applied



2008.01.31 (about)

This plant PER 133600 not applied

This plant PER 133600 applied

Misoriented bearing not discovered.



175



Various OE on defective work instruction not applied

OE on defective work instruction applied

Defective work instruction not discovered.


2010.01.20 and before

None of the following effectively identify any of the above QA weaknesses: Nuclear Assurance Oversight, NSRB, INPO

All of the following effectively identify most of the above QA weaknesses: Nuclear Assurance Oversight, NSRB, INPO

QA Programmatic breakdown not identified.Event allowed to continue.

Crit II (9, 10)Crit XVI (1, 2)Crit XVIII (1)


176



2011.07.21 OE 30492 at Plant Hatch not applied to this plant.

OE 30492 at Plant Hatch applied to this plant.

Misoriented bearings not looked for.

2011.04.21 51 min run for surveillance

OK Damage probably begins

Normal Vib

2011.04.27 7h18m run (tornado)

OK Damage probably increases

Vib data not taken

2011.04.27 Vib data not taken

Vib data taken ECAQ or Missed Opportunity

Crit XVI (1)Programmatic Issue (CAQ?)

2011.04.28 4 runs ~6h (tornado)

OK Damage probably increases


177



2011.04.28 Vib data not taken

Vib data taken ECAQ or Missed Opportunity


2011.05 (About) OE on Ft.Calhoun Screen Wash Pump not applied

OE on Ft.Calhoun Screen Wash Pump applied


2011.05.20 HPCI Discharge Check Valve fails to reseat

HPCI Discharge Check Valve reseats

HPCI Overpressure

Triggering factor for Inop

2011.05.20 HPCI Overpressure

Proper HPCI Pressure

Damage increased

Beginning of Inop Period

2011.05.20 and before and after

Lube Oil Samples not Taken

Lube Oil Samples Taken & Analyzed

Missed LO Contamination.Damage not detected. Inop extended.



178



2011.04.28 Temperature data not taken

Temperature data taken

ECAQ or Missed Opportunity



179



2011.05.20 before

QA Auditing, Self-assessment, OE and Oversight do not find LO Program Weakness

QA Auditing, Self-assessment, OE and Oversight all find LO Program Weakness

LO Program weakness not found. Inop extended.

Crit XVI (1)Programmatic Weaknesses (LOP, CAP, OEP, QAP)

2011.07.20 Surveillance Test

OK Vibration in Alert Range

Inop Discovered

2011.05.20 before

QA Auditing, Self-assessment, OE and Oversight do not find Vib Program Weakness

QA Auditing, Self-assessment, OE and Oversight all find Vib Program Weakness

Vib Program weakness not found. Inop extended.

Crit XVI (1)Programmatic Weaknesses (VMP, CAP, OEP, QAP)


180



2011.07.21 (about)

Lube Oil Samples Taken & Analyzed

OK Contamination reveals BPDamage.

2011.07.27 Bearing Replaced

OK Inop Ended About 68 Days Inop

2012.08.24 and before

None of the following effectively identify any of the above QA weaknesses: Nuclear Assurance Oversight, NSRB, INPO

All of the following effectively identify most of the above QA weaknesses: Nuclear Assurance Oversight, NSRB, INPO

QA Programmatic breakdown not identified.Event allowed to continue. No subsequent learning.

Crit II (9, 10)Crit XVI (1, 2)Crit XVIII (1)


181



2012.08.24 Revised RCAR Issued

OK Over a year between event date and RCAR issue date.

What’s the real story?


182



Bearing can go in

Backwards

Worker put


Bearing Damages

Pump While

Operating


Pump Inoperabl

e


More Days

Damage Discovere

d

Pump Restored

to Operabilit

y


Set-up

Trigger ExacerbationMitigation

MitigationExacerbation

Exacerbation

183


HarmfulEffect: HPCI Inop for DD DaysDirect

Factors Affecting Nature: Internal

Booster Pump Damage

DirectFactors

Affecting Magnitude: Severity of Damage,

Persistence Time

DirectFactors

Affecting Location:

Location of Bearing

DirectFactors

Affecting Timing: Times

of Error, Damage,

Discovery, Restoration.



