Presented by Dorian S. Conger Conger-Elsea, Inc. 2000 Riveredge Parkway, Suite 740 Atlanta, GA 30328...

ROOT CAUSE ANALYSIS AND INCIDENT INVEISTATION

PROTOCOLS: A STATUS UPDATE OF IAEA AND U.S. PROCEDURES

Presented by Dorian S. CongerConger-Elsea, Inc.

2000 Riveredge Parkway, Suite 740Atlanta, GA 30328

800-875-8709 phone770-926-8305 fax

[email protected]

2005 Human Performance, Root Cause, and Trending ConferenceSyracuse, NY

1Copyright 2014 Conger-Elsea, Inc.

Background - May 2005 Consultants Meeting at IAEA in Vienna

1. Root Cause Analysis Experts

2. Various Disciplines

3. Various Countries

Copyright 2014 Conger-Elsea, Inc. 2

International Atomic Energy Agency Proposed Model Root Cause Analysis (RCAP)

The purpose of the working group was to develop a root cause analysis methodology that would combine the best aspects from the various systems currently in use in the nuclear power industry worldwide and to prepare a draft guidance document and manual.


Purpose

1. Management Oversight and Risk Tree Process (MORT) developed in the early 1970's for the U.S. government and enhanced for application since 1982 by Conger & Elsea, Inc.

2. Human Performance Enhancement System (HPES) was originally

based on the techniques and tools from the U.S. National Transportation Safety Board and the MORT process. This process was enhanced by the Institute of Nuclear Power Operations (INPO) in the early 1980's.

3. Assessment of Safety Significant Events Team process (ASSET) was developed by the International Atomic Energy Agency (IAEA) for use in evaluating incidents by member states.


Three Traditions

1. Each identifies what could be considered "direct causes" and through further formal analysis determines "root causes".

2. Each recognizes the importance of understanding the sequence of events.

3. Each includes the search for specific working level causes and the determination of related management system causes.

This new IAEA process represents a merger of these three traditions.


Philosophy

Method driven

Multiple causality

Thoroughness

Fairness

Efficiency Safety Precedence Sequence - the Safety Precedence

Sequence (SPS) is a very critical element of the philosophy


Attributes of the RCAP Process

The SPS establishes a hierarchy of the effectiveness of various approaches to preventing incidents. Six basic methods for preventing incidents are ranked from most effective to least effective as follows:

1. Design for minimum hazard2. Install/use safety devices (automatic engineered or physical

barriers)3. Safety cautions and warnings (visual and auditory)4. Procedures (written and verbal instructions)5. Personnel actions (from directed reading, training, knowledge or

awareness)6. Notify management of risk and accept the situation without

corrective action (documented with a signature of acceptance)


Safety Precedence Sequence

1. Event categories

2. Assigning the investigation

3. Procedures for conducting investigations

4. Define post investigation responsibilities

5. Training


Key Root Cause Program Considerations

Proposed ModelRoot Cause Analysis Matrix


RISKCAT.

ANALYST(S) RELATIONSHIPTO SITUATION

REVIEW ANALYTICALTECHNIQUES

ANALYSTS AND TEAM LEADERS TRAINING

HI 1

Team Inter-discipline

Indep. Indep. ECF and full TREE

Event InvestigationWorkshop

5 days

Mod Hi 2

Team Inter-discipline

Mixed Indep. ECF and full TREE

Event InvestigationWorkshop

5 days

Mod Lo 3

Individual Line Indep. ECF and at least 2 tiers of TREE

Root Cause Workshop2-3 days

Lo4

Individual Line Indep. ECF and at least 1 tier of TREE

Root Cause Workshop1-2 days

RCAP discards the concept of "apparent cause"!

This concept has led to trending programs being cluttered with invalid data based on guess work and not on formal analysis.

Two levels of causation determined by this process.

The first are called the "specific working level" causes, which have generally been described in previous work as the technical, direct, or contributing causes of events.

The second set of causes is called the "management system" causes, which have generally been described in previous work as root causes.


Levels of Causation

The investigator will first identify the specific field level causes. Then for each of those, the investigator will be expected to identify a corresponding management system cause or causes. The final step is an Extent of Condition and Extent of Cause Evaluation.


Application

Two principle required tools for use with the proposed RCAP. These tools merge the two primary methods of analysis that taken together form the most comprehensive event investigation process available. Most significantly, the same two tools can be appropriately used to analyze events of any category from 1 to 4.

1. Events and Causal Factors (ECF) charting from the original MORT process as enhanced by the HPES System.

2. The Specific Working Level Factors and Management

System Factors Tree Analysis (TREE) has been adapted with permission from the most recent MORT Analysis Chart and User's Manual (Conger & Elsea, Inc. - Copyright 2005).


Analysis Tools

Specific Working Level causes by examining the following areas:

S1 - Target (what was damaged or harmed)S2 - Hazard (what did the damage or harm)S3 - Barriers (physical and administrative)S4 - Emergency Response (after an event)C1 - Technical Information Systems (for working level personnel)C2 - Operability (Functional)C3 - Maintenance (plan, procedures and execution)C4 - Inspection (plan, procedures and execution)C5 - Supervision (preparation, detecting and correcting field problems)C6 - Higher Supervision Services and Support (support to working level

personnel)C7 - Human Performance Error (task assignment, procedures, selection,

training, motivation, fitness for duty, etc.)C8 - Task Procedures (clear, concise, complete, etc.)


Specific Working Level Factors and Management Systems Factors Tree Analysis

(TREE)

Management System causes by examining the following areas:

M1 - Policy (written, up-to-date, consistent, etc.)M2 - Implementation (priorities, direction, responsibility,

accountability, delays, budgets, etc.)R1 - Goals (performance and safety)R2 - Technical Information (for engineers, managers, etc.)R3 - Program Review (all types of programs)H1 - Concepts and Requirements (Specifications for planning,

engineering, design or safety Analysis)H2 - Design Development Plan (Implementing process for the

specifications)H3 - Human Factors (task allocation, predicting errors)H4 - General Design Process (initial, standardized, changes, etc.)


Specific Working Level Factors and Management System Factors Tree Analysis

(TREE)

Event Investigation Category 1 Category 2 Category 3 Category 4

Tier 1

ECF + Branches S1, S2, S3, S4

Top Qs from Branches C1 to C8

Tier 2

+ All Qs for any affected “C” Branches (C1-C8)

+ Top Qs only for Branches “M,” “R,” “H”

Tier 3 + All Qs in affected Branches “M,” “R,” “H”


Event Category vs. Depth of Investigation

NOTE: For each finding in S and C investigators need to determine a corresponding failure in Branches M, R or H.

NRC rewriting NUREG 1303 - Incident Investigation Manual

NRC rewriting Management Directive 8.3 - NRC Incident Investigation Program


Highlights of Coming Attractions

Presented by Dorian S. Conger Conger-Elsea, Inc. 2000 Riveredge Parkway, Suite 740 Atlanta, GA 30328...

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