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Expectations in NRC Inspection Procedures 95001 and 95002 Frederick J. Forck 4K onsulting, LLC Slide 2 USE A TOOLUSE A TOOL TO BUILD Slide 3 CAUSE ANALYSIS TOOLS USE TOOLS TO RECONSTRUCT 1. Fault tree analysis 2. Critical incident techniques 3. Events & causal factors analysis 4. Pareto Analysis 5. Change analysis 6. Barrier analysis 7. Management Oversight & Risk Tree (MORT) analysis 8. Why Staircase NRC IP 95001 Slide 4 Clearly identify problem State assumptions Data Timely collection Verification Preserve evidence Document analysis so Progression of the problem is clearly understood Any missing information or inconsistencies are identified Problem can be easily explained and/or understood by others Determine cause & effect relationships resulting in Identification of root and contributing causes that Consider the following types of issues: Hardware: design, materials, systems aging, and environmental conditions; Process: procedures, work practices, operational policies, supervision and oversight, preventive and corrective maintenance programs, and quality control methods; and Human performance: training, communications, human-system interface, and fitness for duty (which includes managing fatigue). NRC IP 95001 Slide 5 Recommend corrective actions Discover causes. Reconstruct the incident. Gather information Slide 6 Problem Prevention Symptom/Effect Analysis Cause Analysis Solution Analysis Follow Up Analysis Avatar International Inc., 1985 Problem Prevention Symptom/Effect Analysis Cause Analysis Solution Analysis Follow Up Analysis Slide 7 Derived from 1.INPO 90-004 2.NUREG/CR-5455, NRC HPIP 3.Entergy Root Cause Analysis Process Slide 8 Written Followed Include Acceptance Criteria 10CFR50, App. B Callaway Plant Lead Auditor Training Slide 9 Scope The Problem Investigate The Factors Reconstruct The Story Establish Contributing Factors Validate Underlying Factors Plan Corrective Actions Report Learnings Precise, complete, bounded problem statement Accurate, factual information Progression of the problem Issues that drove, influenced, or allowed the incident Correctable root and contributing causes Intervention(s) that improve design or change behavior Auditable, defensible record Slide 10 Derived from 1.INPO 90-004 2.NUREG/CR-5455, NRC HPIP 3.Entergy Root Cause Analysis Process Slide 11 Derived from 1.INPO 90-004 2.NUREG/CR-5455, NRC HPIP 3.Entergy Root Cause Analysis Process Techniques Deviation Statement Difference Mapping Problem Description Extent of Condition Review Methodology Selection Slide 12 Identify the GAP : What is the Problem? Method 1: Deviation Statement (noun/verb) OBJECT: What is the item that is affected? DEFECT: Identify the DEVIATION from the EXPECTED or REQUIRED STANDARD of PERFORMANCE. Example: Five gallons of oil spilled (defect) on the B Emergency Diesel Generator room floor (object). OR Use: Method 2: Expected vs. Actual Statement Compare WHAT SHOULD BE*: Requirement, Standard, Norm, or Expectation with WHAT IS: The existing, as-found condition *Sometimes the What Should Be is implied. BPI Problem Solving-Decision Making-Planning Kepner-Tregoe, The New Rational Manager Slide 13 HOW: Extent of [Adverse] Condition Evaluate ONLY from Problem Description Perspective Then evaluate various combinations Same Same Same Same Same Similar Similar Same Same Similar Similar Same etc. Document the basis for bounding with the associated risk and consequence Deviation Statement:ObjectDefectApplication Same-Same-Same An Identical Object in an Equivalent Application with a Matching Defect Same-Same-Similar An Identical Object in an Equivalent Application with a Related Defect Similar-Same-Same A Comparable Object in an Equivalent Application with a Matching Defect Lewis Allen, STP, 15th Annual HPRCT Slide 14 Human Performance Tool Peer Check Slide 15 Techniques Evidence Preservation Interviewing (What & How) Performance Analysis Worksheet Culpability Decision Tree Substitution Test/Survey SORTM questions Derived from 1.INPO 90-004 2.NUREG/CR-5455, NRC HPIP 3.Entergy Root Cause Analysis Process Slide 16 1. Determine how best to fill your information needs. (Information you have vs. Information you still need) review of logsheets, charts, drawings, etc. area walkdowns interviews Decide who to interview and what you hope to learn from them. 2. Determine which information to pursue first. Considerations: Focus on issues that appear to be key. Management Sponsor may need certain information first (e.g. restart issues). Interviewee availability may pose an impact. 