A Practical Approach to Using Causal AnalysisA Practical Approach to Using Causal Analysis

Methods to Evaluate Events as the First Step to Methods to Evaluate Events as the First Step to

Continuous Improvement and Accident PreventionContinuous Improvement and Accident Prevention

at Brookhaven National Laboratoryat Brookhaven National Laboratory

Co-Authors:Co-Authors: Roy Lebel, Brookhaven National LaboratoryRoy Lebel, Brookhaven National Laboratory

Robert McCallum, McCallum-Turner, Inc.Robert McCallum, McCallum-Turner, Inc.

Presenter:Presenter:Robert Crowley, PE, McCallum-Turner, Inc.Robert Crowley, PE, McCallum-Turner, Inc.

• 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

Brookhaven National Laboratory Issues Management Process Improvement Initiative

Why Implement this Strategy?Prevent More Serious Events from Occurring by Focusing on Review and Analysis of Low Significance (low-level) Events

Radiological Awareness Reports

AssessmentsTier 1

ORPS/ACCIDENTS/PAAA

Spills

NonconformancesAudits

SCBNLIncidentsConditions

4

Insert the flowchart here?

• 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

04/21/23 5

Causal Analysis Methods

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

04/21/23 6

Brookhaven Accident\Issues PreventionCausal Analysis Strategy

7

• 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

Brookhaven Accident\Issues PreventionCausal Analysis Strategy (Phase I)

8

• 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

Brookhaven Accident\Issues PreventionCausal Analysis Strategy (Phase II)

04/21/23 9

Event

ErrorPrecursors

Vision, Beliefs, &

Values

LatentOrganizationalWeaknesses

Mission

Goals

Policies

Processes

Programs

FlawedDefenses

InitiatingAction

“ HPI Flavor ” Using Anatomy of Event

04/21/23 10

• Limited short-term memory• Personality conflicts

• Mental shortcuts (biases)• Lack of alternative indication

• Inaccurate risk perception (Pollyanna)• Unexpected equipment conditions

• Mindset (“tuned” to see)• Hidden system response

• Complacency / Overconfidence• Workarounds / OOS instruments

• Assumptions (inaccurate mental picture)• Confusing displays or controls

• Habit patterns• Changes / Departures from routine

• Stress (limits attention)• Distractions / Interruptions

Human NatureWork Environment

• Illness / Fatigue• Lack of or unclear standards

• “Hazardous” attitude for critical task• Unclear goals, roles, & responsibilities

• Indistinct problem-solving skills• Interpretation requirements

• Lack of proficiency / Inexperience• Irrecoverable acts

• Imprecise communication habits• Repetitive actions, monotonous

• New technique not used before• Simultaneous, multiple tasks

• Lack of knowledge (mental model)• High Workload (memory requirements)

• Unfamiliarity w/ task / First time• Time pressure (in a hurry)

Individual CapabilitiesTask DemandsTask Demands Individual Capabilities

Work Environment Human Nature

“HPI Flavor” Anatomy of Event – Error Precursors

04/21/23 11

The Five Whys

Visual Depiction of Causal Factor Analysis Using “Five Whys”

Event 1

Condition 1Causal

Factor 1

Condition 2

Condition 3

Condition 5

Condition 4

Event 2

CausalFactor 2

CausalFactor 3

CausalFactor 5

CausalFactor 4Why 1

Why 1

Why 1

Why 2

Why 2 Why 1

Why 1 Why 2

Why 2

04/21/23 12

The Five Whys

Visual Depiction of Identification of Root Cause Using Five Whys

CausalFactor 1

CausalFactor 2

CausalFactor 3

CausalFactor 4

CausalFactor 5

CausalFactor 3

Collect CFs

CausalFactor 1,2

CausalFactor 4,5

Identify Common CFs

Apply Five WhysTechnique

RootCause

04/21/23 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

• 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.

04/21/23 14

Conclusion