# Presentation: 168173

## BNL Causal Analysis Tree Training

**Presented by Ed Sierra **
**Quality Management Office**

## WHY?

**   ****To provide an introduction to the:**
**Causal Analysis Tree**
**DOE Guide 231-1-2, Occurrence  Reporting Causal Analysis Guide **

##   Tree - a  logical  structure 
         designed  to  describe 
         possible   causes for  problems 
         within  an  operating  environment.

 Branch or “A” Node 
                           - Major  Categories  of  Problems

 “B” Node 
		- Subcategory  of  Problems 

 “C” Node 
		- Apparent  Causes  of  Problems

**  ****Tree** - a  logical  structure
-          designed  to  describe
-          possible   causes for  problems
-          within  an  operating  environment.
** ****Branch or “A” Node**
-                            - Major  Categories  of  Problems
-  **“****B” Node**
- 		- Subcategory  of  Problems
** ****“****C” Node**
- 		- Apparent  Causes  of  Problems

**Definitions - **

**A**

**B**

**C**

**Notes:**
Talking Points:
Before diving in we need to enlighten you on definitions and show you the structure behind the tree

In this course, the term “tree” refers to the Causal Analysis Tree (CAT) that is a major portion of this course. Later slides will more fully explain the structure of the CAT building on these definitions.  CAT  is  designed  for  accidents / events – not  housekeeping & such.
Every tree has branches. For illustration purposes, the tops of the branches are shown in green.  The tree on this slide has 4 branches.  The CAT has seven.
Every branch has at least 2 major subdivisions.  The illustration shows them in yellow. On the CAT, one branch has two B nodes and one has six B nodes.  The rest are in between those extremes depending on how many were needed to complete the logic needed.
The lowest level of this tree is the C node. For convenience they are shown in red.  Every B node has at least two C nodes under it.  On the CAT most B nodes have more than two C nodes.  There are approximately 160 C nodes on the total tree.

## Apparent  Cause  Process

**   ****Identify  Causal  Factors (critical step)**
** ****Causal Analysis Methodologies**
** **

**Use  the  Causal  Analysis  Tree (CAT)**
**     ****to  Identify  Apparent  Causes  **

**Notes:**
Talking  Points:

The  New  terminology  will be  explained  as  we  go.

The  point  of  this  slide  is  to  summarize  today's  course.   Find  the  Causal  Factor then  take  it  to  the  Causal  Analysis  Tree (CAT) -  through  all  three  levels = A, B, and C.  
This gives  you  the  Apparent  Cause(s)  for  the  causal  factor.  
Do  this  for  each  causal  factor.  
Repeat  until  all  causal  factors  have  been coded  for  Apparent  Cause.  

## Causal Analysis Methodologies 

_**Low Complexity Level**_
**What-if Analysis**
**Five Whys**
**Brainstorming**
**Expert Judgment**
_**Moderate Complexity Level**_
**Barrier Analysis**
**Change Analysis**
**Events & Causal Factors Analysis**

_**High Complexity Level**_
**Fault Tree Analysis**
**Management Oversight and Risk Tree Analysis**
**TapRoot**

## Causal  Factor(s) - [CF]

- An  event  or  condition  [“fact”]  that  either  caused  the  problem  under  investigation  or  made  it  worse.
- The  CF  not  only  influenced   the  course  of  the incident  but  was  a  major  contributor  to  it.
- Incidents  generally  have  more  than  one causal factor,  but  the  following  is  true  for  all  CFs:

***If  the  CF  were  eliminated,  the  problem  would  not  have  occurred  ***_***or***_** ***** its  severity  would  ***
***have  been  reduced****  *

**Notes:**
Talking  Points:

This is the definition of a Causal Factor as we use it in our class.

No magic Number defined  by  the  particular  “event”..

During your investigations you are likely to find or figure out many  potentially  incorrect  things.  In general, those are considered part of your investigation and held until the end.  There is one exception.  If one of those is Immediately Dangerous to Life and Health, you are responsible to start the reportability determination on that item.

## Example: BNL Causal  Factors

-   Structure and facility engineering not considered
-   Dumping/disposal of trays and can not originally considered/addressed in TWD
-   Unaware that TLD has a # that coincides with # slot on badge board
-   Unaware that NSLS has temporary TLDs avail. at all times for researchers/visitors

**Example: BNL Causal  Factors**

**Notes:**
Talking  Points:  -  
These  are  merely  examples of  possible  causal  factors.

**The most probable cause(s) that explains why the causal factor happened, that can reasonably be identified, that local or facility management has the control to fix, and for which effective recommendations for corrective action(s) to remedy the problem can be generated.         **

**Notes:**
Talking Points:    

	This  course  is  based  on  finding   Apparent  Causes
	The plural is quite intentional!  There  is   usually more than one apparent  cause  to  an  event.  We  use  the  term  multiple  coding  to  describe  this.
There  are  three  parts  to  this  definition:
1. These  are   probable  causes (consistent  with  the  Significance      Category) 
2. That  management (local  or  facility)  has  control  to  fix    -   	AND 
3. That  effective  recommendations  can  be  generated.

From ORPS  Model - Remedy  the  problem  for  Sig. Cat. 3
For  Sig. Cat  2 -  you  must  prevent  recurrence.

