Cause and Effect Relationship with Trending

Transcription

1 Cause and Effect Relationship with Trending Alex Torres Contractor Assurance Washington River Protection LLC. Contractor to the U.S. Department of Energy 1

2 Purpose Provide an overview of the relationship between trending and cause analysis by demonstrating the interrelationships between cause and effect, common cause, and performance trending. Topics include: Differences between events/accidents and problems/conditions Relationship between cause codes and problem codes Relationship between trending, cause and effect, and common cause 2

3 References DOE O 225-1B, "Accident Investigation" DOE-STD , "Occurrence Reporting Causal Analysis" DOE-HDBK , "Human Performance Improvement Handbook, Volume 1: Concepts and Principles" DOE-HDBK , "Human Performance Improvement Handbook, Volume 2: Human Performance Tools for Individuals, Work Teams, and Management" INPO , "Human Performance Reference Manual" INPO , "Performance Assessment and Trending" 3

4 Events/Error Precursors/Latent Weaknesses An event/accident is an unwanted, unplanned, undesirable change in the state of structures, systems, or components or in human/organizational conditions (health, behavior, administrative controls, environment, and so on) that exceeds established significance criteria. Events Typically triggered by human action (i.e., direct cause). In most cases, the human action causing the event was in error. However, the action could have: Resulted from organizational weakness (hidden conditions in management control processes that directed the action). Been a violation (a shortcut taken to get the job done). Resulted from flawed defenses that failed to prevent the active error. 4

5 Events/Error Precursors/Latent Weaknesses (cont.) A problem is an undesired condition where systems/structures /components or personnel action/behavior is not compliant or does not meet expectations for quality or performance. Problems Can result from active or latent human error. Can be discovered during assessments, observations, audits, inspections, surveillances, or is self-revealing during an event. May not have consequence or is a cause/contributor to an event The problem could have: Resulted from organizational weakness (hidden conditions in management control processes that directed the action) Been a violation (a shortcut taken to get the job done) Resulted from flawed defenses that failed to prevent the error 5

6 Events/Error Precursors/Latent Weaknesses (cont.) Many times there are recurring problems / conditions that exist, but do not result in an event. Identifying problems / conditions that have resulted in past events or recognizing the potential to cause/contribute to an event is where Trend Analysis begins. Flawed controls, Error Precursors, Latent weaknesses, and initiating action, are the causal factors for an event/accident. 6

7 Events/Error Precursors/Latent Weaknesses (cont.) Event examples Fire/explosion Damage to systems, structures, components, or personnel (e.g., bridge collapse, vehicle accident, personnel injury) Release of hazardous/radiological material into the environment Medical procedure incorrectly performed (e.g., wrong limb amputated) Problem examples In adequate hazardous energy isolation (Flawed Control) Procedures not consistently followed (Error Precursors) System/component configuration issues (Error Precursors) Drawing/procedure errors (Latent Organizational Weakness) Insufficient management oversight (Latent Organizational Weakness) 7

8 Problems/Undesired Conditions Problems that do not result in significant consequence are usually just corrected. Due to the low significance, spending time and resources to understand why may not be warranted. For example, identifying inadequate hazardous energy isolation during the review process (i.e., prior to approval) is not consequential. If identified after approval, but prior to work start, a cause analysis to understand why the isolation was inadequate is warranted. A problem can be a causal factor for an event with significant consequences. For example, a worker injured by hazardous energy could have been caused by inadequate hazardous energy isolation in combination with other causal factors. 8

9 Problems/Undesired Conditions(cont.) Problems as Causes Causal Factor a problem/condition that either caused the event/problem or contributed to the unwanted result. If it were not for this problem/condition, the unwanted result would not have occurred (i.e., apparent or root cause) or would have been less severe (i.e., contributing cause). Apparent Cause the most probable cause(s) that explains why the event happened, that can reasonably be identified, that local or facility management has the control to fix. Root Cause the causal factor(s) that, if corrected, would prevent recurrence of the event/accident. It is the most basic cause that explains why the event happened, that can reasonably be identified, that senior management has the control to fix. 9

