1 H.O.P.I. Consulting

2 Common Cause Analysis (CCA) Is not Root Cause Analysis Does not prevent salient events Is an ongoing long term process Is aimed at correcting the cause(s) of dysfunctional behaviors H.O.P.I. Consulting

3 Successful CCA requires 3 things Process Mapping Behavior Categorization Trending H.O.P.I. Consulting

4 Process Mapping What are the critical steps of the task? H.O.P.I. Consulting These will eventually become your trend buckets

5 Process Mapping What Barriers Prevent Error Propagation? H.O.P.I. Consulting Barriers are error detection strategies of self; of others; of process.

6 Behavior Categorization (Why people don’t do what is expected.) Doesn’t understand “what” the behavior does. Doesn’t understand “how” to use the behavior. Doesn’t understand “when” to use the behavior. Cannot demonstrate “effective” use of the behavior. Does not understand “expectation” for use of the behavior. Does not understand “benefit” of using the behavior. (WIFM) “Consequences” of not using the behavior < consequences of using the behavior. (cultural drivers) H.O.P.I. Consulting

7 Other Considerations Process Missing critical step Sequencing problem Branching problem Over specification Under specification Design Limitations Behavior No behavior specified Wrong behavior specified Relying on behavior when risk is too great (SPS) H.O.P.I. Consulting

8 Example: Undesired Equipment Actuation Relay technician to check Synch PT fuses Operator to start Bravo pump I&C tech to replace capacitors on PPS board Electrician to lift red lead on TB4 Step 1 Go to correct switchgear Step 1 Go to correct pump skid Step 1 Go to correct control cabinet Step 1 Go to correct motor control center Step 2 Unlatch and pull PT drawer Step 2 Actuate Bravo hand switch Step 2 Place PPS channel in bypass Step 2 unbolt and lift red lead on TB4 Step 3 Pull PPS board

9 H.O.P.I. Consulting What they said in the interviews. Relay Tech, “I knew I was in the right switchgear. When the procedure said to pull the lower fuses, I thought it meant the lower PT drawer. The lower drawer houses the undervoltage PT.” Operator, “They sent me down to start the pump. I verified I was on the right pump skid. I couldn’t see the pump. How was I to know it was already running?” I&C Tech, “What Engineer would layout the channel bypasses so they were not opposite their corresponding channel? No wonder I pulled the Delta board after putting the Bravo channel in bypass!” Electrician, “The procedure said to lift the red wire. I thought it didn’t matter that there were TWO red wires on the same terminal. I guess interrupting power to all of the SOVs really caused OPS some heartache. Do you think they’ll give me a day off?”

10 H.O.P.I. Consulting What do These Events Tell Us? Different Events Different Departments Different People All using STAR Good Candidates for CCA

11 H.O.P.I. Consulting Analyze the Steps Pull PT Drawer Actuate Handswitch Pull PC Board Lift Wires Irreversible Action When you use STAR to prevent events at irreversible steps it often stands for Shoot, That Ain’t Right

12 H.O.P.I. Consulting Don’t Miss Other Considerations Bottom Fuses or Bottom PT Drawer? No Indication of Pump Status? Confusing PPS Layout? Two Wires on One Terminal? Sequence Error, Go to XX PT Drawer, Pull Bottom Fuses Missing Critical Step, Check Pump Status Under specification, Include PPS Layout Design Limitation, Better Place to Lift Lead?

13 H.O.P.I. Consulting Fix All the Causes Assign Actions to fix the “Other Considerations. ” Create Defense in Depth Assign Actions to Fix “Common Cause.” Reduce Error Propagation by Using Detection Strategy that is Effective for Irreversible Steps. M D + E R = Ø E Managing Defenses and Reducing Error Propagation will get you to Zero Significant Events