## INTEGRATED   SAFETY  MANAGEMENT

**Feedback /**

**improvement**

**LTA**

**Perform work**

**LTA**

**Develop /**

**implement**

**controls LTA**

**Scope of work**

**LTA**

- Determination  of

- Deficient  ISMS

- Function

**INTEGRATED****   ****SAFETY  MANAGEMENT**

**Notes:**
Talking  Points

## Purpose  of   the  CAT        

-  **Trending**

-  **Provides  Data  for  Analysis**

-  **Basis  for  Performance**
**     ****Analysis**

**Notes:**
Talking Points:

Emphasize  that  one  of  the  key  roles  of  the    Tree  is  to  provide  data  for  Trending  on  a  periodic  basis
Binning  and  Bucketing  Information  for  Trending
Drill  down  &  do  RCA  if  warranted

The  tree  is  also  the  basis  for  other  types  of    analysis  as  well -  it’s  not  just  a  one  shot  deal  for  Significance Category  3  events / problems.
You  can  apply  your  Site’s  Root Cause  Methodology  to  the  Apparent  Cause(s) to  determine  Root Cause(s) 

## Causal  Analysis  Tree

***C******ausal  ******A******nalysis  Tree***

**Notes:**

Talking Points:

This  slide  shows  how  the  CAT  is  divided  up  into  three  logical  groups
  Mechanical
  People
  Other
Management
Communications  (oral  and  written)
Training
Other 

##  Tree  Logic / Recommendations

** **_***Tree  Logic / Recommendations***_

**COUPLETS**

**Input:**
**Causal  Factors**

**Output:**
**Apparent  Causes**

**Notes:**
Details  How  the Tree  is  to  be  used

Review all  branches  of  the tree  for  potential  apparent  causes.

A3 should not stand alone -  they  should  be  coupled  with  apparent  causes from  a  different  branch(s)  of  the  tree.  
A  “Couplet”  is  any other code  from  the  CAT  which  can  logically attach  to  an A3 - ‘C’ Node 

1. First  look  at  was  it  a  design  or  equip.  problem -
    This  may  be  20%  or  so  of  events

2.  Next  look  at  what  initiated  the  event  -  this  is  
      usually  a  human  element
     This  is  roughly  the  case  80%  of  the  time

3.  The  trees  real  value  is  in  looking  into  what
      contributed  to  the  event  -  
     What  defenses  failed  that  allowed  the  event  to  happen

Go  over  the  CF  to  determine  if  anything  
        else  was  a  contributor
4.  This is the output of the  process  which  gives  you  the  Apparent  Cause(s)

## A1 - Design / Engineering Problem

**Notes:**
Placeholder  Slide   -  To  Introduce the A1 Branch of the Causal  Analysis  Tree

## A1 Design / Engineering Problem

**B1  DESIGN  INPUT  LTA**
-   C01  Design input cannot be met
-   C02  Design input obsolete
-   C03  Design input not correct
-   C04  Necessary design input not available
**B2  DESIGN  OUTPUT  LTA**
-   C01  Design output scope LTA
-   C02  Design output not clear
-   C03  Design output not correct
-   C04  Inconsistent design output
-   C05  Design input not addressed in design
-            output
-   C06  Drawing, specification, or data error
-   C07  Error in equipment or material
-            selection
-   C08  Errors not detectable
-   C09  Errors not recoverable

**B3  DESIGN / DOCUMENTATION  LTA**
-   C01  Design / documentation not complete
-   C02  Design / documentation not up-to-date
-   C03  Design / documentation not controlled
**B4 DESIGN / INSTALLATION  **
**      ****VERIFICATION  LTA**
-   C01  Independent review of design /
-            documentation LTA
-   C02  Testing of design / installation LTA
-   C03  Independent inspection of design /
-            installation LTA
-   C04  Acceptance of design / installation
-            LTA
**B5  OPERABILITY  OF  DESIGN /**
**       ****ENVIRONMENT  LTA**
-   C01  Ergonomics LTA
-   C02  Physical environment LTA
-   C03  Natural environment
-            LTA

**Notes:**
Talking Points:

This  Branch (A1)  represents  a  significant  expansion  from  what  was  in  the  former  ORPS Codes.  [Inadequate  work  environment  [A1B5],  Defective  Design [A1B1 A1B2],  A1B2C06, A1B2C07].

Reiterate:
Branch  was  reformatted/changed  to  flow  with
   the  typical  progression  of  the  design/engineering
   cycle  -  from  conception  to  acceptance
 Includes  ergonomics  - physical  &  
     environmental  aspects 

 Engineering  personnel  were  involved  in  the
     reformatting / change.

##     DOE Guide 231-1-2, Occurrence Reporting Causal Analysis Guide
  Definitions
  Example(s)
  Potential  corrective  action(s)

-   Definitions
-   Example(s)
-   Potential  corrective  action(s)

**  ****DOE  Causal  Analysis  Guide**** **

**Notes:**
Refer  Students  to  a  Copy  of  this  in Their  Student  Binder - TAB  2

Use  the  DOE  Occurrence  Reporting  System Causal  Analysis  Guide  to  illustrate  points  on  the  slide

The  Guide  is  to  help  with  consistency  in  coding

As  you  use  this  at  your  site  and  find  better  examples  of  these,  please  send  us  your  suggestions

## 

- caused  by  improper  overhead  lighting  prevented
- an  operator  from  detecting  that  an  important
- annunciator  tile  was  illuminated.

