Documente Academic
Documente Profesional
Documente Cultură
Using Tools
USE A TOOL
tree analysis
2. Critical incident techniques
3. Events & causal factors
analysis
4. Pareto Analysis
5. Change analysis
6. Barrier analysis
7. Management Oversight &
Risk Tree (MORT) analysis
8. Why Staircase
NRC IP 95001
Timely collection
Verification
Preserve evidence
Document analysis so
Progression of the problem
is clearly understood
Any missing information or
inconsistencies are identified
Problem can be easily explained
and/or
understood by others
NRC IP 95001
Continuous Performance
Improvement
Problem
Prevention
Symptom/Effect
Analysis
Cause
Analysis
Solution
Analysis
Problem
Prevention
Follow Up
Analysis
Solution
Analysis
Follow Up
Analysis
Symptom/Effe
ct Analysis
Cause
Analysis
Avatar International Inc., 1985
Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis
Process
Written
Followed
Include
Acceptance
Criteria
10CFR50, App. B
Callaway Plant Lead Auditor
Training
Scope The
Problem
Investigate
The Factors
Reconstruct
The Story
Establish
Contributing
Factors
Validate
Underlying
Factors
Progression of the
problem
Precise, complete, bounded
problem statement
Plan
Corrective
Actions
Report
Learnings
Auditable,
defensible record
Correctable root and
contributing causes
Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis
Process
Techniques
Deviation Statement
Difference Mapping
Problem Description
Extent of Condition
Review
Methodology Selection
Defect
Same-Same-Same
An Identical Object
in an Equivalent Application
with a Matching Defect
Same-Same-Similar
An Identical Object
in an Equivalent Application
with a Related Defect
Similar-Same-Same
A Comparable Object
in an Equivalent Application
with a Matching Defect
Peer Check
Techniques
Evidence Preservation
Interviewing (What & How)
Performance Analysis
Worksheet
Culpability Decision Tree
Substitution Test/Survey
SORTM questions
2.
3.
TwoPronged
Approach to
Incident
Prevention
Md
System Factors Prong
Re
Human Factors Prong
Factor Tree
Techniques
Fault Tree
Task Analysis
Critical Activity
Charting
Actions & Factors Chart
Human-Machine Interface
Step 2:
Identify
1st Level
Inputs
Step 3:
Link Using
Logic Gates
Step 4:
Identify
2nd Level
Inputs
Step 8:
Determine
Contributing
Factors
Physical
Roots
Step 7:
Investigate
Remaining
Inputs
Step 6:
Develop
Remaining
Inputs
Step 5:
Evaluate
Inputs
Factor
Flow
Equipment
Physical
Roots
Human-Machine
Interface
Response
Think (Operation)
Human
Stimulus
Roots
Defense-In-Depth
Latent
Organizational
Weaknesses
Latent
Roots
Step 2:
Select
Task(s) of
Interest
Step 3:
Obtain
Background
Information
Step 4:
Prepare a Task
Performance
Guide
Step 7:
Reenact
Task
Performance
Step 7A:
Interview
Personnel
(Alternate
Method)
DOE-NE-STD-1004-92
Step 6:
Select
Personnel
Step 5:
Get Familiar
With the
Guide
Walk-Through Phase
How is a
Critical Human Activity Table
done?
1. Identify the human actions to be analyzed.
(This may be all the human actions in the incident,
or it may be those that are believed to have been
responsible for the event's occurrence.)
2. Decide which human actions caused the
Action
Action
Action
Inciden
t
Factor
Factor
Contributing
Factor
Contributing
Factor
Contributing
Factor
Work
Activity
Causes
Proces
s
Causes
Institution
al
Causes
General Format
ESTABLISH CONTRIBUTING
FACTORS (Step 4)
Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis Process
Techniques
Change Analysis
Barrier Analysis
Production/Protection
Strategy (Defense-In-Depth)
Analysis
Factor Tree
Engineere
d
Barriers
Admin
Control
s
Oversigh
t
Controls
Cultural
Controls
Eliminate task.
Prevent error.
Catch error.
Detect defect.
Mitigate harm.
Accept risk.
Carelessness and overconfidence are more dangerous than deliberately accepted risk.
