Co-Authors: Roy Lebel, Brookhaven National Laboratory Robert McCallum, McCallum-Turner, Inc.

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

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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 FlawedDefenses Vision, Beliefs, & Values Mission Goals Policies Processes Programs Event InitiatingAction LatentOrganizationalWeaknesses ErrorPrecursors

10. “HPI Flavor” Anatomy of Event – Error Precursors Individual Capabilities Task Demands Task Demands Individual Capabilities • Time pressure (in a hurry) • Unfamiliarity w/ task / First time • High Workload (memory requirements) • Lack of knowledge (mental model) • Simultaneous, multiple tasks • New technique not used before • Repetitive actions, monotonous • Imprecise communication habits • Irrecoverable acts • Lack of proficiency / Inexperience • Interpretation requirements • Indistinct problem-solving skills • Unclear goals, roles, & responsibilities • “Hazardous” attitude for critical task Work Environment Human Nature • Lack of or unclear standards • Illness / Fatigue Work Environment Human Nature • Distractions / Interruptions • Stress (limits attention) • Changes / Departures from routine • Habit patterns • Confusing displays or controls • Assumptions (inaccurate mental picture) • Workarounds / OOS instruments • Complacency / Overconfidence • Hidden system response • Mindset (“tuned” to see) • Unexpected equipment conditions • Inaccurate risk perception (Pollyanna) • Lack of alternative indication • Mental shortcuts (biases) • Personality conflicts • Limited short-term memory

11. The Five Whys Visual Depiction of Causal Factor Analysis Using “Five Whys” Why 1 Condition 3 Causal Factor 3 Why 1 Why 2 Why 1 Why 2 Condition 5 Causal Factor 5 Condition 2 Causal Factor 2 Why 1 Why 2 Why 1 Why 2 Condition 4 Causal Factor 4 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.