# Presentation: 156352

## 		Categorizers (CAT) Team Workshop 		#2008-01

**April 23, 2008**
**2:00 - 4:00**
**Brookhaven Center, South Room**
**Ed Sierra**
**ORPS Program Manager**
** ****Quality Management Office**

**Workshop Goals**
**A quote from one of the greats of Science**
**DOE Recurring Type ORPS Reports (2003 – 2007): A Narrative Study**
**ORPS Trending**
**Programmatic Bins**
**Proposed Revisions to ORPS Directives**
**Meeting Evaluation and Wrap-up**
**      **

## CAT Team Workshop

_**Workshop Goals:**_
** ****To ****EVALUATE**** ****and ****CONTINUOUSLY  IMPROVE**** ****the BNL Occurrence Reporting Program.**
** ****To ****MAINTAIN**** a baseline categorization process such that reportability decisions are both ****VALID**** ****and ****CONSISTENT****.**
** ****To ****REVIEW/ EVALUATE**** ****data to determine if repeat events should be identified as **_**potentially**_** ****RECURRING**** ****occurrences.  **
** ****To ****PROMPT**** (via accurate categorization) ****DEEP**** and ****LASTING**** value-added ****CHANGE,**** which results in new ways of ****THINKING**** and ****ACTING****. **
**   **

-   **CAT**

## “And though your good opinion has, as it were, honoured me with a rank similar to that of a general, I shall be always happy to act as a private soldier in the ranks of science.”

**Sir Humphry Davy ****    (*****1778 - 1829***** ) **

## DOE Recurring Type ORPS Reports(2003 – 2007): A Narrative Study 

**Energy Facility Contractors Group****- ORPS Task Group****- Feedback & Improvement Subgroup ****Oak Ridge National Laboratory****March 25 & 27, 2008***** ***

**Quality Management     ** ** ffice **
**E. Anthony Sierra, BNL**
**(631) 344-4080**

## 

Are there any positive or negative trends?

What initiates an “R” Report?

What are the “R” report topics? 

Is the ISM field of any value?

What causal analysis methods are used?

What is the freq of Human Performance cause coding & couplets?

Are any novel corrective actions being implemented?

**Are there any positive or negative trends?**
**What initiates an “R” Report?**
**What are the “R” report topics? **
**Is the ISM field of any value?**
**What causal analysis methods are used?**
**What is the freq of Human Performance cause coding & couplets?**
**Are any novel corrective actions being implemented?**

**Seven Research Questions**

## Study Big Picture

**Type of ORPS Reports:  Recurring **_***Final***_** Reports**
**Time Period:  2003 - 2007**
**Number of Reports:  73**
**Number of Sites Reporting:  24**
**Total Number of Causes Cited:  411**
**Total Number of Corrective Actions:  671   **

##         Is “R” ORPS Reporting on the Decline? 

##                 “R” Report Contributors

##                When Do We Declare "R"     			 Reports?  

##             Distribution by Reporting Criteria 

##               Distribution by Activity Category

##              Top Five Repeat “R” Reports              by Topical Area

**Hazardous Energy Control **
**Radiation/Contamination Control**
**Heavy Equipment/Material Handling**
**Technical Safety Requirements **
**Work Controls**

##       Integrated Safety ManagementCoding:  A Comparison

##       What “Causal” Analysis Methods are Used   	and Are We Getting to the Root?

##        Are A3 Cause Codes & Couplets Underreported?

**411 Causes Cited**
**17% are A3 Causes**
** **
**Only 48% of the Final “R” Reports cited an A3 Cause Code**
**Only 49% of those Reports cited a Cause Code Couplet**

##             Are We Really Getting to the Root 	     Cause(s)?

**“****Root causes reside in the values and beliefs of an organization. **
**Until the analysis moves to this level, an organization has not begun to grapple with root causes.”**
**“****An appropriate rule of thumb for knowing how deep to dig in conducting a root cause analysis is to dig until you reach the point of admitting something really embarrassing about the organization.”**
**	****	****	****	****	****	****	**
**Dew, John R., “The Seven Deadly Sins of Quality Management,” *****Quality Progress*****, September 2003****  **

