continuous improvement and problem solving handbok

8/12/2019 Continuous Improvement and Problem Solving Handbok

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ContinuousImprovement/

Problem SolvingHandbookClosing the Gaps to Excellence

Rob De La EspriellaDLE Total Quality Management, LLC

Revision 0

GENERAL DISTRIBUTION: Copyright 2006 by DLE Total Quality Management, LLC. Not for sale or for commercialuse. All other rights reserved.

NOTICE: DLE Total Quality Management, nor any person acting on the behalf of them (a) makes any warranty orrepresentation, expressed or implied, with respect to the accuracy, completeness, or usefulness of the informationcontained in this document, or that the use of any information, apparatus, method, or process disclosed in thisdocument may not infringe on privately owned rights, or (b) assumes any liabilities with respect to the use of, or fordamages resulting from the use of any information, apparatus, method, or process disclosed in this document.


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Continuous Improvement / Problem Solving Handbook

TABLE OF CONTENTS

1.0 PURPOSE ...................................................................................................................................................... 32.0 SCOPE ........................................................................................................................................................... 33.0 DEFINITIONS .............................................................................................................................................. 3GUIDELINES FOR IMPLEMENTING AN EFFECTIVE PERFORMANCE IMPROVEMENT PROGRAM

....................................................................................................................................................................................... 44.0 INTRODUCTION TO CONTINUOUS IMPROVEMENT ...................................................................... 45.0 THE CONTINUOUS IMPROVEMENT CYCLE ..................................................................................... 4

5.1 Monitor Performance .............. .......... ........... .......... ........... .......... ........... .......... ........... ........... .......... ..... 55.2 Identify And Define The Problems ........... .......... ........... .......... ........... .......... ........... .......... ........... .......... 65.3 Analyze The Problems ............. .......... ........... .......... ........... .......... ........... .......... ........... .......... ........... ..... 65.4 Determine the Causes .......... ........... .......... ........... .......... ........... .......... ........... .......... ........... .......... ......... 65.5 Develop and Implement Corrective Actions ............... .......... ........... .......... ........... .......... ........... .......... .. 65.6 Adjust Programs and Processes .......... .......... ........... .......... ........... .......... ........... .......... ........... .......... .... 6

6.0 MONITORING PERFORMANCE ............................................................................................................. 77.0 DOCUMENTING IDENTIFIED PROBLEMS .......................................................................................... 88.0 PRE-SCREENING OF CONDITION REPORTS ................................................................................... 109.0 ENHANCED CRITERIA FOR THE STATION CR SCREENING TEAM ......................................... 1110.0 QUALITY REVIEWS OF ASSIGNED CRS ............................................................................................ 1111.0 DAILY CAP LOOK-AHEAD REPORTS ................................................................................................ 1212.0 ANALYZING DEPARTMENT PERFORMANCE DATA ..................................................................... 1213.0 PREPARATIONS FOR THE PERIODIC DEPARTMENT PERFORMANCE IMPROVEMENTMEETINGS ................................................................................................................................................................ 1514.0 DEPARTMENT PERFORMANCE IMPROVEMENT MEETINGS .................................................... 1615.0 COMMUNICATING RESULTS ............................................................................................................... 1716.0 TRACKING CORRECTIVE ACTIONS .................................................................................................. 1817.0 PROBLEM SOLVING ............................................................................................................................... 1918.0 SELECTING CORRECTIVE ACTIONS................................................................................................. 2019.0 MONTHLY DCAC/HUDC ALIGNMENT MEETINGS ........................................................................ 21ATTACHMENT 1 ..................................................................................................................................................... 23

PROBLEM SOLVING TOOLS.................................................................................................................................... 23I. DATA ANALYSIS TOOLS ............................................................................................................................... 23

A.