3. Determine who will obtain the information. Divide responsibilities among team members If no team, you can still seek assistance from cognizant parties e.g. system engineer can research material history Adapted from Incident Investigation Training, Callaway Plant Slide 17 Close Question Open Prepare IAEA-TECDOC-1600 Slide 18 Adapted from INPO 06-003 Human Factors Prong System Factors Prong Slide 19 Phoenix Handbook, Corcoran Dana Cooley Slide 20 Techniques Fault Tree Task Analysis Critical Activity Charting Actions & Factors Chart Derived from 1.INPO 90-004 2.NUREG/CR-5455, NRC HPIP 3.Entergy Root Cause Analysis Process Slide 21 Adapted from Callaway Plant Fault Tree Analysis Training Slide 22 Step 1: Identify the Undesirable Incident Step 2: Identify 1 st Level Inputs Step 7: Investigate Remaining Inputs Step 6: Develop Remaining Inputs Step 5: Evaluate Inputs Step 3: Link Using Logic Gates Step 4: Identify 2 nd Level Inputs Step 8: Determine Contributing Factors Physical Roots Fault Tree Analysis, Clemens Callaway Plant Fault Tree Analysis Training Slide 23 Equipment Human-Machine Interface Physical Roots Human Roots Response Think (Operation) Stimulus Defense-In-Depth Latent Organizational Weaknesses Latent Roots Slide 24 Step 1: Obtain Preliminary Information Step 2: Select Task(s) of Interest Step 3: Obtain Background Information Step 4: Prepare a Task Performance Guide Step 8: Evaluate & Integrate Findings Step 7: Reenact Task Performance Step 6: Select Personnel Step 5: Get Familiar With the Guide Step 7A: Interview Personnel (Alternate Method) DOE-NE-STD-1004-92 Slide 25 Note: Not all steps of a work activity are equally important. Critical Human Actions (steps) include: Actions aimed at changing the state of facility structures, systems, or components Steps that are irrecoverable or actions that cannot be reversed Steps where the outcome of an error is intolerable for personnel or facility safety www.hanover.gov NRC NUREG/CR-5455, NRC HPIP Slide 26 A step in the activity that caused or could have made the incident less severe. It is a CHA if the step: Might cause an incid ent if the step is not done Might cause an incident if an error is made Might cause an incident if done some other way Makes incident less severe if done the right way. Could be a Critical Step related to the incident NRC NUREG/CR-5455, NRC HPIP Slide 27 1. Identify the human actions to be analyzed. (This may be all the human actions in the incident, or it may be those that are believed to have been responsible for the event's occurrence.) 2. Decide which human actions caused the incident or, if they had been performed correctly, could have prevented the incident or made the incident less severe (Critical Human Actions or CHAs). 3. Collect and record information about the CHAs. Derived from: 1.NRC NUREG/CR-5455, NRC HPIP 2.UE QIP Slide 28 Action Adapted from DOE Accident Investigation Program How did the factors originate? Incident Institutional Causes What systems allowed The Conditions to exist? Factor Process Causes Work Activity Causes Factor Contributing Factor Why did this Incident happen? Contributing Factor Contributing Factor Slide 29 Slide 30 Techniques Change Analysis Barrier Analysis Production/Protection Strategy (Defense-In-Depth) Analysis Factor Tree Derived from 1.INPO 90-004 2.NUREG/CR-5455, NRC HPIP 3.Entergy Root Cause Analysis Process Slide 31 Evaluate by asking these questions: What was different about this time from all the other times the same hardware operated without a problem or the same task or activity was carried out without error? Why now and not before? Why here and not there? Root Cause Analysis Training Course CAP-02, Palo Verde Nuclear Generating Station Ammerman, The Root Cause Analysis Handbook Slide 32 Local Factor Control Engineered Barriers Admin Controls Oversight Controls Cultural Controls Eliminate task. Prevent error. Catch error. Detect defect. Mitigate harm. Accept risk. Carelessness and overconfidence are more dangerous than deliberately accepted risk. Wilbur Wright, 1901 ( www.faa.gov) Muschara, Managing Critical Steps, HPRCT 2009 Muschara, Managing Defenses, HPRCT 2008 Slide 33 Identify each