Presentation on theme: "A Practical Approach to Using Causal Analysis Methods to Evaluate Events as the First Step to Continuous Improvement and Accident Prevention at Brookhaven."— Presentation transcript:
1 A Practical Approach to Using Causal Analysis Methods to Evaluate Events as the First Step to Continuous Improvement and Accident Prevention at Brookhaven National LaboratoryCo-Authors:Roy Lebel, Brookhaven National LaboratoryRobert McCallum, McCallum-Turner, Inc.Presenter:Robert Crowley, PE, McCallum-Turner, Inc.
2 Brookhaven National Laboratory Issues Management Process Improvement InitiativeBNL determined their issues management process was deficient and embarked on an initiative institutionalize an Issues Management Program for both reportable and non-reportable events and issues as part of an accident/event prevention strategySeveral Key improvements were implemented including:Defining “lower level issues” for line management to evaluateTraining on the conduct of “Critiques” to improve fact findingTraining for staff and managers on Causal Analysis MethodsBNL recognized the need to institutionalize an Issues management process:Move beyond being in a reactive mode responding to the problems of the dayBecome proactive to learn from the causes of lower level eventsFoster the creation of a Learning organization.As part of addressing these needs, BNL embarked on a initiative to improve the BNL Issues Management Program. Some key improvements in defining lower level issues ( below the ORPS threshold) and training for both conduct of critiques and causal analysisThe topic of this presentation will focus on the training of BNL Staff and managers on Causal Analysis methods.
3 Why Implement this Strategy? Prevent More Serious Events from Occurring by Focusing on Review and Analysis of Low Significance (low-level) EventsORPS/ACCIDENTS/PAAAIncidentsConditionsSpillsSCBNLRadiological Awareness ReportsBrookhaven’s Strategy was to implement a program that evaluates lower level issues and events, implement effective corrective actions to prevent ORPS/Accidents ( Type A and B) and PAAA events.NonconformancesAuditsTier 1Assessments
5 Causal Analysis Methods There are a myriad of credible causal analysis methods ranging from simple to complexDOE has guides and standards addressing causal analysis including:DOE-G “Occurrence Reporting Casual Analysis Guide”DOE-NE- STD “Root Cause Analysis Guidance Document”DOE O 225.1A “Accident Investigation Guidance Document”Brookhaven National Laboratory also has guidance that addresses Causal Analysis methods “Causal Analysis Methodologies” that is part of the BNL SBMS SystemThere are many credible causal analysis methods that vary in the level of complexity. DOE has both Guides and standards that address causal analysis methodologies.Brookhaven National Laboratory also had guidance on the conduct of causal analysis that are found in “ Causal Analysis Methodologies” and address many credible causal analysis methods.4/8/2017
6 Brookhaven Accident\Issues Prevention Causal Analysis Strategy Focus of the Strategy:Line organizations would analyze the causes of lower level less complex eventsAnalytical methods used will be recognized by both Brookhaven National Laboratory and the Department of EnergyDevelop case studies tailored to both research and support organizationsFormally train line organizations on “simple” analytical methods that can be readily used after limited training4/8/2017
7 Brookhaven Accident\Issues Prevention Causal Analysis Strategy (Phase I) The first training session was conducted in August 2006 at Brookhaven National LaboratoryFocused on “Barrier Analysis” and introduction to the “Five Whys” analytical methodSimple analytical methods used effectively by BNL and DOE for event and accident investigationsShort training sessions (4 hours) were conducted with case studies developed for ERWM and research organizations based on DOE incidents60 Brookhaven National Laboratory managers and staff were trained and provided a case study for future referenceBARRIER ANALYSIS: The analytical concepts were introduced by William Haddon Jr., M.D. In Human Factors Journal in 1973In 1992 DOE Standard “Root Cause Analysis Guidance Document” identified barrier analysis as a Root Cause analysis method.Since 1995 DOE uses barrier analysis one of five core analytical technique for accident investigationsFIVE WHYS: It was made popular as part of the Toyota Production System in the 1970sA straightforward methodology that is effective in understanding the cause of a problemIt can promote a common and shared understanding of the causes and conditions that created the problemRecognized by BNL as an analytical method in (some document) and a root cause methodology by DOE.
