# Presentation: 513770

## Presentation produced under contract with:

## How to Read and “Right” a Causal Factors Analysis ReportISM Workshop – Feedback and Improvement Session B-2

**Richard S. Hartley, Ph.D., P.E.**
**November 28, 2007**

## What We Are Going To Cover

**HRO Attributes**
**Organizational Causes of Events**
**Demystifying Causal Factors Analysis**
- Black Magic of CFA
- How to Read and “Right” a CFA Report
**CFA Feedback on the HRO**

## HRO AttributesAccidents can be avoided

***HRO Attributes***_**Accidents can be avoided**_

**Leadership Safety Objectives**
**Safety held high as priority**
**Provide clear operational goals**
**Willing to pay for redundancy and continuous training**
**Redundancy**
**Independent barriers reduce the fatal error by one person**
**Decentralization, Culture, Continuity**
**Worker calls the shots**
**Worker calls the shots like management wants him to**
**Worker stays proficient through continous training and work**
**Worker maintains his awareness by expecting the unexpected**
**Organizational Learning**
**Adjust through trial and error**
**Learn from past mistakes**
**Simulate where practice not feasible**

*Scott Sagan, The Limits of Safety*

## How Organizational Accidents Occur

**Vision, Beliefs, &**
**Values**

**Latent****Organizational****Weaknesses**

-       **Mission**
**     ****Goals**
**    ****Policies**
**   ****Processes**
**  ****Programs**

**Different**
**Vision, Beliefs, &**
**Values**

**Event**

**Flawed**
**Defenses**

** ****Human Errors**

**Initiating Action**

**Notes:**
 Note we go back and pickup from Slide #2 to emphasize that we are attempting to develop better organizational processes to move from NAT to HRO (to protect the Plant from the Worker).
 We now have three things (remember HPI has only two) in our practice to focus on to become/remain/strengthen as an HRO to minimize the possibility and magnitude of events: 
1) reduce errors; 
2) manage defenses; 
3) evaluate and close the gap between the “work-as-imagined” and “work-as-done.”
 This is captured as an additional term in our HPI equation making it BWXT Pantex’s HPI+ equation/process (now a green box with green lettering).  Wg is the attempt to reduce the gap between “work-as-imagined” and “work-as-done.”
 The idea is these three things should be practiced all the time so that when we perform the tightly coupled complex operations (e.g. weapons assembly/disassembly) we have good habits established in regards to an HRO (via HPI).

## I/O to Achieve Desired Result of Causal Factor Investigations

***I/O to Achieve Desired Result of Causal Factor Investigations***

**3 Process Outputs To Achieve Results:**
- Safety Culture Insight
- Corrective Actions
- Lessons-To-Be Learned

**Unique Feature**

**Desired Results:**
-     Prevent Recurrence of Events
-      Learn as an Organization

**Criteria to grade**
**CFA Reports**
**“****READ”**

**Key Attributes**
** ****of HRO**

**Criteria to drive**
**CFA Investigations**
**“****RIGHT”**

**Process Input**
- Low consequence, information rich events

## Process Input - Information-Rich Events

**Significant gap between “work-as-imagined” (planned) vs. “work-as-done” (actual efforts)***
**New type of event/error not afforded protection by existing systems**
**Significantly worse consequences could have occurred **

- * The Field Guide to Understanding Human Error – Sidney Dekker

## “Information Rich” Determination Matrix

*Co-developed Bill Corcoran & Richard Hartley 8-21-07*

| Criteria | Evidence | Rating |
| --- | --- | --- |
| Gap between “work as imagined” vs.” work-as-done”  
10 indicates significant gap 
0 indicates insignificant gap |  | 0-10 |
| Precursor (what is this event a precursor to)
10 indicates very significant to a follow-on event
0 indicates not significant in leading to a follow-on event |  | 0-10 |
| Extent
10 indicates could happen at other places on Plant-site 
0 indicates that problem is contained within area of investigation (unique event) |  | 0-10 |
| Barrier Issues
10 indicates many important barriers had problems (missing or failed)
0 indicates that most barriers remained effective |  | 0-10 |
| Fragility of remaining barriers
10 indicates that remaining barriers were few and fragile or not known to worker
0 indicates remaining barriers effective & robust |  | 0-10 |
| Campaign Issues
10 indicates important issue to customer, regulators, corporation, etc.
0 not of high importance to customer, regulators, corporation, etc. |  | 0-10 |
| Overall Figure of Significance
To determine overall figure of significance, take the total and divide by 6 (criteria)
Ranking:
10 – 7  significant event (CFA Investigation)
  6 – 4  important event (CA/MP or streamline cause analysis)
  3 – 1  less significant event (Apparent Cause)  |  | 0-10 |

