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Defining Investigation Extent of Condition/Cause Scope a New Approach Steve Davis The Excellence Engine, LLC June 2010.

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Presentation on theme: "Defining Investigation Extent of Condition/Cause Scope a New Approach Steve Davis The Excellence Engine, LLC June 2010."— Presentation transcript:

1 Defining Investigation Extent of Condition/Cause Scope a New Approach Steve Davis The Excellence Engine, LLC June 2010

2 Extent of Condition/Cause a.k.a. How big is this problem?

3 Transportability of condition - determine whether the same problem/condition exists elsewhere. Is the extent to which the condition may exist in other plant equipment, organizations, processes, or human performance. Extent of Condition

4 Why Perform an Extent of Condition Review? To identify down stream effects from the initial event. To identify possible event initiators and correct them prior to causing an additional event.

5 Extent of Cause Transportability of cause - determine whether the same root or underlying causes of the problem/condition may be affecting performance elsewhere (other plant processes, equipment, or human performance).

6 Why Perform an Extent of Cause Review? To identify other places where this cause exists and correct them prior to causing an additional event.

7 The Problem Extent of Cause/Condition review too narrow. Extent of Cause/Condition review too narrow. Extent of Cause/Condition review too broad. Extent of Cause/Condition review too broad. Extent of Cause/Condition review just right but is criticized as being too broad/narrow. Extent of Cause/Condition review just right but is criticized as being too broad/narrow. Extent of Cause/Condition review assesses the wrong areas. Extent of Cause/Condition review assesses the wrong areas.

8 A Risk Based Approach to Setting Extent of Condition/Cause Assessment Scope The Solution

9 Risk Based Three Step Approach First, define other potential instances of the same/similar condition/cause(s). First, define other potential instances of the same/similar condition/cause(s). Second, determine the risk of a similar event occurring with the same/similar condition/cause(s) by assigning a probability of occurrence and level of consequence if no corrective or preventive actions are taken. Second, determine the risk of a similar event occurring with the same/similar condition/cause(s) by assigning a probability of occurrence and level of consequence if no corrective or preventive actions are taken. Third, decide if action is required. Third, decide if action is required.

10 Define Potential Same/Similar Conditions Restate the event / problem and critical setup conditions Restate the event / problem and critical setup conditions Define Same/Similar using the following criteria. Define Same/Similar using the following criteria. –Same - Same Same Program [e.g., CAP] or Process [e.g., Surveillance Scheduling] or System [Auxiliary Steam] with the Same kind of problem/error/failure or defect. Same Object – Same Defect Same Program [e.g., CAP] or Process [e.g., Surveillance Scheduling] or System [Auxiliary Steam] with the Same kind of problem/error/failure or defect. Same Object – Same Defect –Same - Similar Same Program [e.g., CAP vs. Self-Assessment] or Process [e.g., Surveillance Scheduling vs. 13-Week Scheduling] or System [Auxiliary Steam vs. Heater Drains] with a Similar kind of problem/error/failure or defect. Same Object – Similar Defect Same Program [e.g., CAP vs. Self-Assessment] or Process [e.g., Surveillance Scheduling vs. 13-Week Scheduling] or System [Auxiliary Steam vs. Heater Drains] with a Similar kind of problem/error/failure or defect. Same Object – Similar Defect –Similar - Similar Similar Program [e.g., CAP vs. Self-Assessment vs. Management Oversight] or Process [e.g., Surveillance Scheduling vs. 13-Week Scheduling vs. WM] or System [Auxiliary Steam vs. Heater Drains vs. Main Steam] with a Similar kind of problem/error/failure or defect. Similar Object – Similar Defect Similar Program [e.g., CAP vs. Self-Assessment vs. Management Oversight] or Process [e.g., Surveillance Scheduling vs. 13-Week Scheduling vs. WM] or System [Auxiliary Steam vs. Heater Drains vs. Main Steam] with a Similar kind of problem/error/failure or defect. Similar Object – Similar Defect