Wilbur Wright, 1901 (www.faa.gov)
Muschara, Managing Critical Steps, HPRCT
2009
Muschara, Managing Defenses, HPRCT 2008
LOW HUMAN
INTERFACE
safely
6. Accept risks at appropriate management level
LEAST
EFFECTIVE
MIL-STD882D
HIGH HUMAN
INTERFACE
EFFECT/
CONSEQUENCES
(What Happened)
List one at timesequential order
not required
BARRIER/CONTROL THAT
SHOULD HAVE PRECLUDED
THE INCIDENT
list all applicable physical and
administrative defenses for each
consequence
Exampl
e
www.sandia.gov
www.sandia.gov
If this factor had not existed, could this incident have occurred?
If the answer is no, then youre on your way toward finding a Contributing Factor!
Techniques
WHY Factor Staircase
A-B-C Analysis
HOW-To-WHY Matrix
Cause & Effect Tree
Root Cause Test
Root Cause Evaluation
Extent of Cause
Review
Common Factor
Analysis
Incident
Execution
Preparation
Feedback
Outcomes
Methods
Resources
Plan/Do/Check/Act
Vision
Beliefs
Values
Capabilities/Limitations
Task Demands/Environment
Culture
Goals &
Values
Task
Preview
Pre-Job
Brief
Post-Job
Review
Behavio
r
Business
Result
s
I
The A-B-Cs:
1st Occurrence
Desired behavior: Wear safety glasses
Safety policy
Safety signs
Safety procedure
Safety briefing
Just-in-time
training
Wear safety
glasses
C
Ears hurt
Cant see
clearly
Uncomfortable
Feel odd
The A-B-Cs:
Subsequent Occurrence
Desired behavior: Wear safety glasses
C
Ears dont hurt
Can see clearly
Less bother
Md
Walk-downs
Task Preview
Pre-Job Brief
Turnover
Processes/
Practices
Walk-downs
Task qualifications
Performance Feedback
Task assignment
Tasks/
Behaviors
Leadership
Defense In Depth
Staffing
Continuous Learning
Clear Expectations
Change Management
Benchmarking
Problem-Solving
Reviews & Approvals
Communication Practices
Simple, Effective Processes Management Practices
Accountability Rewards & Reinforcement
Interlocks
Independent Verification
Personal Protective
Equipment
Alarms
Results/
Consequence
s
Goals/
Values
Handoffs
Questioning Attitude
Procedure Use
Procedure Adherence
Self-Check
Place-keeping Observations
Conservative Decision-Making
3 Part Communication
StopWhen Unsure
Peer Check
Post-Job Critiques
Root Cause Analysis
Independent Oversight
Performance Indicators
Task assignment
Berms
Redundant trains
Equipment Reliability
Containment
Equipment Protection Systems
Safeguards Equipment
INPO Human Performance Fundamentals
Course
Deeper Understanding
Safety Culture
Analysis
Do Last!!!
Tasks/
Behavior
s
Processes
/
Practices
Goals/
Values
Peer Check
Step 2
Gather
Data
Step 3
Determine Which
Information to
Evaluate
Step 4
Categorize
the Data
Step 5
Identify Areas
for Further
Analyses
Step 9
Report
Learnings
Step 8
Plan
Corrective
Actions
Step 7
Develop and
Validate Causal
Theories
Step 6
Analyze
Areas of
Interest
Techniques
Action Plan
Solution Selection
Tree
Solution Selection
Matrix
Change Management
Active Coaching Plan
S.M.A.R.T.E.R.
Effectiveness Review
Contingency Plan
Communication Plan
Behavior Change
Institutionalization Plan
Factor/Cause
Being Addressed
Corrective
Action Step
1. Right
Picture
2. Communicate
3. Monitor
4. Feedback
Who
Owner
When
Due Date
www.hanford.gov
Reviewed
Effective
Time-sensitive
Related
Attainable
Measurable
Specific
S.M.A.R.T.E.R. Criteria
Institutionalization
Plan
Cause/Factor
Being
Addressed
1. Right Picture
2. Communicate
3. Monitor
4. Feedback
S.M.A.R.T.E.R.
Specific
Measurable
Attainable
Related
Timely
Effective
WHO
Reviewed
Owne
r
WHEN
Due
Date
Corrective Action
Effectiveness Scale
MIL-STD-882D
Md
TIMELINESS
SUCCESS
S
ATTRIBUTE
METHOD
Improving Performance: How to Manage the White Space on the Organization Chart, Rummler & Brache
REPORT LEARNINGS
(Step 7)
Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis
Process
Forms
Report Template
Grade Cards/Scoresheets
Questions?