## Process Output – Safety Culture Insight

**Types of Safety Culture:**
- Default Culture (what you get if you do nothing)
- Managed Culture (push organization to desired state)
**Safety Culture Can Be Characterized***
- Mental Content (shared values, beliefs)
- Norms (commonly encountered behavior)
- Institutions (programs - QA, Safety, etc.)
- Physical Items (procedures, PPE, etc.)
**Safety Culture Can Be Evaluated****
- Problem Identification & Resolution
- Human Performance
- Safety Conscious Work Environment
- Organizational Issue
**Harmful Attributes of Safety Culture Can Be Modified**

- * © 2007 W. R. Corcoran, NSRC Corporation
- ** NRC – Regulatory Issue Summary 2006-13

*Co-developed Bill Corcoran & Richard Hartley 8-21-07*

## Process Output - Corrective Actions

**Required for**
- Causal Factors
- Human Performance Error Precursors
- Flawed Barriers
- Extraneous Conditions Adverse to Quality
**Modify Based on Extent of Problem**
**Confidence in Corrective Actions Requires Confidence in Factors**
**Confidence in Factors Requires They Explain Nature, Magnitude or Timing of Consequences**
**Consequences**
- Selection of “right” consequences key to “right” factors
- Types: Actual, Expected, Potential
**Confidence in Consequences, Extent, ECAQ Requires:**
- Complete collection and Processing of Accurate Evidence
- Appropriate Selection and Use of Causal Factor Analysis Tools

*Co-developed Bill Corcoran & Richard Hartley 8-21-07*

## Process Output - Lessons To Be Learned

**Lessons To Be Learned (LTBL) are:**
- How the Organization Changes the Way We Should Be Thinking and Behaving
- Developed for Things that Specific Corrective Actions Can’t Solve
**Confidence in LTBL Requires:**
- Confidence in Factors
- Knowledge of the Extent of Condition
- Knowledge of those Additional Factors that Indicate our System is Weak (ECAQ)
**Confidence in Consequences, Extent, ECAQ Requires:**
- Complete Collection and Processing of Accurate Evidence
- Appropriate Selection and Use of Causal Factor Analysis Tools

*Co-developed Bill Corcoran & Richard Hartley 8-21-07*

## CFA Feedback to HRO Attributes

***CFA Feedback to HRO Attributes***
***Re-Actively Preventing Accidents – Protect Plant from Worker***

**Event**

**Notes:**
 So far most of our focus has been on the right hand side of the slide – Post Event.
 Some people will start to question of why do we wait for an event to occur before we go in and see what HPI processes did not work.
 They are right in the aspect we truly want to push the front end and be pro-active vs. reactive.
 Note I would contend that in our Plant-wide training effort we did start building the foundation for the front end.  Now we need to develop an implementation plan to actually use the seeds that were planted.  This is being done in a large part by the HPI 5-year plan.
 It is clear we need a way to transform the data we will acquire (error precursors, flawed defenses, time delay between event and notification, and gaps between work done and  work imagined) into something that management can use to see the latent organizational weaknesses and then for them to fix them.  
 How this is done is foggy at this time.  There is software out there that does Streaming Analysis that professes to help bridge this gap.
 This slides attempts to show that in addition to developing a CFA process (that allows us to determine the facts and causes  back end of the process after an event), we are also conducting HRO/NAT/CFA seminars (blue background) that start in the theory and end up with practical HRO applications used at Pantex (front end of the process before an event).  
 This is being done to provide the necessary foundation to management so that they can be sensitive to, and understand the significance of, the results from the CFA process.  
 That is it provides the management foundation to transform data to information to knowledgeable decision making (noted by two opposing arrows stating that we “Meet in the Middle” until we develop a more systematic process to aid in the transformation and action management.

## Where We Are – Where We Are Going 

***Where We Are – Where We Are Going ***