##                     21st Century Cause Codes:          It’s Time to Dig Deeper 

**Placing budgetary considerations ahead of quality **
**Placing schedule considerations ahead of quality**
**Placing political considerations ahead of quality **
**Being arrogant**
**Lacking fundamental knowledge, research or education**
**Pervasively believing in entitlement**
**Practicing autocratic behaviors, resulting in “endullment”**
**Dew, John R., “The Seven Deadly Sins of Quality Management,” *****Quality Progress*****, September 2003****  **

##                 “R” Report Action Plans that     			Truly Result in Change are LTA

**The Majority of Actions are Procedure and/or Communication Based**
**Why we need to implement Physical (Mistake Proofing) Corrective Actions:**
**Best at minimizing human error **
**No learning curve**
**Difficult to bypass or work around**
**Only defensible choice as single barrier**

##        “R” Report Corrective Action Plans

**Only 29% of Reports Included an Action to Check Action Effectiveness**
**Only 12% of Reports Included an Action to Issue a Lessons Learned Communication to the Complex**
**9 Reports had 1 Action**

## Proposed Path Forward

**Improve Criteria for “R” Reporting**
**Effectiveness Corrective Action – Prewritten (Mistake Proof)**
**Complex Lessons Learned Corrective Action – Prewritten (Mistake Proof)**
**Drop Down Menu for Root Cause Analysis Method (Mistake Proof)**
**Training on Performance Modes**
**Inclusion of Action Plan – (Mistake Proof)**
**Drop Down Menu of 21****st**** Century ****Cause Codes ****(Mistake Proof)**
**The Elephant in the Room; do “R” Reports Minimize the Risk of Recurrence? **

## ORPS Report WritingIt is Hard Work!

**“****Even when the facts relevant to a problem still exist, finding them amid the flotsam of confounding information and assembling them into a cogent argument can be forbiddingly tough.”**
** ****	****	****	****	****	****- John Rennie**
**	****	****	****  ****	****	*****editor in chief***
**	****	****	****  ****	****	****Scientific American, March 2008****	**

**  **

## BNL ORPS by Calendar Year Report Submitted

**As of 3/31**

## Event Categorizer Electronic Entries

## 4th Qtr FY 07

## 4th Qtr FY 07

## ORPS Corrective Action StatusFY 2008 (End of Month)

## CAT Electronic Entries

**12/07 – RK, Hand Injury from Tripping on Rail Track**
**12/07 – RK, Employee walked into bucket and hurt knee**
**12/07 – RK, CFN Redundant Sprinkler Feed Valve Found Shut**
**12/10 – RK, ~ 1 Gallon Hydraulic oil spill from garbage truck**
**12/12 – KK, < 1 Gallon oil spill in the parking lot of B-930**
**12/12 – KK, MRI Occupational Exposure Exceed Agreed Upon Exemption Limits, SC3**
**12/14 – KK, < 1 Gallon Transmission Fluid Spill to Pavement**
**12/14 – KK, Failed Interlock on Shepherd 89 Irradiator**
**12/20 – SM, Heating Coil Pinhole Leak in Bldg 750**
**12/20 – SM, "Article 12" Tanks in Bldg 750 w/Labeling Issues**
**12/24 – MD, Employee Falls to Ground While Exiting Delivery Boxtruck**
**01/08 – MZ, Grad student receives cryogenic helium 2nd degree burn on hand**
**01/08 – MZ, Three 9011 railcars arrive in Utah - 2 with damaged tarps, 1 with tarp missing**
**01/09 – MZ, Tenderness in wrist and thumb**
**01/15 – AL, Off-site Transport of Radioactive Material Less Than Adequate,** **SC3**
**01/16 – AL, BGRR one line drawings were not kept up to date**
**01/16 – AL, Employee transported to hospital due to illness**
**01/18 – AL, Electrician strains lower back while working on eight foot ladder**
**01/18 – AL, plumber lacerates the back of his hand on condenser coil fins**
**01/25 – AP, Minor wrist sprain from packaging activities**
**01/25 – AP, Card reader latch mechanism failure****                   **