Tables and Spreadsheets .......................................................................................................................... 23

B. Histograms .............. .......... ........... ........... .......... ........... .......... ........... .......... ........... .......... ........... .......... ... 24C. Pareto Charts ........................................................................................................................................... 26D. Change Analysis ....................................................................................................................................... 29E. Flowchart / Process Maps ........................................................................................................................ 31

II. TOOLS FOR IDENTIFYING CAUSAL FACTORS .............................................................................................. 34A. Cause and Effect Analysis (Fishbone Diagrams) ..................................................................................... 34B. Hazards / Barriers / Targets (HBT) Analysis ......... ........... ........... .......... ........... .......... ........... .......... ........ 36C. Fault Tree Analysis ................................................................................................................................... 38

III. EVALUATING AND IMPLEMENTING CORRECTIVE ACTIONS .................................................................. 40A. .......................................................................................................................... 40Countermeasures Matrix

Copyright 2006 by DLE Total Quality Management, LLC Page 2 of 41


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1.0 PURPOSE

1.1 The purpose of a Performance Improvement Program is to support the pursuit of andcommitment to excellence and continuous improvement, a fundamental goal of manybusiness units. In a continuous improvement paradigm, personnel practice self-evaluationand problem solving as part of everyday business.

1.2 This Handbook was written to provide enhanced guidelines for implementing a PerformanceImprovement Program, in many cases supplementing existing guidelines for Corrective

Action Programs. The main benefits of the enhanced guidance provided in this Handbookare: (1) a more efficient use of department resources by reviewing low level CAPs/CRscollectively rather than individually; (2) prioritizing corrective action efforts by focusing onresolving the most significant problems first; (3) the identification and elimination ofunderlying causal factors by addressing problems at the lower levels, before they can resultin bigger problems, and (4) a formal methodology (rather than a theory) for establishing aculture that values and practices continuous improvement.

1.3 To enhance the use of formal cause evaluation tools, some of the more effective and easy touse problem solving tools and techniques are also provided. In general, the Handbook willhelp the station improve its Corrective Action Program into a broader PerformanceImprovement Program with continuous improvement as its foundation, and it will help

personnel become better problem solvers.

2.0 SCOPE

2.1 This Handbook is applicable to all personnel that implement the Corrective Action /Performance Improvement Program at your station.

2.2 This Handbook builds on the principles established by your existing Corrective ActionProgram implementing procedures, which establish the framework for identifying andresolving current problems and anticipating and preventing future problems through trendingand analysis. The scope of those procedures usually includes the steps to take to completeperiodic (monthly or quarterly) self-evaluation reviews, and associated meetings and reports.

2.3 It is intended that the guidance in this Handbook does not conflict with any of the guidance in

site specific procedures for Condition Reporting and Station Trending.

3.0 DEFINITIONS

3.1 None



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Guidelines for Implementing an Effective Performance Improvement Program

4.0 Introduction to Continuous Improvement

Continuous improvement is sometimes mistaken for a philosophy rather than a methodical approachto improving performance. Continuous improvement encompasses all programs and processes that

are used to improve station performance, and the effective implementation of those processes is thekey to creating a continuous improvement environment.

Central to an effective continuous improvement method is the identification and resolution of adverseconditions. It is there where there are great gains to be made, by using fundamental problem solvingcapabilities on a continual basis at the lowest levels of an organization. Fostering this self-evaluationand problem solving culture by a broad cross section of the facility as part of everyday business isanother essential element of continuous improvement.

4.1 Additional keys to an effective continuous improvement methodology include:

4.1.1 When monitoring station performance, Key Performance Indicators are not used as beancounts but are used to measure performance in meaningful ways and trigger actionsthat drive performance improvement. Indicators should monitor in-process parametersin addition to outcome indicators such that adjustments can be made prior to a negativeoutcome. For example, monitoring behaviors such that adverse trends can becorrected before the same behaviors result in consequential outcomes.