184

Factor Building Block Example NMLT3.1(Attributes of Consequence-NMLT)

HarmfulEffect: HPCI Inop for DD Days

DirectFactors Affecting Nature: Internal Booster Pump

Damage

Deeper FBBs

DirectFactors Affecting

Magnitude: Severity of Damage,

Persistence TimeDeeper FBBs

DirectFactors Affecting Location: Location

of Bearing

Deeper FBBs

DirectFactors Affecting Timing: Times of Error, Damage,

Discovery, Restoration.Deeper FBBs



185


HarmfulEffect was

Was Bearing BackwardsVulnera

bleItem

(Target)Was

Bearing Would go in

Backwards

Hazard That

CouldHarm Target

was Worker

Error

Co-location

of Target

and Hazard

was WorkerAccess

toPump




There was only one

pump involved


186

Factor Building Block Example THCSL2.1(Barrier Analysis Elements-THCSL)

HarmfulEffect was

Was Lack of BarrierVulnerable

Item (Target)

Was Barrier Control

Hazard That

CouldHarm Target

was No Requirement for Barriers

Co-location

of Target

and Hazard

was Work

Control Informal

ity

They were

there at the

same time.


Between Targetand Hazard (Ineffective Oversight)

Limiting Barrier was no worse

challenges


187

Factor Building Block Example CP1(Existence of Effect: Creation & Persistence [CP])

HarmfulEffect : Bearing BackwardDirect

Factorsof Creation : Worker Installed the Bearing

Backward

Direct Factors

of Persistence: Not noticed, effects not

addressed, etc.


188


HarmfulEffect : Bearing Backwards 2011

Worker Installed the Bearing Backward in 2005

Pump designed such that bearing can go in backwards

Ineffective training

Insufficient experience

Ineffective supervision

Ineffective use of instructions, procedures, drawings

Bearing Left Backwards Until 2011

Deeper FBBs


189



Worker Installed the Bearing Backward in 2005Pump design

ed such that

bearing can go in

backwardsDeeper FBB

s

Ineffective traini

ng

Deeper FBB

s

Insufficient

experience

Deeper FBB

s

Ineffective supervision

Deeper FBB

s

Ineffective

use of instructions

, procedures, drawi

ngsDeeper FBB

s


Deeper FBBs


190




Deeper FBBs


Record reviews do not reveal error

Pump runs with bearing backwards

Lube oil sampling not done

Vibration monitoring not effective

Damage insufficient to cause severe failure

Damage insufficient to cause severe vibration until 2011


191




Deeper FBBs

Bearing Left Backwards Until 2011Reco

rd reviews do not reve

al erro

rDeeper FBBs

Pump

runs with bearing backwardsDeeper FBBs

Lube oil

samplin

g not don

eDeeper FBBs

Vibratio

n monitoring not

effectiveDeeper FBBs

Damage


e seve

re failu

re

Deeper FBBs

Damage


e seve

re vibratio

n until 201

1

Deeper FBBs


192

Factor Building Block #5(Rollup/Breakdown-RB)

Greater HarmfulEffect








193



No Effective Work

Control BarrierDeeper

FBBs

No Effective Supervision

BarrierDeeper

FBBs

No Effective Procedural

BarrierDeeper

FBBs

No Effective Experience

BarrierDeeper

FBBs

No Effective Training BarrierDeeper

FBBs



194

Factor Tree Example 1.0(Begins with-STEM)

HPCI Inoperable for DD Days 1.0

Bearing can go in

Backwards 1.1

See Exampl

e 1.1

Worker put


1.2

See exampl

e 1.2

Bearing Damages

Pump While

Operating 1.3

See Exampl

e 1.3


Pump Inoperabl

e 1.4

See Exampl

e 1.4


More Days 1.5

See Exampl

e 1.5

Damage Discovere

d 1.6

See exampl

e 1.6

Pump Restored

to Operabilit

y 1.7

See exampl

e 1.7


195


Bearing can go in Backwards 1.1

Reduces Spare Parts Inventory

1.1.1

END for now

Missed/Dismissed in FMEA1.1.2

END for now

Done on Previous

Designs 1.1.3

END for now

Mistake Proofing not a

Design Consideration

1.1.3

See Example

1.1.3

Ineffective Application of

App B, Crit. XVI, Sentence

1 (1.1.4)

See Example

1.1.4


196

Factor Tree Example 1.1.3(Begins with-STEM)

Mistake Proofing not a Design Consideration 1.1.3

Ineffective Use of Operating Experience 1.1.3.1

END for now

Other 1.1.1.3.2

END for now


197


Ineffective Application of App B, Crit. XVI, Sentence 1 (1.1.4)

App B did not exist at original design

1.1.4.1

END for now

App B not effectively applied to modified design

1.1.4.2

END for now

Ineffective use of OE related to

design for mis-orientation 1.1.4.3

END for now

Ineffective Licensee QA

Oversight

END for now


198


Worker put Bearing in Backwards 1.2

Pump Rebuild in

2005 (1.2.1)