## CAT Electronic Entries

**01/28 – RK, 110V/208V Breakers Inadvertently Open at B50 While Performing Work**
**01/28 – RK, U-Conn heat transfer fluid spill from B902 helium compressor**
**01/29 – RK, Slip on BGRR stair - No injury**
**01/30 – RK, Malathion Spill on 1st floor of B911**
**01/31 – RK, Contractor strains hand while using drill**
**02/01 – RK, Fall from truck injures neck**
**02/04 – RK, Minor antifreeze spill in the apartment area**
**02/05 – SM, Discovery of Power MOSFET Counterfeit IXYS Components, SC4**
**02/07 – SM, Steam Leak to Condensate Return Line in B902**
**02/07 – SM, Power Supply Capacitor fails at NSLS generating smoke**
**02/08 – SM, Waste Mgmt NCR on Improperly Filled out Rad Waste Control Forms, SC4**
**02/11 – KK, Groundwater Samples Sent to Wrong Analytical Laboratory**
**02/12 – KK, B-490 Diesel Generator Fails During Routine Testing**
**02/13 – KK, Slight Injury to Knuckles**
**02/13 – KK, Employee Walks Into Glass Door Resulting in Cut Above Eye**
**02/19 – KK, Contractor Fractures Finger While Using Drill, SCBNL**
**02/25 – KS, Configuration Control Deficiencies Identified at HFBR**
**03/04 – MZ, Slugs shipped to BNL from ORNL in 1950-51 may be fuel**
**03/05 – MZ, Contractor injures wrist**

## CAT Electronic Entries

**03/05 – MZ, Domestic water leak at HFBR AC cooling towers**
**03/06 – MZ, Loss of SBMS Web Service**
**03/06 – MZ, Small Fire in Outdoor Waste Receptacle at B-400, SCBNL**
**03/07 – MZ, Employee Sustains Laceration Removing Placard**
**03/07 – MZ, Inst shipped offsite w/ Ni63 source w/o going through I & SM**
**03/10 – ES, Raccoon Taken From BNL Expires**
**03/12 – AL, Inspection of Rigging Equipment Reveals Suspect/counterfeit items, SC4**
**03/24 – RK, Minor cut to forehead when contact made with plastic cable tray**
**03/28 – RK, Shoulder injured while closing file cabinet**
**04/03 – SM, Minor Injuries to FF/EMTs during High Risk training**
**04/03 – SM, Trane Solution Removal Procedure Clarification at HFBR**
**04/03 – SM, HEMO Lacerates Finger while repairing forklift cylinder**
**04/04 – SM, WM Tech Receives Tingle Sensation from Contact with Electric Conduit, SC2**
**04/04 – SM, Incomplete Understanding of Details of Lessons Learned Procedure**
**04/07 – SM, Painter Suffers Twinge in Shoulder**
**04/08 – KK, Custodian Injures Head**
**04/16 – MD, Fluorine-18 contamination on wrist and personal clothing, SC4**
**04/18 – SM, Forklift Driver Bumps Head**
**04/18 – ES, Electrician Incurs Neck Muscle Strain**
**04/18 – ES, Carpenters Finger Contacts Point of Nail**
**04/22 – KS, HFBR Instrument Deficiencies**

##                   Programmatic Bins

**Personnel Contamination**
**Medical Department**
**NSLS**
**Physics**
**CA-D**
**BGRR Project**
**Plant Engineering **
**Utilities Struck**
**Haz Material Transportation**
**Electrical Shock Hazards**
**Material Handling Issues**
**Waste Management **
**Chemistry**
**Environmental Restoration**
**Railroad Tracks**
**New Construction**
**Noise  **
**  **

**Site Fire Alarm System **
**Butt Fires **
**CFN **

## Programmatic Review

_**Personnel Contamination – 2006**_
**02/23 – Personnel Cont at Building 901**
**03/22 – Cont Detected on Employee's Shoes at PET**
**03/28 – Cont of two workers at B-801 during removal of BLIP target filter**
_**Personnel Contamination – 2007**_
**04/26 – F-18 finger contamination at PET**
**09/28 – Researcher Contamination at PET, B-901 (Nitrogen -13), (SC4)**
_**Personnel Contamination – 2008**_
**04/16 – Fluorine-18 contamination on wrist an personal clothing, (SC4)**
_**  **_
**	****	**

