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 Laboratory
Co-Authors:
Roy Lebel, Brookhaven National Laboratory
Robert McCallum, McCallum-Turner, Inc.
Presenter:
Robert Crowley, PE, McCallum-Turner, Inc.

2. Brookhaven National Laboratory
Issues Management Process Improvement Initiative
BNL 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 strategy
Several Key improvements were implemented including:
Defining “lower level issues” for line management to evaluate
Training on the conduct of “Critiques” to improve fact finding
Training for staff and managers on Causal Analysis Methods
BNL recognized the need to institutionalize an Issues management process:
Move beyond being in a reactive mode responding to the problems of the day
Become proactive to learn from the causes of lower level events
Foster 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 analysis
The 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) Events
ORPS/ACCIDENTS/PAAA
Incidents
Conditions
Spills
SCBNL
Radiological Awareness Reports
Brookhaven’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.
Nonconformances
Audits
Tier 1
Assessments

4. Insert the flowchart here?

5. Causal Analysis Methods
There are a myriad of credible causal analysis methods ranging from simple to complex
DOE 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 System
There 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.
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6. Brookhaven Accident\Issues Prevention Causal Analysis Strategy
Focus of the Strategy:
Line organizations would analyze the causes of lower level less complex events
Analytical methods used will be recognized by both Brookhaven National Laboratory and the Department of Energy
Develop case studies tailored to both research and support organizations
Formally train line organizations on “simple” analytical methods that can be readily used after limited training
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7. Brookhaven Accident\Issues Prevention Causal Analysis Strategy (Phase I)
The first training session was conducted in August 2006 at Brookhaven National Laboratory
Focused on “Barrier Analysis” and introduction to the “Five Whys” analytical method
Simple analytical methods used effectively by BNL and DOE for event and accident investigations
Short training sessions (4 hours) were conducted with case studies developed for ERWM and research organizations based on DOE incidents
60 Brookhaven National Laboratory managers and staff were trained and provided a case study for future reference
BARRIER ANALYSIS: The analytical concepts were introduced by William Haddon Jr., M.D. In Human Factors Journal in 1973
In 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 investigations
FIVE WHYS: It was made popular as part of the Toyota Production System in the 1970s
A straightforward methodology that is effective in understanding the cause of a problem
It can promote a common and shared understanding of the causes and conditions that created the problem
Recognized 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 Laboratory
Focused 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 investigations
Short training sessions (6 hours) were conducted with a case study based on a DOE accident in a research laboratory
Approximately 40 Brookhaven National Laboratory managers and staff were trained and provided a case study for future reference
ECF ANALYSIS: An analytical method used as one of core analytical technique for DOE accident investigations and documented in BNL requirements
FIVE WHYS: Toyota Production System in the 1970s

9. “ HPI Flavor ” Using Anatomy of Event
Error Precursors
Vision, Beliefs, &
Values
Latent Organizational Weaknesses
Mission
Goals
Policies
Processes
Programs
Flawed Defenses
Initiating Action
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10. “HPI Flavor” Anatomy of Event – Error Precursors
Limited short-term memory
Personality conflicts
Mental shortcuts (biases)
Lack of alternative indication
Inaccurate risk perception (Pollyanna)
Unexpected equipment conditions
Mindset (“tuned” to see)
Hidden system response
Complacency / Overconfidence
Workarounds / OOS instruments
Assumptions (inaccurate mental picture)
Confusing displays or controls
Habit patterns
Changes / Departures from routine
Stress (limits attention)
Distractions / Interruptions
Human Nature
Work Environment
Illness / Fatigue
Lack of or unclear standards
“Hazardous” attitude for critical task
Unclear goals, roles, & responsibilities
Indistinct problem-solving skills
Interpretation requirements
Lack of proficiency / Inexperience
Irrecoverable acts
Imprecise communication habits
Repetitive actions, monotonous
New technique not used before
Simultaneous, multiple tasks
Lack of knowledge (mental model)
High Workload (memory requirements)
Unfamiliarity w/ task / First time
Time pressure (in a hurry)
Individual Capabilities
Task Demands
The 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 task
Individual Capabilities- Unique mental, physical and emotional characteristics of a person that fail to match the demands of a specific task
Work environment- General influences of the workplace, organizational and cultural conditions that affect individual behavior
Human 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.
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11. Visual Depiction of Causal Factor Analysis Using “Five Whys”
The Five Whys
Visual Depiction of Causal Factor Analysis Using “Five Whys”
Why 1
Condition 3
Causal
Factor 3
Why 1
Why 2
Why 1
Why 2
Condition 5
Causal
Factor 5
Condition 2
Causal
Factor 2
Why 1
Why 2
Why 1
Why 2
Condition 4
Causal
Factor 4
Condition 1
Causal
Factor 1
Schematically 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 2
Event 1
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12. Visual Depiction of Identification of Root Cause Using Five Whys
The Five Whys
Visual Depiction of Identification of Root Cause Using Five Whys
Collect CFs
Identify Common CFs
Causal
Factor 1
Causal
Factor 1,2
Apply Five Whys
Technique
Causal
Factor 2
Root
Cause
Causal
Factor 3
Causal
Factor 3
The method can be used to identify root causes
Causal
Factor 4
Causal
Factor 4,5
Causal
Factor 5
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13. The Five Whys
What are the organizational conditions that are more conducive for the Five Whys to be successful?
A “culture” where problems are surfaced quickly
A “culture” where identification of needed actions are viewed as an opportunity to move to an ideal or improved state of performance
A “culture” where the focus is on improving processes and systems
The above are examples of HPI principles and the “learning culture” Brookhaven National Laboratory is institutionalizing
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14. Conclusion
Brookhaven 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 comprehensive
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