4.1.2 When evaluating problems, there must be an understanding that station problems haveto be addressed below the symptomatic level by trending and data analysis todetermine the underlying causal factors and root causes. Solving problems at thesymptomatic level is not the most effective use of limited resources. Use formal toolsfor data analysis and causal factor identification to address problems below thesymptomatic level. Most problems can be evaluated and addressed with these basicevaluation tools: tables, Pareto diagrams, Hazards / Barriers / Targets Analysis, Causeand Effect Diagrams, Fault Tree Analysis, and a Countermeasures Matrix.

4.1.3 Management has to establish the proper balance between problem identification andproblem resolution such that the organization is not overwhelmed. Stations tend to

emphasize documenting identified problems and not sufficient emphasis is applied toevaluating and resolving the problems. In some cases there are resource limitations toovercome, but in most cases there is a lack of efficient methods to use departmentresources in an effective and prioritized manner. For example, trending the CAP dataand showing results on Pareto charts is an effective way to maintain resources focusedon the top issues, rather than on individual problem resolution.

4.1.4 When selecting corrective actions, especially for significant problems, use a gradedapproach to determine which solutions to implement. A tool such as acountermeasures matrix is valuable in sorting out and prioritizing potential solutions,and also documents for posterity which solutions were considered but notimplemented, and the reasons why. A good example where alternate solutions werenot considered is NASAs space pen, which writes under any conditions. The pen cost$12 million to develop. The Russians used pencils.

5.0 The Continuous Improvement Cycle

On average, there may be more than 10,000 condition reports (CR) written each year at a typicalnuclear station. Of the total CR written in a year, only a small percentage will require Root CauseEvaluations (RCEs) or Apparent Cause Evaluations (ACEs). The remaining CRs are addressedindividually or they are closed to actions taken and trended by the station trend programs. What isnoteworthy about the thousands of conditions that did not require RCEs and ACEs is that in manycases, their underlying causes are the same as those that are causing the bigger events.



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With the premise that in many cases the underlying causes of minor and major events may be similar,Parts 1 and 2 of this Handbook recommend approaches to implementing the PerformanceImprovement Program in a manner that prioritizes and resolves problems at the lower levels, beforethey can result in bigger problems.

The following is the INPO Performance Improvement Model that is a sound approach to achievingcontinuous improvement. Although there are different variations of this model across the industry,

most follow this fundamental approach. Below is a simplified description of each of the segments of acontinuous improvement cycle.

5.1 Monitor Performance

5.1.1 Monitoring performance is crucial to continuous improvement. Below are a few of the keyprocesses and tools to monitor performance which are discussed in more detail later in

the Handbook.a. Operator Rounds

b. Human Performance (HU) Program

c. Self-Assessment Program

d. Corrective Action Program

e. Key Performance Indicators (KPIs)

f. Station Trend Program

g. Performance Improvement Program



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h. System Health Reports

5.2 Identify And Define The Problems

5.2.1 Many of the underlying causal factors for lower level issues are the same ones that go onto cause the big events. By documenting as much information as possible for everyproblem, the station can more readily identify and address underlying causal factorsbefore they cause events with considerable more consequences. And the cost ofaddressing these causes from low level problems are a fraction of the cost associatedwith recovering from a consequential event.

5.2.2 Your Condition Reporting procedure describes the requirements for documentingadverse conditions on Condition Reports (CRs) and capturing available information.

5.3 Analyze The Problems

5.3.1 Finding and eliminating the underlying causes of a problem can be a real challenge, andwithout the use of investigative methods or tools, the likelihood of problems recurringincreases. Even subject matter experts would have limited success without the use ofsound fundamental tools and techniques to analyze data and identify the underlyingcausal factors.

5.3.2 For significant problems, the tools used to conduct RCEs and ACEs usually are welldefined in station procedures. The vast majority of lower level problems are addressedindividually through the corrective action program and collectively through thePerformance Improvement Program. However, many station procedures only providebroad guidance for how the performance improvement process is used to evaluate thevast majority of performance data to improve performance.