## Programmatic Review

_**Medical department, 2006**_
**03/07 – Rad Cont Outside a Controlled Area at B-490, (SC3)**
**03/10 – Survey Meter/Frisker Taken Outside Controlled Area @ B490**
**03/13 – PB, Shock from terminal in legacy installed light timer, (SC4)**
**03/28 – Cont of two workers @ B801, during removal of BLIP target filter**
**05/19 – Cont found outside a posted area @ B490**
**07/31 – Trit cont on unposted benchtop in a posted RMA at B490**
**08/24 – Painter's spackling knife contacts aband live electrical wiring @ 490, (SC3)**
**11/16 – KK, Contamination at PET Facility, (SC3)**
**10/31 – BLIP cooling water leak detection system did not function during testing**

## Programmatic Review

_**Medical department, 2007**_
**04/26 – F-18 finger contamination at PET**
**05/16 – Medical Student Passes Out after seeing blood at B-490**
**05/16 – Employee lacerates arm while cleaning a microtome at B-490**
**05/22 – First-degree chemical burn due to small hole in glove @ B-490**
**07/05 – Building 801 D Tank Leak, ~5mL**
**09/12 – Exposed Wiring Electrical Hazard in Building 490, (SC3)**
**09/24 – Empty sharps container found in animal bedding during disposal**
**09/28 – Researcher Contamination at PET, B-901(Nitrogen -13), (SC4)**
_**Medical department, 2008**_
**12/12 – MRI Occupational Exposure Exceed Agreed Upon Exemption Limits, (SC3)**
**02/08 – Waste Mgmt NCR on Improperly Filled out Rad Waste Control Forms, (SC4)**
**04/16 – Fluorine-18 contamination on wrist an personal clothing, (SC4)**

## Programmatic Review

_**NSLS, 2006**_
**02/21 – X17C Laser Procedure Violation (Door left open while laser in operation)**
**05/08 – Improper work sequence during lead shielding removal at beam line**
**06/09 – XSXD Power Supply Shut-off Failure**
**07/17 – Chemical Spill in Wet Chemistry Laboratory, (SC3)**
**08/21 – AL/ES, Accidental cutting of energized power tool line cord, (SC3)**
**11/16 – Spent Fluorescent Bulbs Found Outside Waste Storage Area**
** **
_**NSLS, 2007**_
**05/03 – Minor fire in ventilation system, (SCBNL)**
**06/12 – Aluminum plate pinches beamline User finger tips**
**07/03 – Employee Sustains Injury to Ankle Tripping on Stairs**
_**NSLS, 2008**_
**01/08 – Grad student receives cryogenic helium 2nd degree burn on hand**
**  **
** **

## Programmatic Review

_**Physics, 2006**_
**07/07 – Employee fractured metatarsal after tripping over rug/mat**
**08/09 – Stop Work Order issued due to antennae at edge of B510 roof**
_**Physics, 2007**_
**06/11 – Improper Status provided by Laser/Shutter Indicators at ATF, (SC3)**
**10/01 – Trip/fall when walking in grass results in ankle fracture, (SC3)**

## Programmatic Review

_**CA-D, 2006**_
**03/06 – Discovery of Radiation Monitor in Interlock-Bypass-Mode, (SC3)**
**03/29 – Lack of admin approval (non-safety related) for NASA NSRL experiment **
**04/14 – 400 Amp Electrical Switch Failure, (OE, SC2, SC4)**
**05/04 – CA-D Chipmunks read high and alarms at a lower dose rate than intended**
**06/02 – < 6 oz of tritiated magnet water splashed onto the workers pant-leg @ RHIC**
**06/09 – 3 gals of heat transfer fluid (oil) spilled on Storage Yard pavement by B-924**
**07/20 – Pulling cable along floor results in back strain**
**08/14 – ~ 200 gal spill from 902 Cooling Towers to parking lot and grass**
**08/21 – Leg laceration while descending ladder at B1005**
**09/05 – Non-standard installation of elect disconnect temp wiring, (SC3)**
**09/13 – Trip on stairs results in ~ 1 qt. spill of H2SO4 from battery at B901A**
**10/12 – Worker hit in head/injured by shelf while moving a workbench **
**11/02 – Fire Protection Impairment Process Not Properly Followed @ B1004B**
**11/06 – Man lift damaged during tree cutting operations **
**11/08 – Loose 120 VAC wires on a terminal block results in sparking**
**11/27 – Minor finger laceration **
** **