Target of hazards/threats. Identify each Hazard (adverse effect/consequence) Identify Barriers that should have controlled Hazard Prevented contact between Hazard and Target OR Mitigated consequences of Hazard/Target contact Assign a Safety Precedence Sequence # to each Barrier Assess HOW Barrier failed not provided/missing (not in place) not used/circumvented (but were in place) ineffective Determine WHY Barrier failed (Step 5) Validate analysis results Integrate this information in E & CF Chart Ammerman, The Root Cause Analysis Handbook ASQ Slide 34 1. Eliminate hazards through design selection 2. Incorporate Safety Devices 3. Provide Warning Devices 4. Use Procedures & Administrative Controls 5. Select, train, supervise, and motivate to work safely 6. Accept risks at appropriate management level MIL-STD-882D MOST EFFECTIVE LEAST EFFECTIVE LOW HUMAN INTERFACE HIGH HUMAN INTERFACE $ Slide 35 Ammerman, The Root Cause Analysis Handbook ASQ EFFECT/ CONSEQUENCES (What Happened) List one at time- sequential order not required BARRIER/CONTROL THAT SHOULD HAVE PRECLUDED THE INCIDENT list all applicable physical and administrative defenses for each consequence Slide 36 www.sandia.gov Slide 37 Slide 38 Evaluate factors (ovals) and flawed defense (broken barriers) on the Actions & Factors Chart by asking: If this factor had not existed, could this incident have occurred? If the answer is no, then youre on your way toward finding a Contributing Factor! NRC Inspection Procedure 95001 Slide 39 Techniques WHY Factor Staircase A-B-C Analysis HOW-To-WHY Matrix Cause & Effect Tree Root Cause Test Root Cause Evaluation Extent of Cause Review Common Factor Analysis Stream Analysis Derived from 1.INPO 90-004 2.NUREG/CR-5455, NRC HPIP 3.Entergy Root Cause Analysis Process Slide 40 Incident Execution Preparation Feedback Capabilities/Limitations Task Demands/Environment Outcomes Methods Resources Plan/Do/Check/Act Vision Beliefs Values Phoenix Handbook, Corcoran Root Cause, Martin, HPRCT 2006 Slide 41 Culture Slide 42 Job Performer Behavior Goals & Values Business Results INPO Human Performance Fundamentals Course Pre-Job Brief TW IN Analysis Task Preview Post-Job Review Slide 43 Desired behavior: Wear safety glasses Consequences for current or past behaviors have the strongest influence on our future behavior. Performance Management, Daniels Foundations of Behavioral Accident Prevention: Eagles Management Support Course, BST, Inc. A Safety policy Safety signs Safety procedure Safety briefing Just-in-time training B Wear safety glasses C Ears hurt Cant see clearly Uncomfortable Feel odd Slide 44 Desired behavior: Wear safety glasses A Peers dont wear Supervisors occasionally dont wear Leave at home Embarrassed to ask for spare pair B Work w/o safety glasses C Ears dont hurt Can see clearly Less bother Consequences for current or past behaviors have the strongest influence on our future behavior. Performance Management, Daniels Foundations of Behavioral Accident Prevention: Eagles Management Support Course, BST, Inc. Slide 45 Processes/ Practices Tasks/ Behaviors Goals/ Values Results/ Consequences Self-Check Peer Check 3 Part Communication Questioning Attitude StopWhen Unsure Procedure Use Procedure Adherence Place-keeping Observations Conservative Decision-Making Walk-downs Task Preview Pre-Job Brief Turnover Uneasy Attitude Written Instruction Quality Job Performer Skill, Knowledge, Proficiency Housekeeping Morale Work-Arounds & Burdens Fitness-For-Duty Tool Quality & Availability Equipment Labeling & Condition Equipment Ergonomics Walk-downs Lockout-Tagout Task qualifications Task assignment Performance Feedback Post-Job Critiques Root Cause Analysis Task assignment Performance Indicators Independent Verification Interlocks Alarms Personal Protective Equipment Redundant trains Containment Equipment Protection Systems Berms Equipment Reliability Safeguards Equipment Independent Oversight Continuous Learning Staffing Problem-Solving Accountability Benchmarking Clear Expectations Communication Practices Reviews & Approvals Management Practices Change Management Rewards & Reinforcement Handoffs Simple, Effective Processes INPO Human Performance Fundamentals Course Slide 46 Slide 47 NRC IM Chapter 0305 Areas Slide 48 Safety Culture Analysis NRC IMC 0305 Tasks/ B ehaviors Processes/ Practices Goals/ Values Do Last!!! Slide 49 Adapted from work of