10 Problems/Undesired Conditions(cont.) Recurring non-consequential problems that were casual factors for a previous event or have the potential for significant consequences, is a TREND. For example, multiple non-consequential instances where inadequate hazardous energy isolation is an indicator of a more pervasive programmatic or organizational weakness. Continued performance without correction increases risk and can result in a significant event; It is just a matter of time. 10

11 Trend Codes Trends codes are applied problems and events to better recognize patterns of recurrence. Event/Accident Codes: assigned to identify phenomenon (e.g., fire, vehicle accident, failures, violation); normally self-revealing. Accountability Codes: assigned to identify the facility, organization, department responsible for the problem/event. Problem Codes: assigned to identify the issues as described in the problem statement for non-events/accidents. Normally identified as the 'Trend Codes'. Can be causal factors for events/accidents. Cause Codes: assigned to identify the causes for an event/accident or problem. Normally separate from problems codes, but can be the same. 11

12 Hazardous Energy Control Process Map and Barrier Analysis Precursor Issues / Performance Events 153 personnel authorized to prepare, review, authorized, hang, and verify DDNO lock and tags. CC01 Note: Unidentified Hazard Bypasses LOTO Process Planner/Supervisor/FWS/ Worker Reviews Technical Reviewer COA Administrive Verifications Independent Verification Safe Condition Checks COA Administrative Verification AW TAF Verification Safe-to-Work Check Work Control Job Hazard Analysis & Scope Change 3 PERs Documented Performance Errors. Barrier LOTO Process 5.2 LOTO Development 11 PERs Documented Performance Errors Barrier LOTO Process 5.3 Authorizing LOTO 1 PERs Documented Performance Errors Barrier LOTO Process /5.6 Installation or Removal of LOTO 6 PERs Documented Performance Errors Barrier LOTO Process AW Walkdown, L&T installation, and DDNO tag Verification 8 PERs Documented Performance Errors Barrier Pre-Job Brief Start Work H A Z A R D 9 PERs Involved Barriers Failing to Identify Errors 10 PERs Involved Barriers Failing to Identify Errors 14 PERs Involved Barriers Failing to Identify Errors and poor pre-installation briefs 7 PERs Involved Barriers Failing to Identify Errors LTA Rigor in Verification Performance Common to All Issues Barrier Failing to Identify Error None Noted Existing LOTO Performance Indicators not setup to identify degrading precursor performance. Observations on LOTO were not being performed. Thus, degrading precursor performance not recognized not coached. Annual reviews of LOTOs per DOE-0336 do not evaluate field performance. Thus, poor performance behaviors are not recognized for correction. A single authority to oversee and ensure the health of the LOTO Program has never been assigned. Previous industry or in-house experience was not effectively used to prevent recurrence of LOTO issues. CC02 RC01 RC02 4 Occurrences and 7 Instances of Errors Identified After Work Start Evaluation Period- January 2009 to September

13 Not all Low Level LO/TO Issues Entered in PERs Reportable Non- Reportable Procedure Adherence and Training Issues Unauthorized Removal of Lockout Assessment determined LOTO program effective Inadequate Isolation Boundary SCR Event CAs Fully Implemented Comp Measures Unexpected discovery of energy SCR Event Declared RCA PER Current Performance Period Contact with Energy Minor Shock EPA determined LO/TO program effective

14 LOTO Safety Significance Trend Sig Level 1 Sig Level 2 Sig Level 3 Sig Level 4 Sig Level 5 3 Month Moving Avg 20 Sum of PER Significance Level

15 Cause & Effect Trend Code Relationship (cont.) Low Significance Issue (identified by second checker and corrected) In this case less than adequate (LTA) management oversight was determined to be the cause for the event since personnel are trained on the 3-Touch expectations when they are qualified, but the desired behavior was never reinforced after initial training. LOTO Error Code: LOTO Assumed Component Correct Code: Assumptions 3-Touch HPI Tool not utilized as required Code: Incorrect performance due to mental lapse Management oversight LTA in that use of 3-Touch not enforced Code: Oversight LTA 15

16 Cause & Effect to Trend Code Relationship (cont.) Significant Issue (Contact with hazardous energy resulting in injury) LTA Management oversight was determined to be the cause for this issue that resulted in consequence. LOTO Event- Contact with Energy Code: LOTO Unlabeled breaker assumed correct Code: Assumptions 3-Touch HPI Tool not utilized as required Code: Incorrect performance Management oversight LTA in that due to mental lapse use of 3-Touch not enforced Code: Oversight LTA Corrective Actions 1. Revise Observation Procedure 2. Schedule and perform periodic observations on LOTO evolutions 16