5.4 Determine the Causes

Levels of Causes: a problem or an event is usually the result of multiple causes that combine tocause the problem. By evaluating a set of problems (symptoms) you can find underlying causesas they are the ones that contributed to multiple symptoms. In classic problem solving, you canidentify some of the stations biggest underlying causes and root causes by evaluating just a fewevents thoroughly.

5.4.1 Symptoms: these are not regarded as actual causes but signs of existing problems.5.4.2 Underlying Causes: causes that directly contributed to the problem, or causes that did not

directly cause the problem but are linked through a cause-and-effect relationship to othercauses that ultimately created the problem.

5.4.3 Root Causes: the lowest most actionable cause of the problem. If the root causes werenot present, the problem would never have occurred. If the root causes are removed, theproblem or event would not recur.

5.5 Develop and Implement Corrective Actions

Corrective Actions are the countermeasures you put in place to address the identified causes andprevent similar problems from recurring. There is a vast range of corrective actions that can beapplied to any given set of causes, with varying degrees of effectiveness and cost. The challengeis to implement the most cost-effective solution, as in every business there are limited budgetsand resources available to implement the corrective actions.

5.6 Adjust Programs and Processes

Once corrective actions were determined to have been effective in a particular application,consider where else the corrective actions would be beneficial. Using a similar approach to theextent of condition for an identified problem, consider the extent of the solution for replicationin other departments or stations.

5.6.1 Determine which fleet standards and procedures were affected by the corrective actionsand whether they would benefit from standardizing the corrective actions.



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5.6.2 Determine whether the corrective actions should be incorporated into associated trainingprograms.

5.6.3 Discuss the corrective actions and their effectiveness at Department PerformanceImprovement Meetings such that they can be evaluated for site-wide implementation.

5.6.4 Discuss the corrective actions and their effectiveness at Station PerformanceImprovement Meetings such that they can be evaluated for fleet-wide implementation.

6.0 Monitoring Performance

Monitoring performance is crucial to continuous improvement. Below are a few of the key processesand tools that should be in place to monitor performance.

6.1 Operator Rounds: one of the most effective means to monitor the plant are the Operators andtheir daily routine of monitoring station parameters, as well as general conditions in the plant.

6.2 Human Performance (HU) Program: the HU Program requires us to conduct performanceobservations to collect data on human performance behaviors that can be trended.

6.3 Self-Assessment Program: the Self-Assessment Program provides guidance for conductingcontinuous and focused self-assessments.

6.4 Corrective Action Program: our ability to effectively monitor performance relies heavily on thecorrective action program. Identifying and documenting adverse conditions, problems, issuesand near misses allows the station to conduct meaningful reviews of performance in all areas.

6.5 Key Performance Indicators (KPIs): KPIs are largely reliant on the CAP data base for its source ofinformation, and they are used extensively to monitor performance and identify adverse trends inmost area of the station.

6.6 Station Trend Program: trending is usually conducted at the station level by a Station TrendCoordinator and supported at the department level by Department Corrective ActionCoordinators.

6.7 Performance Improvement Program: the Performance Improvement Program is used to monitorperformance on a periodic (quarterly or monthly basis) by reviewing available sources of

performance-related information, including CRs and Human Performance observations, to identifyand address adverse trends.

6.8 System Health Reports: the Equipment Reliability Program relies heavily on System Engineersand their monitoring of system performance. This has grown from Maintenance Rule monitoringto a more advanced process that is managed by the Plant Health Committee.

These processes should be periodically assessed to ensure they are being implemented in aneffective manner.



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7.0 Documenting Identified Problems

Why is Documentation so Important?

A key to being able to evaluate the lower significance issues is by doing anexcellent job of documenting every problem put in the corrective action

database.

Many of the underlying causal factors for lower level issues are the same onesthat go on to cause the big events. Therefore a major benefit of having greatdocumentation for every problem is that you can identify and address underlyingcausal factors before they cause events with considerable more consequences.In many cases, only the subject matter experts know a key piece of informationthat will be lost or forgotten if it is not captured when a CR is written.

