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

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 BNL recognized the need to institutionalize an Issues management process: Move beyond being in a reactive mode responding to the problems of the day Become proactive to learn from the causes of lower level events Foster the creation of a Learning organization. As part of addressing these needs, BNL embarked on a initiative to improve the BNL Issues Management Program. Some key improvements in defining lower level issues ( below the ORPS threshold) and training for both conduct of critiques and causal analysis The topic of this presentation will focus on the training of BNL Staff and managers on Causal Analysis methods.

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 Brookhaven’s Strategy was to implement a program that evaluates lower level issues and events, implement effective corrective actions to prevent ORPS/Accidents ( Type A and B) and PAAA events. Nonconformances Audits Tier 1 Assessments

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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 There are many credible causal analysis methods that vary in the level of complexity. DOE has both Guides and standards that address causal analysis methodologies. Brookhaven National Laboratory also had guidance on the conduct of causal analysis that are found in “ Causal Analysis Methodologies” and address many credible causal analysis methods. 4/8/2017

Brookhaven Accident\Issues Prevention Causal 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 4/8/2017

Brookhaven Accident\Issues Prevention Causal 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 BARRIER ANALYSIS: The analytical concepts were introduced by William Haddon Jr., M.D. In Human Factors Journal in 1973 In 1992 DOE Standard 1004-92 “Root Cause Analysis Guidance Document” identified barrier analysis as a Root Cause analysis method. Since 1995 DOE uses barrier analysis one of five core analytical technique for accident investigations FIVE WHYS: It was made popular as part of the Toyota Production System in the 1970s A straightforward methodology that is effective in understanding the cause of a problem It can promote a common and shared understanding of the causes and conditions that created the problem Recognized by BNL as an analytical method in (some document) and a root cause methodology by DOE.

Brookhaven Accident\Issues Prevention Causal 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 ECF ANALYSIS: An analytical method used as one of core analytical technique for DOE accident investigations and documented in BNL requirements FIVE WHYS: Toyota Production System in the 1970s

“ HPI Flavor ” Using Anatomy of Event Error Precursors Vision, Beliefs, & Values Latent Organizational Weaknesses Mission Goals Policies Processes Programs Flawed Defenses Initiating Action 4/8/2017

“HPI Flavor” Anatomy of Event – Error Precursors 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 Nature Work 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 Capabilities Task Demands The Error Precursor short list was used since this list is nothing more that a bunch of conditions that can used to populate the ECF chart for analysis using the “Five Whys” method. Task demands- include specific mental physical and team requirement to perform an activity that may exceed the capabilities or challenge the limitations of human nature of the individual assigned to the task Individual Capabilities- Unique mental, physical and emotional characteristics of a person that fail to match the demands of a specific task Work environment- General influences of the workplace, organizational and cultural conditions that affect individual behavior Human nature – Generic traits, disposition, and limitations that may incline individuals to error under unfavorable conditions. The error precursors shown here are a short list in order of their importance by category. 4/8/2017

Visual Depiction of Causal Factor Analysis Using “Five Whys” 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 Schematically here is how the Five Whys was used….. but what else can we use the Five Whys for after we identify a gaggle of causal factors???? Event 2 Event 1 4/8/2017

Visual Depiction of Identification of Root Cause Using Five Whys 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 The method can be used to identify root causes Causal Factor 4 Causal Factor 4,5 Causal Factor 5 4/8/2017

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 4/8/2017

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. Use of the Error precursor short list resulted in identification of 20 percent more conditions making the analysis more comprehensive 4/8/2017