Later
Frederick J. Forck, CPT*
4Konsulting, LLC
2320 Knight Valley Drive
Jefferson City, Mo 65101-2253
Phone: 573-645-8854
Fax: 573-636-7734
Email: fforck@4konsulting.com
www.4konsulting.com
*International Society for Performance Improvement (ISPI) Certified Performance Technologist (CPT)
Extent of Condition
Review Criteria
Deviation Statement
Same-Same-Same
An Identical Object
in an Equivalent Application
with a Matching Defect.
Same-Same-Similar
An Identical Object
in an Equivalent Application
with a Related Defect.
Similar-Same-Same
A Comparable Object
in an Equivalent Application
with a Matching Defect.
Similar-Same-Similar
A Comparable Object
in an Equivalent Application
with a Related Defect.
Same-Similar-Same
An Identical Object
in a Corresponding Application
with a Matching Defect.
Similar-Similar-Same
A Comparable Object
in a Corresponding Application
with a Matching Defect.
Same-Similar-Similar
An Identical Object
in a Corresponding Application
with a Related Defect.
Object
(Person, Place, Thing)
Application
(Activity, Form, Fit, Function)
Defect
(Flaw, Failing, Deficiency)
Object
Extent of Condition
(Person, Place, Thing)
Review Criteria
Deviation Statement Drivers Side Front Tire on
Same-Same-Same
An Identical Object
in an Equivalent Application
with a Matching Defect.
Same-Same-Similar
An Identical Object
in an Equivalent Application
with a Related Defect.
Similar-Same-Same
A Comparable Object
in an Equivalent Application
with a Matching Defect.
Similar-Same-Similar
A Comparable Object
in an Equivalent Application
with a Related Defect.
Same-Similar-Same
An Identical Object
in a Corresponding Application
with a Matching Defect.
Similar-Similar-Same
A Comparable Object
in a Corresponding Application
with a Matching Defect.
Same-Similar-Similar
An Identical Object
in a Corresponding Application
with a Related Defect.
Application
(Activity, Form, Fit, Function)
Defect
(Flaw, Failing, Deficiency)
Parked in My Driveway
Flat
Rental Car
1. Other Tires on Rental Car
2. Tires on Pickup Truck
1. Parked in My Driveway
2. Parked in My Driveway
1. Flat
2. Flat
1. Parked in My Driveway
2. Parked in My Driveway
1. Low on Air
2. Low on Air
1. Parked in My Driveway
2. Parked in My Driveway
1. Flat
2. Flat
1. Parked in My Driveway
2. Parked in My Driveway
1. Low on Air
2. Low on Air
1.
2.
3.
1.
1.
2.
3.
1.
1.
2.
3.
1.
In Trunk as a Spare
Parked on the Street
Parked in the Garage
Parked Behind My House
1. In Trunk as a Spare
2. Parked on Street
3. Parked in the Garage
Flat
Flat
Flat
Flat
1. Low on Air
2. Low on Air
3. Low on Air
O
R
O
R
O
R
O
R
(2)
Walk Through
by Analyst
or trained
individual.
(3)
Questions/
Conclusions about
how task
was/should be
performed.
WCNOC
(2)
Walk Through
by Analyst
or trained
individual.
Pig trap is not labeled.
Nearest pressure gauge is
up 2 flights of stairs about
50 away.
Other pig traps all have
pressure gauges near
opening.
(3)
Questions/
Conclusions about
how task
was/should be
performed.
Is there a requirement to label?
Why is the location without a
pressure gauge?
Has it been modified?
Steps are all very general.
How does the operator know how
to do them?
WCNOC
Example
www.sandia.gov
A.
B.
C.
D.
E.
Factors
that Influence
Performance
Failed
Performance
Past
Successful
Performance
Difference
or Change
Contributing
Factor?
(Yes/No)
When
Supervision
No co-workers
Yes. Worker
were available to came to work
help with the job. early, so was
working alone,
carrying tools.
Work activities
Yes. Because
were not
worker came to
discussed.
work early, job
hazards were not
discussed.
www.sandia.gov