7.1 Your Condition Reporting process describes the requirements for documenting adverseconditions and assigning problem resolution to applicable departments. The following guidelinesare provided to help originators, department CAP and HU coordinators and supervisors betterunderstand what should be considered when filling out a CR.

a. Detailed Description (required field): provide as much information as possible, including:

The plant status/conditions at the time of the problem

How the problem was discovered

The personnel that were involved (by title/position), what shift or schedule theywere on and what crew they were assigned to

What process or evolution was being conducted (e.g. maintenance, tagging,testing, operating the plant, planning, scheduling, boric acid corrosion controls,self-assessment, management observations, administrative tasks)

What procedures were being used

The location where the problem took place

The equipment involved and how it performed

What tools were in use and their contribution to the problem

Observations from other involved personnel

Any physical evidence that can be shown to others

b. Why did this occur: even if the originator does not know or is unsure, they can add valueby documenting their observations on the following areas.

Think of the physical or administrative barriers in place to prevent this problemfrom happening in the first place, and which ones might have failed:

1) Physical controls include:a) Automatic shutdown devices

b) Safety and relief devices

c) Conservative design margins

d) Redundant equipment

e) Locked doors and valves

f) Fire Barriers and seals

g) Alarms and annunciators



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2) Administrative controls include:

a) Management & supervisory oversight

b) Operating and maintenance procedures

c) Programs, policies and practices

d) Training and qualification programe) Worker practices

f) Signs and postings

Whether the problem or issue specifically involved human performance, workerpractices or equipment failure.

Whether the processes in use at the time were new or recently revised.

Whether that task or evolution was conducted successfully in the past, andwhether there was anything different when this problem occurred.

Any environmental factors or conditions that were pertinent to the problem, suchas working on the second night of a back shift, the lighting in a particular location

or the physical conditions of the work environment. Whether there was any supervision on the job.

Any known previous history in the problem area and past corrective actions (toprompt a review of the TeamTrack database).

Any similar experiences at other plants (operating experience).

c. Immediate Actions Taken to address the issue: there may be more actions needed toaddress a bigger issue, so look for a detailed description of actions taken.

d. Recommendations: if the problem has not been corrected, in many cases the persondocumenting the problem is the subject matter expert and may know best how to addressit in the future to prevent it from recurring. Check with the originator and ask what theybelieve would address the problem if money were no object. In some cases the subject

matter experts can help the station avoid costly solutions for simple problems.

e. References: the specific reference numbers for any documents that was associated withthe problem, such that they can be researched at a later time. For example,

Work Order numbers

Procedures

Drawing numbers

Operator logs

Alarm printouts

Laboratory test reports

Sample analysis results

Recorded measurements

Vendor data



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8.0 Pre-Screening of Condition Reports

8.1 After a CR is generated it is typically pre-screened by the department supervisor and theCorrective Action Coordinators (DCACs) for completeness, and then they are sent to the StationScreening Team.

8.2 The following guidelines are provided to ensure that the CRs contain as much information aspossible prior to going before the Screen Team and being assigned for action.

a. Reference material for use during pre-screening:

Condition Reporting Process

Guidance on CR Significance Levels

Guidance on CR Trending

INPO Performance Objectives and Criteria Binning Tool (chart)

Station logic diagrams and flow diagrams

Procedures listed on the CR

Plant Procedures

b. Enter as much information as is available into the CR. In some cases a little researchmay be involved, such as looking up work order numbers for equipment problems andreferring to your stations Trend Handbook for the proper codes. The following fieldsshould be filled in to provide good information for processing the CR and for station anddepartment trending.

System Number

Equipment Number

Significance Level

Process Codes

Activity Codes

Method of Discovery

Focus areas such as:

Safety

Human Performance

Equipment Reliability

Corrective Action Program

Management & Supervision

Group causing the problem

INPO Performance Objective: refer to the INPO binning chart Equipment failure mode (may require contacting originator or subject matter

expert)

Any other appropriate trend codes

c. Conduct a review of CR history to look for trends:

Conduct word searches in the CR data base to identify whether the componentshave failed in the past or the issues have recurred.



