1. Presented by Dorian S. Conger Conger-Elsea, Inc. 2000 Riveredge Parkway, Suite 740 Atlanta, GA 30328 800-875-8709 phone 770-926-8305 fax dorian.conger@conger-elsea.com 2005 Human Performance, Root Cause, and Trending Conference Syracuse, NY 1 Copyright 2014 Conger-Elsea, Inc.

2. Background - May 2005 Consultants Meeting at IAEA in Vienna 1.Root Cause Analysis Experts 2.Various Disciplines 3.Various Countries Copyright 2014 Conger-Elsea, Inc. 2

3. The purpose of the working group was to develop a root cause analysis methodology that would combine the best aspects from the various systems currently in use in the nuclear power industry worldwide and to prepare a draft guidance document and manual. Copyright 2014 Conger-Elsea, Inc. 3

4. 1. Management Oversight and Risk Tree Process (MORT) developed in the early 1970's for the U.S. government and enhanced for application since 1982 by Conger & Elsea, Inc. 2.Human Performance Enhancement System (HPES) was originally based on the techniques and tools from the U.S. National Transportation Safety Board and the MORT process. This process was enhanced by the Institute of Nuclear Power Operations (INPO) in the early 1980's. 3.Assessment of Safety Significant Events Team process (ASSET) was developed by the International Atomic Energy Agency (IAEA) for use in evaluating incidents by member states. Copyright 2014 Conger-Elsea, Inc. 4

5. 1.Each identifies what could be considered "direct causes" and through further formal analysis determines "root causes". 2.Each recognizes the importance of understanding the sequence of events. 3.Each includes the search for specific working level causes and the determination of related management system causes. This new IAEA process represents a merger of these three traditions. Copyright 2014 Conger-Elsea, Inc. 5

6.  Method driven  Multiple causality  Thoroughness  Fairness  Efficiency  Safety Precedence Sequence - the Safety Precedence Sequence (SPS) is a very critical element of the philosophy Copyright 2014 Conger-Elsea, Inc. 6

7. The SPS establishes a hierarchy of the effectiveness of various approaches to preventing incidents. Six basic methods for preventing incidents are ranked from most effective to least effective as follows: 1.Design for minimum hazard 2.Install/use safety devices (automatic engineered or physical barriers) 3.Safety cautions and warnings (visual and auditory) 4.Procedures (written and verbal instructions) 5.Personnel actions (from directed reading, training, knowledge or awareness) 6.Notify management of risk and accept the situation without corrective action (documented with a signature of acceptance) Copyright 2014 Conger-Elsea, Inc. 7

8. 1.Event categories 2.Assigning the investigation 3.Procedures for conducting investigations 4.Define post investigation responsibilities 5.Training Copyright 2014 Conger-Elsea, Inc. 8

9. 9 RISK CAT. ANALYST(S)RELATIONSHIP TO SITUATION REVIEW ANALYTICAL TECHNIQUES ANALYSTS AND TEAM LEADERS TRAINING HI 1 Team Inter- discipline Indep. ECF and full TREE Event Investigation Workshop 5 days Mod Hi 2 Team Inter- discipline MixedIndep.ECF and full TREE Event Investigation Workshop 5 days Mod Lo 3 IndividualLineIndep.ECF and at least 2 tiers of TREE Root Cause Workshop 2-3 days Lo 4 IndividualLineIndep.ECF and at least 1 tier of TREE Root Cause Workshop 1-2 days

10. RCAP discards the concept of "apparent cause"! This concept has led to trending programs being cluttered with invalid data based on guess work and not on formal analysis. Two levels of causation determined by this process.  The first are called the "specific working level" causes, which have generally been described in previous work as the technical, direct, or contributing causes of events.  The second set of causes is called the "management system" causes, which have generally been described in previous work as root causes. Copyright 2014 Conger-Elsea, Inc. 10

11. The investigator will first identify the specific field level causes. Then for each of those, the investigator will be expected to identify a corresponding management system cause or causes. The final step is an Extent of Condition and Extent of Cause Evaluation. Copyright 2014 Conger-Elsea, Inc. 11

12. Two principle required tools for use with the proposed RCAP. These tools merge the two primary methods of analysis that taken together form the most comprehensive event investigation process available. Most significantly, the same two tools can be appropriately used to analyze events of any category from 1 to 4. 1. Events and Causal Factors (ECF) charting from the original MORT process as enhanced by the HPES System. 2.The Specific Working Level Factors and Management System Factors Tree Analysis (TREE) has been adapted with permission from the most recent MORT Analysis Chart and User's Manual (Conger & Elsea, Inc. - Copyright 2005). Copyright 2014 Conger-Elsea, Inc. 12

13. Specific Working Level causes by examining the following areas: S1 - Target (what was damaged or harmed) S2 - Hazard (what did the damage or harm) S3 - Barriers (physical and administrative) S4 - Emergency Response (after an event) C1 - Technical Information Systems (for working level personnel) C2 - Operability (Functional) C3 - Maintenance (plan, procedures and execution) C4 - Inspection (plan, procedures and execution) C5 - Supervision (preparation, detecting and correcting field problems) C6 - Higher Supervision Services and Support (support to working level personnel) C7 - Human Performance Error (task assignment, procedures, selection, training, motivation, fitness for duty, etc.) C8 - Task Procedures (clear, concise, complete, etc.) Copyright 2014 Conger-Elsea, Inc. 13

14. Management System causes by examining the following areas: M1 - Policy (written, up-to-date, consistent, etc.) M2 - Implementation (priorities, direction, responsibility, accountability, delays, budgets, etc.) R1 - Goals (performance and safety) R2 - Technical Information (for engineers, managers, etc.) R3 - Program Review (all types of programs) H1 - Concepts and Requirements (Specifications for planning, engineering, design or safety Analysis) H2 - Design Development Plan (Implementing process for the specifications) H3 - Human Factors (task allocation, predicting errors) H4 - General Design Process (initial, standardized, changes, etc.) Copyright 2014 Conger-Elsea, Inc. 14

15. Event InvestigationCategory 1Category 2Category 3Category 4 Tier 1 ECF + Branches S1, S2, S3, S4 Top Qs from Branches C1 to C8 Tier 2 + All Qs for any affected “C” Branches (C1-C8) + Top Qs only for Branches “M,” “R,” “H” Tier 3 + All Qs in affected Branches “M,” “R,” “H” Copyright 2014 Conger-Elsea, Inc. 15 NOTE: For each finding in S and C investigators need to determine a corresponding failure in Branches M, R or H.

16.  NRC rewriting NUREG 1303 - Incident Investigation Manual  NRC rewriting Management Directive 8.3 - NRC Incident Investigation Program Copyright 2014 Conger-Elsea, Inc. 16