1. Excellence in Causal Analysis Establishing the infrastructure to support high quality causal analysis Frederic Lake/Larry Leavitt Palo Verde Nuclear Power Station Establishing the infrastructure to support high quality causal analysis Frederic Lake/Larry Leavitt Palo Verde Nuclear Power Station

2. Objectives Define the essential infrastructure to support high quality, effective causal analysis Discuss methods to assess and measure these essential elements Define the essential infrastructure to support high quality, effective causal analysis Discuss methods to assess and measure these essential elements

3. Unrealistic Teams vs. Defensive Managers? Different ideas about what represents a good investigation and a good report –Teams – dig deep, failed barriers, precursors –Managers – actionable recommendations & reestablish control Managers tend to wait for draft report rather than taking time to work with teams Result: –Negotiations to gain manager approvals –watered-down recommendations Different ideas about what represents a good investigation and a good report –Teams – dig deep, failed barriers, precursors –Managers – actionable recommendations & reestablish control Managers tend to wait for draft report rather than taking time to work with teams Result: –Negotiations to gain manager approvals –watered-down recommendations

4. Competent Evaluators Fundamental Tools Rigorous Oversight Effectiveness Monitoring SMART Solutions Personally Involved Leaders

5. Attributes of an Excellent Causal Analysis Program Leaders are personally involved Evaluations are performed by highly competent, well-supported evaluators Readily available, user-friendly set of fundamental evaluation tools Rigorous oversight board SMART Solutions Effectiveness Reviews Leaders are personally involved Evaluations are performed by highly competent, well-supported evaluators Readily available, user-friendly set of fundamental evaluation tools Rigorous oversight board SMART Solutions Effectiveness Reviews

6. Highly Competent and Well- Supported Evaluators Formal Documented Training Program –Rigorous –Focus on fundamentals Job Qualification Retraining and Proficiency Continuing Education Mentoring and Feedback Assessment & Measurement: –Post-job feedback, Quality metrics, trainee feedback, review of cause analysis reports, CARB results Formal Documented Training Program –Rigorous –Focus on fundamentals Job Qualification Retraining and Proficiency Continuing Education Mentoring and Feedback Assessment & Measurement: –Post-job feedback, Quality metrics, trainee feedback, review of cause analysis reports, CARB results Competent Evaluators

7. User-Friendly, Readily Available Analysis Tools Rigorous process drives use of appropriate tools to preempt existing mindsets Best-Fit Tools –Human Performance –Equipment –Organizational Black-Belts have advanced tools and training Assessment & Measurement: –Procedure reviews, Review of causal analysis products, interviews with investigators Rigorous process drives use of appropriate tools to preempt existing mindsets Best-Fit Tools –Human Performance –Equipment –Organizational Black-Belts have advanced tools and training Assessment & Measurement: –Procedure reviews, Review of causal analysis products, interviews with investigators Fundamental Tools

8. Rigorous Oversight Board Oversight of entire process – not just the final report Strategic challenge so that solutions are aligned with station goals Ownership of issue resolution Assessment & Measurement: –Post-job feedback, procedure/process review, Observations focused on critical review behaviors Oversight of entire process – not just the final report Strategic challenge so that solutions are aligned with station goals Ownership of issue resolution Assessment & Measurement: –Post-job feedback, procedure/process review, Observations focused on critical review behaviors Rigorous Oversight

9. SMART Solutions Change that which needs to be changed – and no more Targeted, timely, and measurable actions Engage training expertise Use formal change management plans for significant actions Use Operating Experience to informed the investigation and actions Assessment & Measurement: –Review alignment between causes and actions, review procedures, effectiveness review metrics Change that which needs to be changed – and no more Targeted, timely, and measurable actions Engage training expertise Use formal change management plans for significant actions Use Operating Experience to informed the investigation and actions Assessment & Measurement: –Review alignment between causes and actions, review procedures, effectiveness review metrics SMART Solutions

10. Effectiveness Reviews Actions completed as intended AND are effective in preventing or minimizing recurrence Confirm that behaviors, work practices, and barriers are institutionalized Methods, Attributes, Success Criteria, and Timing determined by the investigation team Positive statement of effectiveness Oversight board review Assessment & Measurement: –Procedure review to ensure right guidance, review of completed effectiveness reviews, metrics Actions completed as intended AND are effective in preventing or minimizing recurrence Confirm that behaviors, work practices, and barriers are institutionalized Methods, Attributes, Success Criteria, and Timing determined by the investigation team Positive statement of effectiveness Oversight board review Assessment & Measurement: –Procedure review to ensure right guidance, review of completed effectiveness reviews, metrics Effectiveness Monitoring

11. Leaders are Personally Involved Personal Involvement: –Problem statement –Oversight –Resources –Quality and Timeliness Issue Ownership vs. Task Completion Assessment & Measurement: –Post-job feedback, interviews, CARB involvement, observations Personal Involvement: –Problem statement –Oversight –Resources –Quality and Timeliness Issue Ownership vs. Task Completion Assessment & Measurement: –Post-job feedback, interviews, CARB involvement, observations

12. Competent Evaluators Fundamental Tools Rigorous Oversight Effectiveness Monitoring SMART Solutions Personally Involved Leaders

13. Questions