Dr. William R. Corcoran, NSRC Corp. Slide 50 Human Performance Tool Peer Check Slide 51 Adapted from Incident Investigation Training, Callaway Plant Step 1 Determine the Scope of the CFA Step 3 Determine Which Information to Evaluate Step 2 Gather Data Step 4 Categorize the Data Step 5 Identify Areas for Further Analyses Step 6 Analyze Areas of Interest Step 7 Develop and Validate Causal Theories Step 8 Plan Corrective Actions Step 9 Report Learnings Slide 52 Techniques Action Plan Solution Selection Tree Solution Selection Matrix Change Management Active Coaching Plan S.M.A.R.T.E.R. Effectiveness Review Contingency Plan Communication Plan Derived from 1.INPO 90-004 2.NUREG/CR-5455, NRC HPIP 3.Entergy Root Cause Analysis Process Slide 53 Plan for contingencies. Map out implementation of interventions/actions that will prevent or mitigate recurrence. Decide which alternatives will be recommended to management. Ensure corrective actions address the underlying factors [i.e. the root cause(s)]. Evaluate alternative courses of action. Develop alternative actions which address the underlying factors [i.e. the root cause(s)]. Slide 54 Slide 55 Institutionalization Plan WhoWhen Factor/Cause Being Addressed Corrective Action Step 1. Right Picture 2. Communicate3. Monitor4. FeedbackOwnerDue Date 2009 4K onsulting, LLC Slide 56 What exactly needs to be done? Focus on results. WHO does WHAT by WHEN S pecific Describes desired behaviors so an observer can compare observed behavior to a desired behavior M easurable Doable? Feasible? Realistic? Cost/Benefit? Agreed to by Stakeholder? Good business? A ttainable Logical tie between the problem and cause(s) Logical tie between cause(s) and corrective actions R elated Should be completed before next shot on goal If not, interim corrective actions are needed T ime-sensitive Degree of Dependability/Reliability Leveraged solution w. Behavior Engineering Model E ffective By Stakeholders? By Subject Matter Experts? For Unintended Consequences? R eviewed www.hanford.gov Slide 57 Institutionalization Plan S.M.A.R.T.E.R. WHOWHEN Cause/Factor Being Addressed Corrective Action Plan To Prevent Recurrence SpecificMeasurableAttainableRelatedTimelyEffectiveReviewed Owner Due Date 1. Right Picture 2. Communicate 3. Monitor 4. Feedback Slide 58 MIL-STD-882D Slide 59 Slide 60 Describe the means that will be used to verify that the actions taken had the desired outcome. M ETHOD Describe the process characteristics to be monitored or evaluated. A TTRIBUTES Establish the acceptance criteria for the attributes to be monitored or evaluated. S UCCESS Define the optimum time to perform the effectiveness review. T IMELINESS Grand Gulf Nuclear Station Slide 61 Improving Performance: How to Manage the White Space on the Organization Chart, Rummler & Brache Slide 62 Forms Report Template Grade Cards/Scoresheets Derived from 1.INPO 90-004 2.NUREG/CR-5455, NRC HPIP 3.Entergy Root Cause Analysis Process Slide 63 The investigation will have determined the following: What was expected (anticipated consequences); What has happened (real consequences); What could have happened (potential consequences); Cause-effect relations; Faulty/failed technical elements (structures, systems, or components); Inappropriate actions (human, management, organizational); Failed or missing defenses (barriers, controls). IAEA-TECDOC-1600 Slide 64 What was the Job Performer focused on? Could they do the Job if their lives depended on it? Equally qualified person likely to make same error? What were the factors that directly resulted in the nature, the magnitude, the location, and the timing of the key consequences? What happens to them when they do what they do? Mager & Pipe, Analyzing Performance Problems Corcoran, Phoenix Handbook Daniels, Performance Management Slide 65 Who identified issue (licensee? regulator? self-revealing?) under what conditions? How long did issue exist? prior opportunities to identify? Plant-specific risk consequences? individual & collective compliance concerns? Systematic method used to identify underlying factors? Evaluation detail commensurate with significance of the problem? Evaluation considered prior occurrences? operating experience? Extent of condition addressed? extent of cause? Corrective actions for each underlying factor? or adequate evaluation why no corrective actions are necessary? Corrective action