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 - PowerPoint PPT Presentation

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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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Title: Evaluation of Effectiveness of Corrective Actions Related to DOE OA-50 Review and PNNL Causal Analysis Review Author: Bob Collum Last modified by – PowerPoint PPT presentation

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Title: 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


1
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.

2
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

3
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
4
Insert the flowchart here?
5
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

6
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

7
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

8
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

9
HPI Flavor Using Anatomy of Event
10
HPI Flavor Anatomy of Event Error Precursors
11
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
12
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
13
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

14
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.
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