-   **Design  input  cannot  be  met**
-   **Design / documentation  not  controlled**
-   **Ergonomics  LTA**

-   **B4** **-  Design/Installation Verification LTA**
-   **B3**** -  Design  Documentation  LTA**
-   **B5**** -  Operability  of  Design / Environment  LTA**

**A1  Exercise**

**Notes:**
Talking Points:

Present  slide  and  have  class  take  a  minute  and  read  through the  first  portion  that  shows  on  the  screen.
Ask  the  class  to  choose  the  B Level  Node  they  feel  best  represents  the   scenario.
Discuss  student  choices  then  reveal  the  KEY  ANSWER
B5  is  Correct – the  Design Input was  not  the  problem  in  this  case, nor  was  the  Documentation.  This  was  a  problem  with  where  the  light  was  placed  in  relation  to  the  lighted panel
Ask  the  class  to  choose  the  Apparent  Cause (C Level  Node)  they  feel  best  represents  the   scenario.
Discuss  student  choices  then  reveal  the  KEY  ANSWER
Ergonomics  LTA (A1B5C01) – is Correct
Could  be  multiple coded  under A1B2 or A1B4 if given more details

## A2 - Equipment/material Problem

**Notes:**
Placeholder  Slide   - to  Introduce  the A2 Branch  of  the Causal  Analysis  Tree

## A2  Equipment/Material

**      ****INSTRUMENTS LTA**
- C01  Calibration LTA
- C02  Equipment found outside
-          acceptance criteria
**B2 PERIODIC/ CORRECTIVE**
-       **MAINTENANCE  LTA**
- C01  Preventive maintenance for
-          equipment LTA
- C02  Predictive maintenance LTA
- C03  Corrective maintenance LTA
- C04  Equipment history LTA
**B3  INSPECTION/ TESTING  LTA**
- C01  Start-up testing LTA
- C02  Inspection/testing LTA
- C03  Post-maintenance/Post-
-          modification testing LTA

**A2  **_**Equipment/Material**_
**       **_**Problem**_

**B4  MATERIAL  CONTROL  LTA**** **
- C01  Material handling LTA
- C02  Material storage LTA
- C03  Material packaging LTA
- C04  Material shipping LTA
- C05  Shelf life exceeded
- C06  Unauthorized material substitution
- C07  Marking/labeling LTA
**B5  PROCUREMENT  CONTROL  LTA**
- C01 Control of changes to procurement
-          specifications/ purchase order LTA
- C02  Fabricated item did not meet requirements
- C03  Incorrect item received
- C04  Product acceptance requirements LTA
**B6  DEFECTIVE,  FAILED  OR**
**      ****CONTAMINATED**
- C01  Defective or failed part_ _
- C02  Defective or failed material_ _
- C03  Defective weld, braze or soldering joint
- C04  End of life failure_ _
- C05  Electrical or instrument noise_ _
- C06  Contaminant

**Notes:**
Talking Points:

A2  – Node  A2B6  should  look   familiar (old ORPS),  the  rest  of  the  Nodes  are  an  expansion.  Most  of  this  previously  may  have  been  covered  by  Inadequate  Administrative  Control  or  Other  Management  Problems.

6 - B  level  nodes

Discuss  the  logic  built  into  this  Branch

Aside  from  Design (A1),  A2B1 – B5  are  the  Major  Programs  affecting  equipment

## 

- mechanics  were  installing  several  pumps  and
- had  them  all on  a  cart.  They  were  “mixed up”
- and  installed  in  the  wrong  locations.

-   **Incorrect  item  received**
-   **Unauthorized  material  substitution**
-   **Material  handling  LTA**

-   **B5** **-  Procurement  Control**
-   **B4**** -  Material  Control  LTA**
-   **B6**** -  Defective, Failed,  or  Contaminated**

**A2  Exercise**

**Notes:**
Talking Points:

Present  slide  and  have  class  take  a  minute  and  read  through the  first  portion  that  shows  on  the  screen.
Ask  the  class  to  choose  the  B Level  Node  they  feel  best  represents  the   scenario.
Discuss  student  choices  then  reveal  the  KEY  ANSWER
B4  is  Correct – Procurement  Control  was  not  an  issue  here,  nor  was  this  a  Defective, Failed,  or  Contaminated pump – this  issue  pure  and  simple  was  a  Material  Control  error.
Ask  the  class  to  choose  the  Apparent  Cause (C Level  Node)  they  feel  best  represents  the   scenario.
Discuss  student  choices  then  reveal  the  KEY  ANSWER
Material  Handling  LTA  (A1B5C01) – is Correct

## A3 - Human Performance LTA

**A3 - Human Performance LTA**

**Notes:**
Placeholder  Slide   - to  Introduce  the A3 Branch  of  the CAT – It  deals  with  individual  behaviors.

Accidents  are  preventable – many  are  initiated  by  people  making  mistakes
People  do  not  come  to  work  intending  to  error - errors  are  part  of  being  human
Most  human  errors  are  influenced / caused  by  systems  they  operate  or  in  which  they  are  operating
Finding  fault  with  the  system  is  not  the  same  as  blaming  the  person  who created / used  the  system

## A3 Human  Performance  LTA

**       ****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
-          assumptions for
-          completion

**A3 **_**Human  Performance  LTA**_

**B2  RULE  BASED**
**       ****ERROR**
- C01  Strong rule
-         incorrectly chosen
-         over other rules
- C02  Signs to stop were
-         ignored &  step
-         performed
-         incorrectly
- C03 Too much activity
-         was  occurring  &
-         error made in
-         problem  solving
- C04  Previous success
-          in use of rule
-          reinforced
-          continued  use of
-          rule
- C05  Situation
-          incorrectly  id.ed
-          or  represented
-          resulting  in  wrong
-          rule  used

**B3  KNOWLEDGE  BASED**
**       ****ERROR**
** **C01  Attention was given to
- 	    wrong issues
- C02  LTA conclusion based on
-          sequencing  of  facts
- C03  Individual justified action by
-          focusing on biased evidence
- C04   LTA review based on
-           assumption  that process will
-           not  change
-  C05  Incorrect  assumption  that  a
-           correlation  existed  between
-            two  or  more facts
- C06   Individual  underestimated  the
-           problem  by  using  past events
-           as  basis
**B4  WORK  PRACTICES  LTA**
- C01  Individual’s capability to
-          perform   work   LTA
- C02  Deliberate violation

**Notes:**
Talking Points:

We  will walk  through  this  branch  and  
       discuss  the  Human  Performance  philosophy
       behind  each  “B” level  node

 To  understand  this  Branch  you  really  need
        to  understand  a  little  of  the  basics  of  
        human  performance.
 The  next few slides will give you  some of  the  necessary  background  to facilitate  your
understanding.  