priority considers risk significance & regulatory compliance? Schedule established for implementing and completing corrective actions? Quantitative/qualitative effectiveness measures of actions to prevent recurrence? Corrective actions adequately address Notice of Violation, if applicable? NRC IP 95001 NRC IP 95002 Slide 66 Later Frederick J. Forck, CPT* 4K onsulting, LLC 2320 Knight Valley Drive Jefferson City, Mo 65101-2253 Phone: 573-645-8854 Fax: 573-636-7734 Email: fforck@4konsulting.comfforck@4konsulting.com www.4konsulting.com *International Society for Performance Improvement (ISPI) Certified Performance Technologist (CPT) Slide 67 Extent of Condition Review Criteria Object (Person, Place, Thing) Application (Activity, Form, Fit, Function) Defect (Flaw, Failing, Deficiency) Deviation Statement Same-Same-Same An Identical Object in an Equivalent Application with a Matching Defect. Same-Same-Similar An Identical Object in an Equivalent Application with a Related Defect. Similar-Same-Same A Comparable Object in an Equivalent Application with a Matching Defect. Similar-Same-Similar A Comparable Object in an Equivalent Application with a Related Defect. Same-Similar-Same An Identical Object in a Corresponding Application with a Matching Defect. Similar-Similar-Same A Comparable Object in a Corresponding Application with a Matching Defect. Same-Similar-Similar An Identical Object in a Corresponding Application with a Related Defect. Slide 68 Extent of Condition Review Criteria Object (Person, Place, Thing) Application (Activity, Form, Fit, Function) Defect (Flaw, Failing, Deficiency) Deviation Statement Drivers Side Front Tire on Rental Car Parked in My DrivewayFlat Same-Same-Same An Identical Object in an Equivalent Application with a Matching Defect. 1.Other Tires on Rental Car 2.Tires on Pickup Truck 1.Parked in My Driveway 2.Parked in My Driveway 1.Flat 2.Flat Same-Same-Similar An Identical Object in an Equivalent Application with a Related Defect. 1.Other Tires on Rental Car 2.Tires on Pickup Truck 1.Parked in My Driveway 2.Parked in My Driveway 1.Low on Air 2.Low on Air Similar-Same-Same A Comparable Object in an Equivalent Application with a Matching Defect. 1.Tires on Boat Trailer 2.Tires on Bicycle 1.Parked in My Driveway 2.Parked in My Driveway 1.Flat 2.Flat Similar-Same-Similar A Comparable Object in an Equivalent Application with a Related Defect. 1.Tires on Boat Trailer 2.Tires on Bicycle 1.Parked in My Driveway 2.Parked in My Driveway 1.Low on Air 2.Low on Air Same-Similar-Same An Identical Object in a Corresponding Application with a Matching Defect. 1.Car Spare Tire 2.Tires on Sons Vehicle 3.Tires on Spouses Vehicle 1.In Trunk as a Spare 2.Parked on the Street 3.Parked in the Garage 1.Flat 2.Flat 3.Flat Similar-Similar-Same A Comparable Object in a Corresponding Application with a Matching Defect. 1.Garden Tractor1.Parked Behind My House1.Flat Same-Similar-Similar An Identical Object in a Corresponding Application with a Related Defect. 1.Car Spare Tire 2.Tires on Sons Vehicle 3.Tires on Spouses Vehicle 1.In Trunk as a Spare 2.Parked on Street 3.Parked in the Garage 1.Low on Air 2.Low on Air 3.Low on Air Slide 69 OR Adapted from Callaway Plant Fault Tree Analysis Training Slide 70 Task Analysis Technique Slide 71 Example: Task Analysis Technique Slide 72 Guidelines for Preventing Human Error in Process Safety, Center for Chemical Process Safety of the American Institute of Chemical Engineers Error Type: Wrong Information Obtained Error Description: Wrong Weight Entered Consequence: Alarm does not sound before tanker overfills Error Type: Check Omitted Error Description: Tanker not monitored while filling Consequence: Leaks not detected early Slide 73 A.B.C.D.E. Factors that Influence Performance Failed Performance Past Successful Performance Difference or Change Contributing Factor? (Yes/No) When Job Performer came in early to avoid the heat. Job Performer started day the same time as co- workers. No co-workers were available to help with the job. Yes. Worker came to work early, so was working alone, carrying tools. Supervision Employee did not meet with supervisor the morning of the accident. Employee met with supervisor to discuss the days work activities. Work activities were not discussed. Yes. Because worker came to work early, job hazards were not discussed. www.sandia.gov Slide 74 Slide 75 Slide 76