Dorian Conger General Manager Conger-Elsea, Inc Riveredge Parkway, Suite 740 Atlanta, GA phone fax 2011 Human Performance, Root Cause, and Trending Conference Del Ray Beach, FL Copyright 2014 Conger-Elsea, Inc. 1

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 Poor decision making – not risk informed, using non-conservative assumptions;  Inadequate evaluation of management and organizational contributors;  Narrow and shallow extent of condition evaluations and resulting actions;  Narrow and shallow extent of cause evaluations and resulting actions;  Inadequate consideration of safety culture during cause evaluations;  Less than adequate corrective actions to fix the real problems;  Inadequate identification of poor use of operating experience as a cause; and  Inadequate use of self and independent assessments to make improvements. Copyright 2014 Conger-Elsea, Inc. 3

 Behind the regulatory eight-ball…  Out of step with current regulatory expectations…  Bringing a “knife to a gun fight”… Copyright 2014 Conger-Elsea, Inc. 4

Poor decision making – not risk informed, using non- conservative assumptions.  Scrap the old way of thinking and become a risk informed culture –risk Informed; performance based.  Understand and apply the full meaning of “nuclear safety” – CDF, Radiation Safety, Environmental Safety, Industrial Safety, Security, Emergency Preparations, and Safety Culture. Copyright 2014 Conger-Elsea, Inc. 5

Inadequate evaluation of management and organizational contributors.  Need to tackle the tough issues before they gain regulatory attention.  Can’t be afraid of comprehensive and even complicated analyses; good root cause work is BOTH. Copyright 2014 Conger-Elsea, Inc. 6

Narrow and shallow extent of condition evaluations and resulting actions.  Stop trying to artificially reduce the scope!  Force the big picture approach; extent of condition is the extent to which the actual condition exists or could exist in other plan processes, equipment, or human performance.  Adopt a three-step process – widest possible net; reduce scope based only on “nuclear safety”; and sample, if the universe is too big. Copyright 2014 Conger-Elsea, Inc. 7

Narrow and shallow extent of cause evaluations and resulting actions.  Stop trying to reduce the scope artificially.  Don’t be afraid of far reaching extents; extent of cause is the extent to which the root and contributing causes impact or could impact other plan processes, equipment, or human performance.  Adopt the same type three-step process – widest possible net; reduce scope based only on “nuclear safety”; and sample, if the universe is too big. Copyright 2014 Conger-Elsea, Inc. 8

Inadequate consideration of safety culture during cause evaluations.  Treat the safety culture evaluation as a part of the ongoing analysis and STOP making it an after-thought.  Use the language out of IMC 0310 and stop waiting for the NRC to accept NEI and INPO positions. Copyright 2014 Conger-Elsea, Inc. 9

Less than adequate corrective actions to fix the real problems.  Stop using low reliability solutions (procedures and training) for high risk problems. They just don’t work. Copyright 2014 Conger-Elsea, Inc. 10

Inadequate identification of poor use of operating experience as a cause.  Let’s go back to what it was originally supposed to help us do – identify and act before the problem strikes us; even when it may be uncomfortable or costly (in the short term) to do.  When it wasn’t used to full advantage; it must be called out as a cause and the process improved. Copyright 2014 Conger-Elsea, Inc. 11

Inadequate use of self and independent assessments to make improvements.  It’s a mirror; not a window.  If you don’t like what you see in the report; make significant changes to make it go away. Copyright 2014 Conger-Elsea, Inc. 12

Increased regulatory attention; more team inspections.  Increased emphasis on risk; particularly on beyond design basis events.  Increased expectations for the implementation of all parts of problem identification and resolution – corrective action program, operating experience, and self and independent assessments. Copyright 2014 Conger-Elsea, Inc. 13

 Not easy tasks.  The ball will be in your court for much of this!! You can have a direct and long lasting impact on your plan and the industry.  When someone around you says, “We’re not trying to solve world hunger?” Copyright 2014 Conger-Elsea, Inc. 14

IF NOT NOW; WHEN? Copyright 2014 Conger-Elsea, Inc. 15