## Programmatic Review

_**CA-D, 2007**_
**05/02 – Minor brush fire in Front of building 911**
**05/10 – Power Supplies for Booster to AGS trip**
**05/15 – Microwave fire in Building 1005, (SC3)**
**08/09 – Hand caught in freight elevator door at 911, (SC4)**
**09/19 – Employee injures hand closing elevator at 911**
**11/18 – Contractor rigger climbs over rad shielding wall at C-AD**
**12/04 – RK, Worker falls walking on wooden pallet & bruises elbow outside B1000P**
_**CA-D, 2008**_

## Programmatic Review

_**BGRR Project, 2006**_
**08/03 – Removal of fuel anchor (BGRR) not approved by work procedure**
**09/26 – Cont (80, 000 dpm) found outside the BGRR RCA, (SC3)**
_**BGRR Project, 2007**_
**07/20 – 5,000dpm found on Workers Glove at BGRR**
** **
** **

## Programmatic Review

_**Plant Engineering**__**, 2006**_
**01/27 – Burning Cotton Apron In PPE/Tool Bag Causes Evac @B197, (SC3)**
**05/10 – Vehicle window damaged during concrete sidewalk removal work, (SC3)**
**06/16 – Asbestos discovered during demolition of B-422**
**10/13 – Silica Exposure During Concrete Crushing Machine Operation, (SC3)**
**12/05 – PE groundskeeper received a minor injury to the chin **
**12/13 – Pump leak results in 100 gal spill of propylene glycol @ B729 **
_**Plant Engineering**__**, 2007**_
**09/21 – Lawn Maintenance Results in AC unit Falling onto Mower, (SC3)**

## Programmatic Review

_**Utilities struck, 2006**_
**08/08 – Fiber-Optic Cable inadvertently severed  at B707A, HFBR pump house swgear**
_**Utilities struck, 2007**_
_**Utilities struck, 2008**_

## Programmatic Review

_**Material Transportation, 2007**_
_**Material Transportation, 2008**_
**01/08 – Three 9011 railcars arrive in Utah - 2 with damaged tarps, 1 with tarp missing**
**01/15 – Off-site Transport of Radioactive Material Less Than Adequate, (SC3)**
**03/07 – Inst shipped offsite w/ Ni63 source w/o going through I & SM**
**	**

## Programmatic Review

_**Electrical Shock, 2006**_
**03/13 – Shock from terminal in legacy installed light timer, (SC4)**
**09/06 – AP, Table lamp electrical fault at apartment 4B results in finger tingle**
_**Electrical Shock, 2007**_
**07/20 – Tech receives minor electrical shock when B-452 struck by lighting**
**11/21 – Shock, Near miss to an occupational injury, (SC3)**
_**Electrical Shock, 2008**_
**04/04 – Tech receives tingle sensation from contact with electric conduit, (SC2)**

##        Programmatic Review 

_**Material Handling Issues, 2006**_
**01/17, Tennelec smear counter falls during transport, (SC3)**
**06/30, Computer server unit falls out of BNL box truck grazing workers leg, (SC3)**
**07/20, Pulling cable along floor results in back strain**
**08/28, During transport a forklift dropped a secured aerial lift, (SC3)**
_**Manual Material Handling Issues, 2007**_
**09/28 – Motor pool worker injures back while lifting a forty pound starter, SCBNL**
**11/30 – Minor Back Strain from Material Handling in B-479**

##  Programmatic Review 

_**Waste Management, 2006**_
**01/20 – USQ on rusting HEPA exhaust stack @ B860, (SC3)**
**02/22 – Lapse in USQ training qualification**
**08/04 – HFBR Dumpster alarms BNL Radiation Truck Monitor, (SC3)**
**08/16 – Walk through of HFBR identifies rad/non-rad items that are not segregated**
_**Waste Management, 2007**_
_**Waste Management, 2008**_
**02/08 – SM, Waste Mgmt NCR on Improperly Filled out Rad Waste Control Forms, (SC4)**
** **
** **
** **