See Example 1.2.1

Defective Instructions 1.2.2

See Example 1.2.2

25-75 Chance Failed 1.2.3

END-Normal

No QA Hold Point

1.2.4

See Example 1.2.4

Critical Step Not Flagged

1.2.5

See Example 1.2.5

Workers not

qualified 1.2.6

See Example 1.2.6

No Supervisor

y Intervention 1.2.7

See Example 1.2.7


Orientations1. Tandem (Left)2. Tandem (right)3. Back-to-back4. Front-to-front

199


Defective Instructions 1.2.2

Non-plant Procedures

used in turnkey work 1.2.2.1

See Example 1.2.2.1

Purchasing failed to apply App B, Crit. I, Sentence 2

(1.2.2.2)

See Example 1.2.2.2

Plant failed to apply App B,

Crit. II, Sentence 5(1.2.2.3)

See Example 1.2.2.3

Plant failed to apply App B,

Crit. V, Sentence 1(1.2.2.4

See Example 1.2.2.4

Ineffective Pre-job Brief 1.2.2.5

See Example 1.2.2.5


200


Workers not qualified 1.2.6

Failure to apply App B, Crit. II, Sentence 8 (1.2.6.1)

See Example 1.2.6.1

Safety Related Work Assigned to Unqualified Contractor

1.2.6.2

BREAKDOWN OF QA PROGRAM 1.2.6.2.1

See Example 1.2.6.2.1

Defective Contract 1.2.6.3

Failure to apply App B, Crit. IV, Sentence 1 & 2

(1.2.6.3.1)

See Example 1.2.6.3.1.1


201


Bearing Damages Pump While Operating 1.3

Bearing Rubs if Backwards 1.3.1

END Normal

Pump Operated HH Hours1.3.2

See Example 1.3.2


202


Damage Undiscovered Until Pump Inoperable 1.4

Ineffective Vibration Monitoring 1.4.1

See Example 1.4.1

Ineffective Lube Oil Purity Monitoring 1.4.2

See example 1.4.2


203



Ineffective Use of OE Related to Vibration Monitoring 1.4.1.1

See Example 1.4.1.1

Failure to Consider Vibration Monitoring as Required by App B, Crit. XVI, Sentence 1

( 1.4.1.2)

See example 1.4.1.2


204



Ineffective Use of OE Related to Vibration Monitoring 1.4.2.1

See Example 1.4.2.1

Failure to Consider Lube Oil Purity Monitoring as Required by App B, Crit. XVI, Sentence 1

( 1.4.2.2)

See example 1.4.2.2


205


Damage Undiscovered for DD More Days 1.5

Pump Performs with Bearing in Backwards 1.5.1

END for now


See example 1.4.1


See Example 1.4.2


206


Damage Discovered 1.6

Surveillance Test Run 1.6.1

END for now

Vibration Exceeds Alert Level 1.6.2

See Example 1.6.2

Staff Notices Excessive Vibration 1.6.3

See Example 1.6.3


207


Pump Restored to Operability 1.7

Damage Discovered 1.7.1

See example 1.6

Parts Available 1.7.2

END for now.

Pump Repaired 1.7.2

END for now.


208

Missed Opportunities

• The situations in which ordinary people or groups could have done ordinary things ordinarily well that would have resulted in reduced or eliminated harmful outcomes.

• Expect to see many missed opportunities.


209

Missed Opportunity Matrix (MOM) [HPCI Inop for DD Days] Sheet n of N

Who Situation Opportunity Expected Result

Impact and Notes

Template for MOM Slides


210

Missed Opportunity Matrix (MOM) [HPCI Inop for DD Days] Sheet 1 of N

Who Situation Opportunity Expected Result

Impact and Notes

Highest Mgt Planning for R/R

Apply App B to ITS/SR work

18 Criteria Applied

No event, Not a root cause

Purchasing Mgt Writing Purchasing Policy


18 Criteria Applied


QA Audit of Planning for R/R

Find that App B is left out of Planning for R/R

18 Criteria Applied


Work Planner Planning for HPCI BP Rebuild


18 Criteria Applied


Supervisor of HPCI BP Rebuild

Pre-job Brief Call out bearing installation as critical step

Bearing installed right



R/R=Restart/

Recovery

211

Barrier Analysis Matrix (BAM) [HPCI Inop for DD Days] Sheet n of N



Significance

Template for BAM Slides


212

Barrier Analysis Matrix (BAM) [HPCI Inop for DD Days] Sheet 1 of N



Significance

Outsource QA Appendix B Compliance by

Contractor

Critical Noncompliance

Ineffective. Contractor not in compliance with

Criterion V and others,.

