A Practical Approach to Using Causal Analysis Methods to Evaluate Events as the First Step to Continuous Improvement and Accident Prevention at Brookhaven National Laboratory

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A Practical Approach to Using Causal
AnalysisMethods to Evaluate Events as the First
Step to Continuous Improvement and Accident
Preventionat Brookhaven National Laboratory

• Co-Authors
• Roy Lebel, Brookhaven National Laboratory
• Robert McCallum, McCallum-Turner, Inc.
• Presenter
• Robert Crowley, PE, McCallum-Turner, Inc.

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Brookhaven National Laboratory Issues Management
Process Improvement Initiative

• BNL determined their issues management process
  was deficient and embarked on an initiative
  institutionalize an Issues Management Program for
  both reportable and non-reportable events and
  issues as part of an accident/event prevention
  strategy
• Several Key improvements were implemented
  including
• Defining lower level issues for line management
  to evaluate
• Training on the conduct of Critiques to
  improve fact finding
• Training for staff and managers on Causal
  Analysis Methods

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Why Implement this Strategy?

• Prevent More Serious Events from Occurring by
  Focusing on Review and Analysis of Low
  Significance (low-level) Events

ORPS/ACCIDENTS/PAAA
Incidents Conditions
Spills
SCBNL
Radiological Awareness Reports
Nonconformances
Audits
Tier 1
Assessments
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Insert the flowchart here?
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Causal Analysis Methods

• There are a myriad of credible causal analysis
  methods ranging from simple to complex
• DOE has guides and standards addressing causal
  analysis including
• DOE-G 231.1 Occurrence Reporting Casual Analysis
  Guide
• DOE-NE- STD-1004-92 Root Cause Analysis Guidance
  Document
• DOE O 225.1A Accident Investigation Guidance
  Document
• Brookhaven National Laboratory also has guidance
  that addresses Causal Analysis methods Causal
  Analysis Methodologies that is part of the BNL
  SBMS System

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Brookhaven Accident\Issues PreventionCausal
Analysis Strategy

• Focus of the Strategy
• Line organizations would analyze the causes of
  lower level less complex events
• Analytical methods used will be recognized by
  both Brookhaven National Laboratory and the
  Department of Energy
• Develop case studies tailored to both research
  and support organizations
• Formally train line organizations on simple
  analytical methods that can be readily used after
  limited training

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Brookhaven Accident\Issues PreventionCausal
Analysis Strategy (Phase I)

• The first training session was conducted in
  August 2006 at Brookhaven National Laboratory
• Focused on Barrier Analysis and introduction to
  the Five Whys analytical method
• Simple analytical methods used effectively by BNL
  and DOE for event and accident investigations
• Short training sessions (4 hours) were conducted
  with case studies developed for ERWM and research
  organizations based on DOE incidents
• 60 Brookhaven National Laboratory managers and
  staff were trained and provided a case study for
  future reference

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Brookhaven Accident\Issues PreventionCausal
Analysis Strategy (Phase II)

• The second training session was conducted in
  December 2006 at Brookhaven National Laboratory
• Focused on Events and Casual Factor Analysis
  and application of the Five Whys analytical
  methods (with an HPI flavor)
• Simple analytical methods used effectively by BNL
  and DOE for event and accident investigations
• Short training sessions (6 hours) were conducted
  with a case study based on a DOE accident in a
  research laboratory
• Approximately 40 Brookhaven National Laboratory
  managers and staff were trained and provided a
  case study for future reference

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HPI Flavor Using Anatomy of Event
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HPI Flavor Anatomy of Event Error Precursors
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The Five Whys
Visual Depiction of Causal Factor Analysis Using
Five Whys
Why 1
Condition 3
Causal Factor 3
Why 1
Why 2
Condition 5
Causal Factor 5
Why 1
Why 2
Condition 2
Causal Factor 2
Why 1
Why 2
Condition 4
Causal Factor 4
Why 1
Why 2
Condition 1
Causal Factor 1
Event 2
Event 1
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The Five Whys
Visual Depiction of Identification of Root Cause
Using Five Whys
Collect CFs
Identify Common CFs
Causal Factor 1
Causal Factor 1,2
Apply Five Whys Technique
Causal Factor 2
Root Cause
Causal Factor 3
Causal Factor 3
Causal Factor 4
Causal Factor 4,5
Causal Factor 5
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The Five Whys

• What are the organizational conditions that are
  more conducive for the Five Whys to be
  successful?
• A culture where problems are surfaced quickly
• A culture where identification of needed
  actions are viewed as an opportunity to move to
  an ideal or improved state of performance
• A culture where the focus is on improving
  processes and systems
• The above are examples of HPI principles and the
  learning culture Brookhaven National Laboratory
  is institutionalizing

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Conclusion

• Brookhaven National Laboratory trained over 100
  managers and staff in simple causal analysis
  methods.
• Training incorporating the Error Precursor Short
  List resulted in identification of
  approximately 20 more conditions for analysis in
  case studies used for training.
• Brookhaven National Laboratory Causal Analysis
  Implementation Strategy using these simple
  methods is being used across Laboratory
  Organizations that experienced lower level
  events.
• No Type A or Type B Accidents since beginning
  this initiative.