##  Programmatic Review 

_**Chemistry, 2006**_
**01/17 – Energ ckt disc in cut conduit in floor slab @ B555, (SC3)**
**02/23 – Personnel Cont at Building 901**
**03/22 – Cont Detected on Employee's Shoes at PET**
_**Chemistry, 2007**_
**08/02 – BNL employee trips on asphalt lip near B-555 and bruises knee**
**10/08 – Suspicious suit case outside B555 - precautionary evacuation**
**11/14 – Condensate Tank Motor Fire at B-555, SCBNL**

##  Programmatic Review 

_**Environmental Restoration Projects, 2006**_
**09/22 – HFBR air conditioning water pump seal leak, (SC3)**
**10/30 – Flaw in ERP calculation of total recordable injury statistics**
**11/30 – SM, Failure to Maint Config Control of DOE-SER specified Documents, (SC3)**
** **
_**Environmental Restoration Projects, 2007**_
**05/01 – Contamination in HFBR fuel vault**
**06/14 – Tool Bag at HFBR Measures above Rad Release Limits**
**07/09 – Untrained Personnel Entry into Confined Space at HFBR**
**07/17 – Inappropriate Change to Work Procedure at HFBR**
**08/23 – Work Proceeds at HFBR Without BHSO Approval**
_**Environmental Restoration Projects, 2008**_** **
**02/25 – Configuration Control Deficiencies Identified at HFBR**
** **

## Programmatic Review

_**Railroad Tracks, 2007**_
_**Railroad Tracks, 2008**_

## Programmatic Review

_**New Construction, 2006**_
**04/21 – Sub incurs severe laceration of leg at CFN, (SC3)**
**07/31 – A/C mechanic cuts arm at RSB Construction Site**
_**New Construction, 2007**_
_**New Construction, 2008**_

## Programmatic Review

_**Noise, 2006**_
**01/18 – Noise over exposure per ACGIH TLV @ B902, (SC3)**
**03/07 – Over-exposure to noise hazard @ Motor Pool Repair Facility, (SC3)**
_**Noise, 2007**_
**09/12 – Worker Exposure to Excessive Noise During Vacuuming**
_**Noise, 2008**_

##         Programmatic Review

_**CFN, 2007**_
**05/04 – Disc of smoldering mulch bed on south side of CFN**
**08/01 – Rain water intrusion into CFN**
**09/14 – Installation Error in Manufactured Modular Wall Assembly**
_**CFN, 2008**_
**12/07 – CFN Redundant Sprinkler Feed Valve Found Shut**

##          Programmatic Review

_**Site Fire Alarm System**_
**06/14 – Site-wide Fire Alarm Communications Malfunction, (SC4)**
**07/05 – Site Fire Alarm System Loop 1 Bldgs not Reporting**
**08/17 – Loss of BNL Fire Alarm Loops to Firehouse**
**09/12 – Partial Loss of Site Fire Alarm System, (SC3)**

##           Programmatic Review

_**Butt Fires, 2007**_
**05/02 – Minor brush fire in Front of building 911**
**05/04 – Discovery of smoldering mulch bed on south side of CFN**
**05/15 – Fire in Building 120 Butt Stop**
**05/24 – Brush fire at remote location in the SE corner of site**
**06/15 – Issued Fact-finding/Causal Analysis/Preventive Actions No.: QMO-2007-0001, ATS 3788**
**06/28 – Butt Can Fire at Building 153**
**10/08 – RK, Brush Fire (cause unknown) at North side of RHIC Ring**
_**Butt Fires, 2008**_
**03/06 – MZ, Small Fire in Outdoor Waste Receptacle at B-400**

##                  Proposed Rev to ORPS 			   Directives

**Clarified Apparent Cause Analysis Process description, and added modified flow diagram (taken from DOE ORPS CAT CBT module)**
**Generic Error Modeling System (GEMS) diagram (taken from new INPO HPI reference manual)**
**Other definitions of HPI-, error- and causal-analysis-related terms**

## Apparent Causal Analysis Process

**Develop causal factors**
**For each causal factor:**
**If CF involves human, start with A3 node. Then find process/system causes to couple it.**
**If CF does not involve human, most likely will be equipment/material related (A1 or A2).**
**Note: “N/A” as a pseudocouplet in ORPS software is not a defined code, yet shows up as a code in reports.**

## ?

**Low**

**High**

**Familiarity (with task)**

**Attention (to task)**

**Low**

**High**

- Is task proceeding OK?