Failed Barrier. Allowed nonconforming

installation.

Work Package Quality of Work Critical Work Defect Ineffective. Work had critical defect.

Failed barrier. Defective installation.

Pre-job brief for Booster Pump Work



Did not identify critical step.


Contractor Work Supervision



Did not identify critical step done wrong.


Vendor Technical Manual

Work instructions Errors and omissions Not used.. Failed barrier. Missed Opportunity. Negative

factor.

In-house Operating Experience Program




Industry Operating Experience Program





213

FACTOR-CONSEQUENCE MATRIX 1.0FACTOR Actual

CaseCase 1

Can’t go in wrong

Case 2 Right Guess

Case 3Effective Plant QAP

Case 4 Effective Contractor QAP

Case 5 Effective Procedure

Case 6 Effective Training

Case 7 Effective

QC

Case 8 Accident

Needing HPCI

Brg Can Go In Wrong Yes Brg in Properly

Yes Yes Yes Yes Yes Yes Yes

Worker Guesses Wrong

Yes Could not happen

Brg in Properly

Could not happen

Could not happen

Could not happen

Could not happen

Would be caught

Yes

Lack of Effective Plant QAP

Yes Would not matter

Would not matter

Brg in Properly

Would not matter

Would not matter

Would not matter

Would not matter

Yes

Lack of Effective Plant QAP


Would not matter

Could not happen

Brg in Properly

Would not matter

Would not matter

Would not matter

Yes

Lack of Effective Procedure


Would not matter

Could not happen

Could not happen

Brg in Properly

Would not matter

Would not matter

Yes

Lack of Effective Training


Would not matter

Could not happen

Could not happen

Would not matter

Brg in Properly

Would not matter

Yes

Lack of Effective QC Yes Would not matter

Would not matter

Could not happen

Could not happen

Would not matter

Would not matter

Brg in Properly

Yes

No accident needing HPCI


Would not matter

Would not matter

Would not matter

Would not matter

Would not matter

Would not matter

Accident Needing HPCI

Consequences

HPCI Inop DD Days None None None None None None None Not Applicable

Actual Fuel Damage Increase

None None None None None None None None Yes

HPCI BP Inop


214

Problem Finding Matrix (PFM) [HPCI Inop for DD Days] Sheet n of N

Harmful Factor/Effect

How Found Earlier, better, safer…


Measures to assure prompt ID

Template for PFM Slides


215

Problem Finding Matrix (PFM) [HPCI Inop for DD Days] Sheet 1 of N


How Found Earlier, better, safer…


Measures to assure prompt ID

No QA for Safety-related Job

Event Investigation of Inop HPCI

QA Audit of Purchasing

Audit Planning Audit Planning Check List



QA Department Review of Work Order

Work Order Review Procedure

Work Planning Check List



Engineering Department Review of Work Order

Conduct of Engineering Procedure

Work Planning Check List


216

Extent

• Magnitudinal Extent– Causation of Magnitudinal Extent

• Inferential Extent– Causation of Inferential Extent


217



More of X (1.2.1)


1.2.1

Items Similar to X (1.2.2)


1.2.2

Items that resulted in X

(1.2.3)See Taxonomy of Extent

1.2.3

Items resulting from X (1.2.4)


1.2.4



218

Problem ThatGot Noticed

DownstreamImpact

UpstreamCausation

More of the Same Item

More of the SameClass of Issue


219

Corrective Action Matrix (CAM) [HPCI Inop for DD Days] Sheet n of N


Corrective Actions

Expected Effectiveness

Effect if Pre-implemented

Short Term/ Long Term/ Comments

Template for CAM Slides


220

Corrective Action Matrix (CAM) [HPCI Inop for DD Days] Sheet 1 of N


Corrective Actions

Expected Effectiveness

Effect if Pre-implemented

Short Term/ Long Term/ Comments

No QAP required in PO

Adhere to App. B, Criterion IV

QAP Applied No event

No App B QA applied

Adhere to App. B, Criterion II

QAP Applied No event

VTM leaves out bearing orientation

Adhere to App. B, Criterion V

VTM includes instructions for installing bearings

No event

VTM not used Adhere to App. B, Criterion IV

VTM used in preparing work order

Would not have mattered unless VTM had been right.

Defective VTM accepted for use

Adhere to App. B, Criterion XVI

VTM rejected, then fixed

No event


End of Case Study

Comments? Questions?


222

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223

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224

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Five types of factor building blocks with case study 2014.05.05.0730

Engineering

Transcript of Five types of factor building blocks with case study 2014.05.05.0730