11 Define Potential Same/Similar Causes Restate the problem statement and identified cause. Restate the problem statement and identified cause. (Typically just the Root Cause or principal Apparent Cause) (Typically just the Root Cause or principal Apparent Cause) Define Same/Similar using the following criteria. Define Same/Similar using the following criteria. –Same - Same Same Same Same Cause – Same Impacts Same Same Same Cause – Same Impacts –Same - Similar Same Similar Same Cause – Similar Impact Same Similar Same Cause – Similar Impact –Similar - Similar SimilarSimilar Similar Cause – Similar Impact SimilarSimilar Similar Cause – Similar Impact

12 Set the Scope of the Assessment Using the defined Same/Similar conditions/ cause(s): Using the defined Same/Similar conditions/ cause(s): Determine the consequences for each defined potential condition/cause. Determine the consequences for each defined potential condition/cause. Evaluate the chance of occurrence for each defined potential condition/cause. Evaluate the chance of occurrence for each defined potential condition/cause. Identify the Risk for each defined potential condition/cause. Identify the Risk for each defined potential condition/cause. Bound the Extent of Condition evaluation based on the defined risk. (e.g. No Risk = No evaluation) Bound the Extent of Condition evaluation based on the defined risk. (e.g. No Risk = No evaluation)

13 Roofing Nails In Driveway Nails in Tires Roofer Foreign Material Mgt. Roofing Nails In Other Places Other Foreign Material Problems with the New Roof Consequence Extent of cause Same - Same Similar - Similar Same - SimilarSame - Same

14 Suggested Extent of Condition Analysis Template Set up Conditions Problem / Event Extent of Condition Potential SAME – SAME Condition RISK RISK MITIGATING ACTIONS MITIGATING ACTIONS Potential SAME – SIMILAR Condition RISK RISK MITIGATING ACTIONS MITIGATING ACTIONS POTENTIAL SIMILAR - SIMILAR CONDITION RISK RISK MITIGATING ACTIONS MITIGATING ACTIONS ©2008 The Excellence Engine

15 Suggested Extent of Cause Analysis Template Problem Statement Apparent / Root Cause Extent of Cause Potential SAME – SAME Impacts RISK MITIGATING ACTIONS Potential SAME – SIMILAR Impacts RISK MITIGATING ACTIONS POTENTIAL SIMILAR - SIMILAR IMPACTS RISK MITIGATING ACTIONS ©2008 The Excellence Engine

16 Extent of Condition/Cause Assessment Definition Matrix ©2008 The Excellence Engine

17 Extent of Condition/Cause Assessment Risk Matrix ©2008 The Excellence Engine

18 Extent of Condition/Cause Assessment Mitigating Actions Matrix

19 Extent of Condition/Cause Assessment Risk to Action Matrix ©2008 The Excellence Engine

20 Example Problem A few gallons of hydrazine contaminated with sodium hydroxide waste was pumped from the secondary hydrazine addition tank to the Auxiliary Feedwater Storage Tank, which was being used to feed the Steam Generators while the plant was in Hot Standby.

21 Set up Conditions Problem / Event Extent of Condition An empty hydrazine drum filled with sodium hydroxide waste was not labeled per station requirements. The waste drum was later mistaken for a new drum of hydrazine and its contents were added to the secondary hydrazine addition tank. A few gallons of hydrazine contaminated with sodium hydroxide waste was pumped from the secondary hydrazine addition tank to the Auxiliary Feedwater Storage Tank, which was being used to feed the S/Gs while the plant was in Hot Standby. Potential SAME – SAME Condition RISK What other systems or tanks are contaminated due to transfer from the secondary hydrazine addition tank or other direct transfers from the contaminated waste drum? MITIGATING ACTIONS Potential SAME – SIMILAR Condition RISK Are there any other mislabeled drums that could mistakenly be added to the same or other plant systems? MITIGATING ACTIONS POTENTIAL SIMILAR – SIMILAR CONDITION RISK Are there any other chemical transfer tasks that could be mistakenly performed because of a labeling error? MITIGATING ACTIONS Extent of Condition Example ©2008 The Excellence Engine