- Recognize problem situation

- Identify available symptoms

***If***:
- familiar situation?

- Identify available symptoms or other familiar analogy

- Problem-solving mode:
- Recall mental model. Apply observed symptoms & fundamental principles to update mental model.

- No

- Yes

- No

- Yes

***Then***:
- Apply known action

- Select problem solution:
- Develop corrective action. Apply to problem situation. Observe results.

- Is task proceeding OK?

- Solved?

- No

- Yes

**Skill-based Performance**
- Routine actions in a familiar situation

**Rule-based Performance**
- Pre-packaged actions determined by recognition of familiar problem situations

**Knowledge-based Performance**
- Analysis of unfamiliar problem situation using stored knowledge

**?**

**Δ**

- Subsequent Attempts

**Generic Error Modeling System (GEMS)**

## New Definitions

**Error**
**Causal analysis**
**Cause**
**Couplet**
**Human performance**
**Skill-based / Rule-based / Knowledge-based error**
**Violation**

## CAT Human Performance Node (A3)

**Complete restructuring of A3B1 node (skill-based errors) based on research:**
**Norman, Donald A. “Categorization of Action Slips,” *****Psychological Review*****, Vol. 88 [1981], pp. 1-15.**
**Norman, Donald A, “Design rules based on analyses of human error,” *****Communications of the ACM (Association for Computing Machinery)*****, Vol. 26 No. 4 [April 1983], pp. 254-258.**

## Skill-Based Error Codes

_**FROM:**_
**A3****	****  Human Performance LTA**
**B1****	****    Skill-Based Error**
**C01****	****Check of work was LTA**
**C02****	****Step was omitted due to ****	****distraction**
**C03****	****Incorrect performance due ****	****to mental lapse**
**C04****	****Infrequently performed ****	****steps were performed ****	****incorrectly**
**C05****	****Delay in time caused LTA ****	****actions**
**C06****	****Wrong action selected ****	****based on similarity with ****	****other actions**
**C07****	****Omission/repeating of ****	****steps due to assumption ****	****for completion **

_**TO:**_
**A3****	****  Human Performance LTA**
**B1****	****    Skill-Based Error**
**C01****	****Description error**
**C02****	****Data-driven activation**
**C03****	****Associative activation**
**C04****	****Loss of activation**
**C05****	****Mode error**
**C06****	****Capture error**
**C07****	****Misordering, omission   ****	****or repeating of steps **

## DOE M 231.1-2ORPS Manual

**Change notion of “prevent” recurrence to “reduce risk of” recurrence.**
**Expansion of section 1.5 **_**Occurrence Investigation and Analysis**_**:**
**Incorporate HPI and ISM principles **
**Purpose and goals of an investigation (not to place blame; opportunity to learn)**
**Information-gathering methods**
**Forming investigation teams**

## ORPS Manual (contd.)

**Critique described**
**Graded approach for investigation should be based on potential as well as actual consequences.**
**Eliminate use of antiquated cause terms (direct, root, contributing)**

## ORPS Reporting Criteria Proposed Rev:Loss of Categorizer Accident (LOCA)?

**An event, condition, or series of events that do not meet any of the other reporting criteria, but is determined by the Facility Manager **_**or DOE/contractor line management**_** to be a safety concern for that facility or other facilities or activities in the DOE complex.   The significance category assigned to the management concern should be based on an evaluation of the potential risks and associated corrective actions.**
**Review WORD file **

## CAT Team Workshop

**CAT Team Action Item Review**
**Meeting Evaluation and Wrap-Up**
** **