Challenges to Conducting a Good Investigation: A National Laboratory Perspective

1. Challenges to Conducting a Good Investigation: A National Laboratory Perspective Debbie Jenkins Director, Performance Analysis and Quality, ORNL • Accident Investigation Workshop, Oak Ridge National Laboratory

2. Battelle Memorial Institute has chartered “Communities of Practice” to promote continuous improvement • A formal cross-cutting effort designed to help establish laboratory operations' standards and expected levels of performance for management systems • Each COP’s expectations include • Identifying, documenting, and sharing of best practices • Strengthening capability development and stewardship • Ensuring deployment of expertise to meet internal needs The Integrated Performance Management COP has the responsibility for event investigation processes

3. Formal Investigations are performed for serious events/issues • Examples of serious events have included • Serious injury caused by 1500 lb. falling magnet • Gun accidently discharged during training class • Radiological release and employee exposures • Our serious events are not mass casualty events that are sometimes seen in the commercial industry • From FY2013 – FY2016, Battelle Laboratories have conducted approx. 120 investigations Investigations & Root Cause Analysis Apparent Cause Analysis No Causal Required • The vast majority of our investigations are • conducted internally

4. The process for investigation and analysis

5. Rarely do we see an event caused by one thing, usually it’s a combination of factors March 1580 lb chamber tipped over onto employee, resulting in fractures and lacerations (surgery required) Inadequate safety culture in work groups and supervisors Inexperienced supervision and salvage handlers Led to 41 corrective actions over 4 years 2014

6. Our investigation process is rigorous and self-critical • However, there are some common challenges: • Multiple causal factors can lessen the importance of the critical issues to address • Overwhelming list of corrective actions can result from these types of investigations • You can fall into the trap of treating all identified causes equally • Considerable resource challenge result that could detract from the important criteria or causes • Corrective actions can take up to months and years to close Are we diluting the impact of our improvement actions by trying to fix everything?

7. INPO found that allowing supervisors to spend more time coaching staff is required to improve human performance • Improving operational reliability and safety performance • Promote steps that supervisors and managers can take to manage administrative burden and improve reinforcing worker behaviors • Streamline activities and time needed for supervisors to prepare workers for daily activities “A disproportionate number of human resources are focused on the administrative aspects of the corrective action program (CAP) process, and extensive causal analysis…As a result, these administrative aspects detract supervisors and managers from being in the field coaching workers and preventing problems.” • Increase supervisor coaching and reduce efforts to capture and trend observations • Reduce the number of low-value corrective actions assigned to an issue (some issues are best handled by managers coaching individuals or reinforcing accountability)

8. We are asking ourselves some key questions about our investigation processes • Are we losing focus on the most important issues in an effort to find every possible contributing causes? • Are we using the best techniques to isolate the true root cause of an event? • Are we hindering organizational learning by overwhelming our staff with corrective actions? • Does volume of cause and corrective actions equate to a good investigation? • Is our investigation process perpetuating a lack of focus on the most significant aspects of preventing recurrence?