17 Cause & Effect to Trend Code Relationship (cont.) In this case, an assessment identified observations have not been performed on the Lockout/Tagout (LOTO) performance in the field for last five years; only administrative reviews were performed. In this scenario, LTA oversight is the undesired conditions identified and not the cause. Code: Oversight LTA Management oversight LTA LOTO Observations not Performed No expectation to perform field observations Code: Management policy guidance / expectations not well-defined Corrective Actions 1. Revise Procedure 2. Schedule & perform periodic observations to enforce expectation for performacne 17

18 Cause & Effect to Trend Code Relationship (cont.) DOE Standard DOE-STD , "Occurrence Reporting Causal Analysis," provides: Associations between INPO human performance error precursors 1 to cause codes. 1 Task Demands, Work Environment, Individual Capabilities, Human Nature (TWIN) INPO HU Error Precursor Associated DOE Cause Code TASK DEMANDS High Workload (Memory A4B4C07- Too many concurrent tasks assigned to worker requirements) A5B2C05- Ambiguous instructions / requirements A5B2C08- Incomplete / situation not covered WORK ENVIRONMENT Distractions/ Interruptions A4B3C07- Job scoping did not identify potential task interruptions and/or A4B4C07- Too many concurrent tasks assigned to worker INDIVIDUAL CAPABILITIES Unfamiliarity with task/first A4B2C02- Insufficient supervisory resources to provide necessary supervision time A6B2C01- Practice or hands on experience LTA HUMAN NATURE Inaccurate risk perception A4B1C03- Management direction created insufficient awareness of impact A4B3C07- Job scoping did not identify potential task interruptions and/or 18

19 Cause & Effect to Trend Code Relationship (cont.) DOE Standard DOE-STD , "Occurrence Reporting Causal Analysis," provides (continued): Associations between Human Performance codes to organizational, functional, and process cause codes Human Performance Cause Codes A3B1C01 Check of work was LTA A3B1C03 Incorrect performance due to mental lapse A3B1C06 Wrong action selected based on similarity with other actions A3B2C02 Signs to stop were ignored and step performed incorrectly A3B2C04 Previous success in use of rule reinforced continued use of rule Potential Associated Organizational or Programmatic Cause Code Level C nodes applicable to the Additional Level C Nodes applicable to the particular A3 Level C Node associated A3 Level B Node A1B5C02, Physical environment LTA, A1B1C03, Design input not correct, A5B1C03, Checklist LTA A4B1C03, Management direction A4B4C07, Too many concurrent tasks created insufficient awareness assigned to worker, A4B4C03, Appropriate level of in task A4B4C08, Frequent job or task shuffling supervision not determined prior to A5B1C07, Unclear / complex wording or task, grammar, A4B4C06, Job performance and A5B2C05, Ambiguous instructions self checking standards not properly... A4B4C06, Job performance and self checking standards not properly communicated A4B3C10, Problem performing repetitive tasks and/or subtasks A4B1C09, Previous corrective actions inadequate to prevent recurrence, A5B2C05, Ambiguous instructions / requirements, A6B2C01, Practice or hands on experience LTA 19

20 Behaviors are Transportable Behaviors can be transferred between functional areas since they reside within humans. Undesired behaviors can trigger events or allow poor performance to go unrecognized. Procedures Construction Industrial Hygiene Radcon Assumptions Rationalization Step was omitted Check of work LTA Step incorrectly performed Performance expectation not met Wrong action/rule selected/used Procedure not followed/used Signs to stop were ignored Deliberate violation Oversight LTA Safety Identify the organizational and programmatic drivers for unwanted behaviors and correct. Design Field Work Safety Basis 20

21 Summary A Cause and Effect relationship exist with problems and events Common cause analyses should look at cause codes and similar problem codes to obtain insight into precursor behaviors that contributed to the event/problem. Trend analysts need to evaluated past performance and contributing precursor behaviors for past events to determine if current precursor performance is declining with potential for a consequential event. Trend codes applied to problems inherently retained Cause and Effect relationship 21