22 Extent of Condition/Cause Assessment Risk to Action Matrix

23 Set up Conditions Problem / Event Extent of Condition An empty hydrazine drum filled with sodium hydroxide waste was not labeled per station requirements. The waste drum was later mistaken for a new drum of hydrazine and its contents were added to the secondary hydrazine addition tank. A few gallons of hydrazine contaminated with sodium hydroxide waste was pumped from the secondary hydrazine addition tank to the Auxiliary Feedwater Storage Tank, which was being used to feed the S/Gs while the plant was in Hot Standby. Potential SAME – SAME Condition RISK What other systems or tanks are contaminated due to transfer from the secondary hydrazine addition tank or other direct transfers from the contaminated waste drum? Probable & Critical = HIGH RISK MITIGATING ACTIONS Evaluate & Correct Potential SAME – SIMILAR Condition RISK Are there any other mislabeled drums that could mistakenly be added to the same or other plant systems? Probable & Critical = HIGH RISK MITIGATING ACTIONS Evaluate & Correct POTENTIAL SIMILAR – SIMILAR CONDITION RISK ? Are there any other chemical transfer tasks that could be mistakenly performed because of a labeling error? Remote & Critical = MEDIUM RISK MITIGATING ACTIONS Mgmt. Discretion Extent of Condition Example ©2008 The Excellence Engine

24 Problem Statement Apparent / Root Cause Extent of Cause A few gallons of hydrazine contaminated with sodium hydroxide waste was pumped from the secondary hydrazine addition tank to the Auxiliary Feedwater Storage Tank, which was being used to feed the S/Gs while the plant was in Hot Standby. Willful violation (i.e. shortcut taken) on the part of the individual responsible for labeling the waste drum. Potential SAME – SAME Impacts RISK Has the same individual taken shortcuts when labeling other waste drums? MITIGATING ACTIONS Potential SAME – SIMILAR Impacts RISK Has the same individual taken any other safety significant shortcuts? MITIGATING ACTIONS POTENTIAL SIMILAR – SIMILAR IMPACTS RISK Are other individuals in the same work group willfully violating labeling requirements? MITIGATING ACTIONS Extent of Cause Example ©2008 The Excellence Engine

25 Extent of Condition/Cause Assessment Risk to Action Matrix

26 Problem Statement Apparent / Root Cause Extent of Cause A few gallons of hydrazine contaminated with sodium hydroxide waste was pumped from the secondary hydrazine addition tank to the Auxiliary Feedwater Storage Tank, which was being used to feed the S/Gs while the plant was in Hot Standby. Willful violation (i.e. shortcut taken) on the part of the individual responsible for labeling the waste drum. Potential SAME – SAME Impacts RISK Has the same individual taken shortcuts when labeling other waste drums? Probable & Critical = HIGH RISK MITIGATING ACTIONS Evaluate & Correct Potential SAME – SIMILAR Impacts RISK Has the same individual taken any other safety significant shortcuts? Probable & Marginal = MEDIUM RISK MITIGATING ACTIONS Evaluate & Correct POTENTIAL SIMILAR – SIMILAR IMPACTS RISK Are other individuals in the same work group willfully violating labeling requirements? Improbable & Marginal = LOW MITIGATING ACTIONS No Action Extent of Cause Example ©2008 The Excellence Engine

27 Risk Based Approach to Setting Extent of Condition/Cause Assessment Scope Value-Added Provides standardized approach for setting extent of condition/cause assessment scope. Provides standardized approach for setting extent of condition/cause assessment scope. Makes thinking visible. Makes thinking visible. Simplifies identifying appropriate corrective actions. Simplifies identifying appropriate corrective actions.

28 Questions??? Steve Davis Chet Rowe


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