  This  will be  illustrated  with  in-class
      exercises  led  by  the  instructor

This  session  will  last  approximately  60  minutes  
depending  on  questions  and  discussion.

## Performance  Modes

- Low

- High

**Familiarity **(w/ task)

**Attention** (To Task)

- Low

- High

***CHANGE***

***Uncertainty***

**Chance for error**

**Performance  Modes**

**% Actual error**

**Inaccurate**
**Mental  Picture**

**Patterns**

**Misinterpretation**

**Industry / INPO  Statistics**

**Notes:**
Talking Points:
SB - Performance involves highly practiced actions in a very familiar situation -- usually executed from memory without significant conscious thought. Roughly  90% of a person’s activities are spent in this mode. Examples: performing a calculation, hanging a tag, taking logs.
Error Mode:  Misattention - Execution errors involving slips and lapses in attention or concentration. Unintentional omissions triggered by not recognizing changes in task requirements, system response, or plant conditions.  Can  also  concentrate   too  much!

RB - The  shift  to  RB  is  change.  Performance is based on the selection of stored rules derived from one’s recognition of the situation. Examples: responding to a control board annunciator, using infrequently performed procedures, performing radiological surveys.
Error Mode:  Misinterpretation -- unintentional deviation from an approved procedure, applying the wrong response to a situation, or applying a correct procedure to the wrong situation. 

KB - The  shift  to  KB  is  uncertainty.  Performance is a response to a totally unfamiliar situation (no skill or rule is recognizable to the individual).  People transition into the KB mode when  they realize that they are uncertain. Examples: troubleshooting, performing root cause analysis, responding to unknown plant transient.
Error Mode: Inaccurate mental picture.  Inaccuracy in the structured understanding of knowledge a person has in their mind about how something works or operates. 

## Skill  Based  Performance  Mode

-   **Highly  practiced  routines**
**  ****Behavior  governed  by**
**    ****preprogrammed  instructions**
** **
**  ****Habit  driven**

-  **Inattention  **
** ****Perceived   risk**  **does  not  match**
**	**** ****actual  risk**

**Error  Modes**

-  Self-checking
-  Peer checking
-  Questioning
-  Precise
-     communications
-  Repeat  backs
-  Pre-job  briefs

**Notes:**

Talking Points:

Self-Checking,  Peer Checking,  Questioning, Precise communications, Repeat backs  and  Pre-Job  Briefs are Prevention  Tools  that  will  greatly  assist  in  preventing  Skill  Based  Errors.

## Rule Based Performance Mode

**Rule Based Performance Mode**

-  Unanticipated  problem
-  Selection  of  stored  rules  based
-   	 on  situation
-  Making  choices
-  Trained  for  problems

- Procedure use
- Procedure compliance
- Clear verbal directions
- Drills
- Conservative  decision
- 	making
- Pre-job  brief

**Error   Mode**

- Misinterpretation  of
-    	equipment  or  plant
-  	conditions

**Notes:**

Talking Points:

Rule  Based  Performance - does  NOT  mean  there’s  a  written (procedure)  or  recent  oral  instruction  involved.  
 “Rules”  are  most  likely  stored  in  the   individual’s   head.

## Knowledge  Based  Performance Mode

**Knowledge  Based  Performance Mode**

** ****Totally  unfamiliar  situation**
** ****Dependent  upon  understanding  &  knowledge**
** ****High  uncertainty**
** ****Search  for  patterns**

**Error Mode**

- Inaccurate  mental  model
- Erroneous  assumptions
- Short  cuts  due  to  mental
-   	biases

-   Stop  &  collaborate
-   Systematic  troubleshooting
-   Conservative decision making
-   Drills
-   Healthy  team  dynamics
-   Pre-job  brief

**Notes:**
Talking Points:

There  are  times  when  people  must  function  in  the  Knowledge Based  Mode  but  it  should  never  happen  at  the  sharp-end  of  the process,  i.e.,  during  the  manipulation  of  process  components.   Stop  and  collaborate  BEFORE  manipulating  equipment  when  you find  yourself  in  this  mode.

Problem  solving  teams  should  gather  data  using  healthy  team dynamics  in  order  to  get  all  of  the  information  necessary  to make  sound  decisions.

Managers  and  researchers  spend  most  of  their  time  in  this  mode.  This  helps  to  explain  the  Trial  and  Error  effect. 

## Performance  Mode  Recognition

**Notes:**
Talking Points:

This  exercise  will  take  10 – 15 minutes

Read  each  example  and  determine  if  it’s  Skill Based,  Rule  Based   or  Knowledge  Based  -  then  select  the best  answer  from  the  available  choices.

Examples  may  have  more  than  one  Causal  Factor - focus  on  the  causal  factor  that  is  underlined.

 Instructor  will  discuss  when  completed. 