8 Brookhaven Accident\Issues Prevention Causal Analysis Strategy (Phase II) The second training session was conducted in December 2006 at Brookhaven National LaboratoryFocused on “Events and Casual Factor Analysis” and application of the “Five Whys” analytical methods (with an HPI flavor)Simple analytical methods used effectively by BNL and DOE for event and accident investigationsShort training sessions (6 hours) were conducted with a case study based on a DOE accident in a research laboratoryApproximately 40 Brookhaven National Laboratory managers and staff were trained and provided a case study for future referenceECF ANALYSIS: An analytical method used as one of core analytical technique for DOE accident investigations and documented in BNL requirementsFIVE WHYS: Toyota Production System in the 1970s
9 “ HPI Flavor ” Using Anatomy of Event Error PrecursorsVision, Beliefs, &ValuesLatent Organizational WeaknessesMissionGoalsPoliciesProcessesProgramsFlawed DefensesInitiating Action4/8/2017
10 “HPI Flavor” Anatomy of Event – Error Precursors Limited short-term memoryPersonality conflictsMental shortcuts (biases)Lack of alternative indicationInaccurate risk perception (Pollyanna)Unexpected equipment conditionsMindset (“tuned” to see)Hidden system responseComplacency / OverconfidenceWorkarounds / OOS instrumentsAssumptions (inaccurate mental picture)Confusing displays or controlsHabit patternsChanges / Departures from routineStress (limits attention)Distractions / InterruptionsHuman NatureWork EnvironmentIllness / FatigueLack of or unclear standards“Hazardous” attitude for critical taskUnclear goals, roles, & responsibilitiesIndistinct problem-solving skillsInterpretation requirementsLack of proficiency / InexperienceIrrecoverable actsImprecise communication habitsRepetitive actions, monotonousNew technique not used beforeSimultaneous, multiple tasksLack of knowledge (mental model)High Workload (memory requirements)Unfamiliarity w/ task / First timeTime pressure (in a hurry)Individual CapabilitiesTask DemandsThe Error Precursor short list was used since this list is nothing more that a bunch of conditions that can used to populate the ECF chart for analysis using the “Five Whys” method.Task demands- include specific mental physical and team requirement to perform an activity that may exceed the capabilities or challenge the limitations of human nature of the individual assigned to the taskIndividual Capabilities- Unique mental, physical and emotional characteristics of a person that fail to match the demands of a specific taskWork environment- General influences of the workplace, organizational and cultural conditions that affect individual behaviorHuman nature – Generic traits, disposition, and limitations that may incline individuals to error under unfavorable conditions.The error precursors shown here are a short list in order of their importance by category.4/8/2017
11 Visual Depiction of Causal Factor Analysis Using “Five Whys” The Five WhysVisual Depiction of Causal Factor Analysis Using “Five Whys”Why 1Condition 3CausalFactor 3Why 1Why 2Why 1Why 2Condition 5CausalFactor 5Condition 2CausalFactor 2Why 1Why 2Why 1Why 2Condition 4CausalFactor 4Condition 1CausalFactor 1Schematically here is how the Five Whys was used….. but what else can we use the Five Whys for after we identify a gaggle of causal factors????Event 2Event 14/8/2017
12 Visual Depiction of Identification of Root Cause Using Five Whys The Five WhysVisual Depiction of Identification of Root Cause Using Five WhysCollect CFsIdentify Common CFsCausalFactor 1CausalFactor 1,2Apply Five WhysTechniqueCausalFactor 2RootCauseCausalFactor 3CausalFactor 3The method can be used to identify root causesCausalFactor 4CausalFactor 4,5CausalFactor 54/8/2017
13 The Five WhysWhat are the organizational conditions that are more conducive for the Five Whys to be successful?A “culture” where problems are surfaced quicklyA “culture” where identification of needed actions are viewed as an opportunity to move to an ideal or improved state of performanceA “culture” where the focus is on improving processes and systemsThe above are examples of HPI principles and the “learning culture” Brookhaven National Laboratory is institutionalizing4/8/2017
14 ConclusionBrookhaven National Laboratory trained over 100 managers and staff in “simple” causal analysis methods.Training incorporating the “Error Precursor Short List” resulted in identification of approximately 20% more conditions for analysis in case studies used for training.Brookhaven National Laboratory Causal Analysis Implementation Strategy using these “simple” methods is being used across Laboratory Organizations that experienced “lower level” events.No Type A or Type B Accidents since beginning this initiative.Use of the Error precursor short list resulted in identification of 20 percent more conditions making the analysis more comprehensive4/8/2017