## 

-    Underestimates  the  problem  by  using  past  events  as  basis.
-    Attention  is  given  to  wrong  issues
-    Individual  justifies  action  by  focusing  on  biased  evidence

**Notes:**
Talking  Points

Big  Bayou  Canot  Bridge  Accident,  1993

While  lost  in  a  heavy  fog  in  the  early  morning  hours  of September 22, 1993,  the  towboat  Mauvilla,  pushing  a  cargo  of six  barges,  struck  the  Big  Bayou  Canot  Railroad  Bridge, dislocating   a  section  of  rail  on  a  CSXT  rail  line.  Eight  minutes  later, at 2:53 A.M.,  the  Sunset  Limited  Amtrak  passenger train  crossed  the  bridge  and  plunged  into  the  Big  Bayou  tributary  of  the  Mobile  River - killing  47  passengers  and crewmembers  and  injuring  103  passengers.

Knowledge  Based  Mode:  No  visual  clues,  dense  fog,  pilot  was  disoriented  all  suggest  that  the pilot  was  functioning  in  the KB  mode.

C01 - Attention  Given  to  the  Wrong  Issues:  Pilot  was  apparently trying  to  find  his  way  by  looking  at  the  river’s  banks  instead of  monitoring  his  position  with  the  radar.

## 

**it,  then  gave  it  to  my  supervisor.  **_**I  thought  that **_
_**I  had  initialed  all  of  the  appropriate  steps**_**.**
**The  supervisor  found  a  step  that  I  failed  to **
**initial. **

-   Check  of  work  is  LTA
-   Infrequently  performed  steps  are  performed  incorrectly
-   Wrong  actions  selected  based  on  similarity  with  other  actions

**Notes:**
Talking  Points

Skill  Based Mode:  Seems  likely  that  the  operator / mechanic has  performed  this  procedure  successfully  in  the  past.  There  is  no  indication the  he / she  was  responding  to  any  unusual  conditions.

Check  of  Work  is  Less  Than Adequate:  Step  was  performed but  a  simple  check  to  ensure  all  steps  had  been  properly initialed was not completed.

## 

**manipulation.  The  recent  facility  practice  had  been  to  use **
**alternative  valve  locking  devices  for  the  valves  that  had  been**
**proven  to  be  more  effective  in  preventing  the  valve  from  **
**being  manipulated.  The company  wanted everyone to  use  this  “new” practice,  however,  they  did  not  prevent  the  use  of  chains.  **_**Lockout  Installers   were  comfortable  using  chains  &  continued  to  use  the  chain  method**_**.  As  a  result  a  “chained”  valve  vibrated  partially  open  causing  a  spill.   **

-   Signs  to  stop  are  ignored  &  step  performed  incorrectly
-   Too  much  activity  occurring  &  error  made  in  problem  solving
-   Previous  success  in use  of  rule  reinforces  continued  use  of  rule

**Notes:**
Talking  Points

Rule Base Mode:  Lockout  Installers  continuing  to  use  the  old  past  method  of   locking  equipment  out  and  resisting  the  move  to  the  newer  alternative  valve  locking  devices  suggests  the Lockout  Installers  were  in  the  Rule  Based  Mode. 

C4 -	Previous  Success  in  Use  of  Rule  Reinforces   Continued  Use  of  the  Rule:  
The  Lockout  Installers  have  had  past  success  and   are  comfortable  with  using  the  old  method  of  locking  out  valves - therefore  the  old  rule  continues  to  be  used.

## A3B4C01

**The  operator  made  an  error  while  attaching   two  **
**color-coded  wires.   **_**He  was  color  blind**_**.   There  were  no  **
**standards  or  requirements  concerning  color  blindness  **
**associated  with  this   job - even  though  discriminating  **
**between  colors   was  necessary.****     **

-   Check  of  work  was  LTA
-    Individual  capabilities  to  perform  work  LTA.
-    Wrong  actions  selected  based  on  similarity  with  other  actions

**A3B4C01**

**Notes:**
Talking  Points

This  operator  is  in  the  A3B4  Node - Work  Practices  LTA 
This  is  not  an  error - as  it  deals  with  the  individual’s  capabilities  to  perform  work,  in  this  case  he  was  color blind.

C01 - Individual  capabilities  to  perform  work  LTA

This  is  repeated  here  for  instructor’s  convenience.
The  operator  made  an  error  while  attaching   two  
color-coded  wires.   He  was  color  blind.   There  were  no  
standards  or  requirements  concerning  color  blindness  
associated  with  this   job - even  though  discriminating  
between  colors   was  necessary.     

## I  knew  that  the  area  was  a  “safety-glasses  required”  area.  I  was only  going  to  read  a  gauge  and  I  didn’t  have  my safety  glasses  with  me.  I  figured  that  by  the  time  I  went  to  get  my  glasses  and  got  back  I  could  have already  taken  the  reading  and  gone  to  lunch.  I  didn’t  think  that  it  was  a  big  deal  but  if  I  had  known  that  the  Safety  Engineer  was  watching  I  would  have  gone to  get  them.

-   Check of work was LTA
-   Attention is given to wrong issues
-   Strong rule incorrectly chosen over other rules

- Violation
- A3B4C2

**Notes:**
Talking  Points
This  person  committed  a  deliberate,  intentional  act  to evade  a  known  policy  or  procedure  for personal advantage.  Violations  and  at-risk  practices  are  usually adopted  for  fun / convenience,  and  have  a  low  potential for detection  or  happen  due  to  an  absence of  authority in  the  immediate  vicinity.
This  person  is  in  the  A3B4  Node - Work  Practices  LTA 
This  is  a  Violation -  see  above  for  details.
C02 - Deliberate  Violation

This  is  repeated  here  for  instructor’s  convenience.
I  knew  that  the  area  was  a  “safety-glasses  required”  area.  I  was only  going  to  read  a  gauge  and  I  didn’t  have  my safety  glasses  with  me.  I  figured  that  by  the  time  I  went  to  get  my  glasses  and  got  back  I  could  have already  taken  the  reading  and  gone  to  lunch.  I  didn’t  think  that  it  was  a  big  deal  but  if  I  had  known  that  the  Safety  Engineer  was  watching  I  would  have  gone to  get  them.

## A4 - Management  Problem

**A4 - Management  Problem**

**Notes:**
The A4 branch looks for causes under Management Control that contribute to work conditions. Within A4, there may be multiple management causes at work that contribute to errors at the working level. 

The Management Problem branch methodically takes many of our current analyses beyond the typical “re-train/discipline the employee and/or revise the procedure” solutions so often seen in corrective action plans.

This branch has been heavily based on the  INPO model.

## A4 – Management  Problems

-    **The  Largest  Branch  on  the  Tree**
- There  are  5  ‘B’  Level  Nodes  associated
- 	 with  this  Branch
- There  are  56  ‘C’  Level  Nodes !

-    **Likely  to  be  Coupled  With  Other  **
**      ****Nodes**
- A3  Nodes  are  Typically  Coupled  Here

**Notes:**
Talking  Points:

Cover  the  points  on  the  slide – It  is  an  introduction  to  the  A4  Branch

## A4 Management  Problem 

-   C01  Management policy guidance / expectations not well-defined,
-            understood or enforced
-   C02  Job performance standards not adequately defined
-   C03  Management direction created insufficient awareness of impact of actions on safety / reliability
-   C04  Management follow-up or monitoring of activities did not
-            identify problems
-   C05  Management assessment did not determine causes of previous
-            event or known problem
-   C06  Previous industry or in-house experience was not effectively used to prevent recurrence
-   C07  Responsibility of personnel not well-defined or personnel not held accountable
-   C08  Corrective action responses to a known or repetitive problem was untimely
-   C09  Corrective action for previously identified problem or event was not adequate to prevent recurrence

**A4 **_**Management  Problem **_

**Notes:**
B1 - Management  Methods  addresses  causal factors  in  several areas  where  management  is  involved  with  or  affects  work processes

	When  investigating in this node, you need to become familiar with the local work standards and particularly with local management expectations.

C-1,  2,  3  involve  Management defining the big picture aspects (policy, guidance, performance standards) that  identify  what  we   are  to  do &  how  we  are  to  do  it.

C-4,  5,  6  concern  management’s  monitoring  of  what  is  going   on  (assessments  &  Lessons  Learned)

C-7  concerns  management  holding  employees  accountable

C-8,  9  concern  getting  proper  corrective  actions  identified  for problems. 

## A4 Management  Problem (continued) 

-   C01  Too many administrative duties assigned to immediate supervisor
-   C02  Insufficient supervisory resources to provide necessary supervision
-   C03  Insufficient manpower to support identified goal / objective
-   C04  Resources not provided to assure adequate training is provided / maintained
-   C05  Needed resource changes not approved / funded
-   C06  Means not provided to assure procedures / documents / records were of adequate quality and up-to-date
-   C07  Means not provided for assuring adequate availability of appropriate materials / tools
-   C08  Means not provided for assuring adequate equipment quality, reliability, or operability
-   C09  Personnel selection did not assure match of worker motivations / job descriptions
-   C10  Means / method not provided for assuring adequate quality of contract services

**A4 **_**Management  Problem **_(continued)_** **_

**Notes:**
B2 – Resource  Management  -  addresses causal factors that involve problems with manpower or material allocation

 C-1, 2 concern problems with supervision workload

C-3, 4 concern basic problems with manpower, with C4 specific to trainers.

C-5  concerns a specific issue of funding resources for corrective actions

C-6, 7, 8  are similar - they all concern problems with management  providing  resources in  certain  areas

C-9 concerns finding the right person for the right job.

C-10 concerns subcontractors.  That is finding the right subcontractor for all aspects of performing a job.

## Multiple

**Paths  Through**
**Causal  Analysis  Tree**

**Proposed**
**Corrective  Action**

**RECOMMENDED   DOCUMENTATION**

**The  Operator  **
**turned  the  wrong**
**valve**

**Multiple**
**Coding **

## A4 Management  Problem (continued) 

-   C01  Insufficient time for worker to prepare task
-   C02  Insufficient time allotted for task
-   C03  Duties not well-distributed among personnel
-   C04  Too few workers assigned to task
-   C05  Insufficient number of trained or experienced workers assigned to task
-   C06  Planning not coordinated with inputs from walkdowns / task analysis
-   C07  Job scoping did not identify potential task interruptions and / or environmental stress
-   C08  Job scoping did not identify special circumstances and / or conditions
-   C09  Work planning not coordinated with all departments involved in task
-   C10  Problem performing repetitive tasks and / or subtasks
-   C11  Inadequate work package preparation

**A4 **_**Management  Problem **_(continued)_** **_

**Notes:**
B3 – Work  Organization & Planning LTA  -  addresses how the work was organized.  This includes problems with work planning, assignment of people, and scheduling of a task.   This is a very specialized area that can be a big contributor to human error

C-1, 2  concern time needed to prepare for or complete a task.
C-3, 4, 5  concern a specific parts of human resource management
C-6, 7, 8 & 9  concern problems with work planning or job scoping activities
C-10  concerns a specific type of job that can cause a human error.
C-11  concerns problems with basic work package administration

## A4 Management  Problem (continued) 

-   C01  Tasks and individual accountability not made clear to worker
-   C02  Progress / status of task not adequately tracked
-   C03  Appropriate level of in-task supervision not determined prior to task
-   C04  Direct supervisory involvement in task interfered with overview role
-   C05  Emphasis on schedule exceeded emphasis on methods / doing a good job
-   C06  Job performance and self-checking standards not properly communicated
-   C07  Too many concurrent tasks assigned to worker
-   C08  Frequent job or task “shuffling”
-   C09  Assignment did not consider worker’s need to use higher-order skills
-   C10  Assignment did not consider worker’s previous task
-   C11  Assignment did not consider worker’s ingrained work patterns
-   C12  Contact with personnel too infrequent to detect work habit / attitude changes
-   C13  Provided feedback on negative performance but not on positive performance

**A4 **_**Management  Problem **_(continued)_** **_

**Notes:**
B4 - Supervisory  Methods  LTA  -  identifies causes that can be traced back to immediate supervision.  
C-1   concerns  tasks  that  do  not  have  written  guidance  or  specific  training
C-2, 3  involve  problems  with supervisor  tracking  and supervisor  tracking  planning
C-4  excessive  supervision  
C-5  schedule vs. performance 
C-6  insufficient self-monitoring  guidance  given  to worker 
C-7, 8  too  many  tasks  assigned  or  switching  jobs too soon
C-9  Supervisor didn’t consider workers talents or strengths or workers needs to use higher order skills
C-10, 11 - Job  assignments
C-12, 13 - Supervisor contact LTA - Feedback LTA

## A4 Management  Problem (continued) 

-   C01  Problem identification did not identify need for change
-   C02  Change not implemented in timely manner
-   C03  Inadequate vendor support of change
-   C04  Risks / consequences associated with change not adequately reviewed / assessed
-   C05  System interactions not considered
-   C06  Personnel / department interactions not considered
-   C07  Effects of change on schedules not adequately addressed
-   C08  Change-related training / retraining not performed or not adequate
-   C09  Change-related documents not developed or revised
-   C10  Change-related equipment not provided or not revised
-   C11  Changes not adequately communicated
-   C12  Change not identifiable during task
-   C13  Accuracy / effectiveness of change not verified or not validated

**A4 **_**Management  Problem **_(continued)_** **_

**Notes:**
B-5  Change  Management  - addresses  precursors  not  factored  in  by  management  when  new  changes  are implemented.  

This category considers the process by which changes are controlled and implemented by MANAGEMENT

C-1, 2, 3, 4  concern  problems  in  identifying  a change

C-5, 6, 7  concern  problems  made  because  of  the change

C-9, 10  concern  changes  needed  to  support  the  change  (documents & equipment)

C-11, 12  concern  change  communication

C-13  concerns  post  change  effectiveness  reviews 

## 

**instrumentation  was  out  of  calibration.  Corrective  **
**measures  had  been  identified  for  a  previous  **
**overflow  of  the  tank  but  had  not  been  implemented  **
**when  the  second  overflow  occurred.**

-  **Inadequate  vendor  support  of  change**
-  **Too  many  concurrent  tasks  assigned  to  worker**
-  **Corrective  action  response  to  a  known  or  **
**      ****repetitive  problem  was  untimely**

-   **B1** **-  Management  Methods**
-   **B2**** -  Resource  Management**
-   **B4**** -  Supervisory Methods**

**A4  Exercise**

**Notes:**
Talking Points:

Present  slide  and  have  class  take  a  minute  and  read  through the  first  portion  that  shows  on  the  screen.
Ask  the  class  to  choose  the  B Level  Node  they  feel  best  represents  the   scenario.
Discuss  student  choices  then  reveal  the  KEY  ANSWER
B1  is  Correct – Resource  Management  was  not  the  problem  here,  nor  was  this  a  Change  Management  issue.
Ask  the  class  to  choose  the  Apparent  Cause (C Level  Node)  they  feel  best  represents  the   scenario.
Discuss  student  choices  then  reveal  the  KEY  ANSWER
Corrective  action  response  to  a known  or  repetitive  problem  was  untimely  (A4B1C07) – is Correct

## A5 - Communications  LTA

**A5 - Communications  LTA**

**Notes:**
Placeholder  Slide   - to  Introduce  the A5 Branch  of  the Causal  Analysis  Tree

## A5 Communications LTA 

-   C01  Format deficiencies
-   C02  Improper referencing or branching
-   C03  Checklist LTA
-   C04  Deficiencies in user aids (charts, etc.)
-   C05  Recent changes not made apparent to user
-   C06  Instruction step / information in wrong sequence
-   C07  Unclear / complex wording or grammar
**B2  WRITTEN  COMMUNICATION  CONTENT** LTA
-   C01  Limit inaccuracies
-   C02  Difficult to implement
-   C03  Data / computations wrong / incomplete
-   C04  Equipment identification LTA
-   C05  Ambiguous instructions/ requirements
-   C06  Typographical error
-   C07  Facts wrong / requirements not correct
-   C08  Incomplete / situation not covered
-   C09  Wrong revision used

**A5 **_**Communications LTA**__** **_

**B3  ****WRITTEN  COMMUNICATION    **
**       ****NOT   USED**
-   C01  Lack of written communication_ _
-   C02  Not available or inconvenient    for use
**B4  VERBAL  COMMUNICATION LTA**
-   C01  Communication between work   groups LTA
-   C02  Shift communications LTA
-   C03  Correct terminology not used
-   C04  Verification / repeat back not used
-   C05  Information sent but not understood
-   C06  Suspected problems not communicated to supervision
-   C07  No communication method available

**Notes:**
Talking  Points:

Based  on  the  Best  Practices  from  our  benchmarking  data

This  is  a  combination  of  the  old  ORPS  Procedure  Problem  and  part  of  Inadequate  Administrative  Control  with  the  old  ORPS  Personnel  Error  /   Communication  Problem   Node

Discuss  the  4 ‘B’ Level  Nodes

 Has  both  verbal  and  written  communication  nodes  under  one  Branch.

## 

- The  instructions  simply  stated  “replace  the  pump.”
- Numerous  actions  were  required  to  replace  the  pump,
- including  an  electrical  lockout,  which  were  not
- correctly  performed.

-  **Recent  changes  not  made  apparent  to  user**
-  **Incomplete / situation  not  covered**
-  **Communication  between  work  groups  LTA**

-   **B2** **-  Written  Communication  Content  LTA**
-   **B3**** -  Written  Communication   Not  Used**
-   **B4**** -  Verbal  Communication  LTA**

**A5  Exercise**

## A6 - Training  Deficiency

**A6 - Training  Deficiency**

**Notes:**
Placeholder  Slide   - to  Introduce  the A6  Branch  of  the   Causal  Analysis  Tree

## A6 Training  Deficiency 

**B1  NO  TRAINING  PROVIDED**
-   C01  Decision not to train
-        C02  Training requirements not identified
-        C03  Work incorrectly considered “skill of the craft”
**B2  TRAINING  METHODS   LTA**
-        C01  Practice or hands-on experience LTA_ _
-        C02  Testing LTA
-        C03  Refresher training LTA_ _
-        C04  Inadequate presentation_ _
**B3  TRAINING   MATERIAL   LTA**
-        C01  Training objectives LTA
-        C02  Inadequate content_ _
-        C03  Training on new work methods LTA
-        C04  Performance standards LTA

**Notes:**
Talking  Points:

This  is  an  event  or  condition  resulting  from  a  management  or  human  performance  error  caused  by  a  fault  in  the  training  process.

B1 - NO  TRAINING  PROVIDED - Training  on  the  task  was  not  given  to  the  worker.

B2 - TRAINING  METHODS  LTA - Training  was  provided,  but  in  an  ineffective  manner.

B3 - TRAINING  MATERIAL  LTA - Training  was  provided,  but  the  training  content  was  flawed.

## 

- because  of  incorrect  use  of  a  scale.  He  had  received
- instruction  on  the  use  of  the  scale  but  had  not  been
- tested  on  his  ability  to actually  use  the  scale.

-  **Work  incorrectly  considered  “skill  of  the  craft”**
-  **Training  objectives  LTA**
-  **Testing   LTA**

-   **B1** **-  No  Training  Provided**
-   **B2**** – Training  Methods  LTA**
-   **B3**** -  Training  Content  LTA**

**A6  Exercise**

**Notes:**
Talking Points:

Present  slide  and  have  class  take  a  minute  and  read  through the  first  portion  that  shows  on  the  screen.
Ask  the  class  to  choose  the  B Level  Node  they  feel  best  represents  the   scenario.
Discuss  student  choices  then  reveal  the  KEY  ANSWER
B2  is  Correct – No  Training  Provided  is  not  correct - he  had  received  instruction,  Training  Content  is  not  correct  either - use of  the  scale  was  taught.
Ask  the  class  to  choose  the  Apparent  Cause (C Level  Node)  they  feel  best  represents  the   scenario.
Discuss  student  choices  then  reveal  the  KEY  ANSWER
Testing  LTA  (A6B2C02) – is Correct

## A7 - Other Problem

**A7 - Other Problem**

**Notes:**
Placeholder  Slide   - to  Introduce  the A7  Branch  of  the   Causal  Analysis  Tree

## A7 Other  Problem 

**B1  EXTERNAL  PHENOMENA**_** **_
-        C01  Weather  or  ambient  conditions    LTA
-        C02  Power  failure  or  transient
-        C03  External  fire  or  explosion
-        C04  Other  natural  phenomena  LTA
**B2  RADIOLOGICAL / HAZARDOUS**
**       ****MATERIAL   PROBLEM**
-        C01  Legacy  contamination_ _
-        C02  Source  unknown

## 

- environmental  survey.   The  location  had  been
- previously  used  as  a  storage  site  for  transformers.
- The  transformers  had  leaked.   The  leakage  was
- unknown / undiscovered  at  the  time  the  transformers
- were  removed.

-  **Other  natural  phenomena**
-  **Legacy  contamination**
-  **Source  unknown**

-   **B1** **-  External  Phenomena**
-   **B2**** – Radiological / Hazardous  Material  **
**                ****Problem**

**A7  Exercise**

**Notes:**
Talking Points:

Present  slide  and  have  class  take  a  minute  and  read  through the  first  portion  that  shows  on  the  screen.
Ask  the  class  to  choose  the  B Level  Node  they  feel  best  represents  the   scenario.
Discuss  student  choices  then  reveal  the  KEY  ANSWER
B2  is  Correct – This  was  not  an  External  Phenomena.
Ask  the  class  to  choose  the  Apparent  Cause (C Level  Node)  they  feel  best  represents  the   scenario.
Discuss  student  choices  then  reveal  the  KEY  ANSWER
Legacy  Contamination  (A7B2C01) – is Correct

## End  of  Course !