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Document the results of the CR history review in the CR. Note any potential oradverse trends that should be reviewed by the department that is assigned theCR.

9.0 Enhanced Criteria for the Station CR Screening Team

9.1 Criteria for the Station CR Screening Team are usually found in the CAP / CR procedures.

NOTE

The following guidance should not supercede nor conflict with existinginstructions. It provides additional basis for consideration whendetermining whether a CR should be closed to actions taken and evaluatedcollectively by the departments.

9.2 Enhanced CAP/CR Screening Criteria

If the documented condition meets the criteria below, then the CR is assigned as usual underexisting guidelines. Otherwise, the CR should be closed to actions taken or to trend, allowingthe departments to evaluate the conditions collectively rather than individually under acontinual Performance Improvement Program:

a. It is a significance level A or B condition requiring a root or apparent cause evaluation.

b. It is a significance level C condition, but requires immediate actions because it is animmediate safety concern in the areas of

Industrial Safety

Nuclear Safety

Radiological Safety

c. It is a significance level C condition, but requires immediate actions because thecondition impacts Plant Reliability. For example:

The condition is causing a loss of megawatts

Degraded performance of redundant equipment

d. In addition to the above criteria, additional actions may be warranted if the conditionposes a Risk to the station. For example:

Conditions impacting commitments with fixed deadlines

Conditions affecting actions to complete station initiatives

Any condition that warrants immediate actions based on Management orSupervisory inputs

e. If there is not enough information on the CR to determine how to disposition it, theCAP/CR should go back to the supervisor of the originator for additional information.

10.0 Quality Reviews of Assigned CRs

10.1 Once the CRs have been screened by the Station Screen Team and assigned to thedepartments, the CRs should be screened by the receiving department:



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a. Check that the CR has been assigned to the correct organization.

b. Check that the level of effort assigned is appropriate for the task.

c. If there are any issues with either the assigned organization or the level of effort, refer toexisting guidance on how to resolve those issues with the CAP administrators.

d. DCACs can review the CRs and provide initial recommendations to the department

supervisor on:

Priority

Due date

The responsible activity performer

11.0 Daily CAP Look-Ahead Reports

11.1 On a daily basis, DCACs should monitor corrective action backlogs and conduct a one-weeklook-ahead to ensure that there will be no overdue corrective actions in the department.

11.2 On the CR data base, run a report using the responsible group codes for the associated

department, for activities (actions or evaluations) that are coming due within the next calendarweek.

11.3 Notify management of those activities that are coming due within the next two days.

11.4 Periodically (at managements discretion) provide department management with a completelisting of all activities for the department for their consideration.

a. DCACs should proactively review the station schedule for activities impacting work in theorganization, such as refueling outages, major inspections, holidays and heavy vacationperiods, against the due dates for assigned activities.

b. DCACs can make recommendations to their management on pulling actions up ormoving them back past those periods where there is a high likelihood for competingresources.

12.0 Analyzing Department Performance Data

12.1 Each department should conduct periodic (monthly or quarterly) trending of CR data, keyperformance indicators and other measures of performance. Therefore the following guidanceis provided to assist the DCACs in managing the periodic self-evaluations.

a. Each month, DCACs query the CR data base and prepare reports containingapproximately six months worth of closed CRs assigned to their department. Thereports should include the following information.

CR Number

Description

Why did this occur

Immediate actions taken

Recommendations

References

Process Codes

Activity Codes

Method of Discovery



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Focus areas:

Safety

Human Performance


Corrective Action Program Management & Supervision

Group Causing the Problem

INPO Performance Objective

Equipment failure mode

b. Transfer the six months worth of data from TeamTrack into a spreadsheet.

NOTES

Because the amount of CRs varies greatly between departments,

time frames longer or shorter than six months should be consideredbased on collecting a meaningful amount of data to analyze.

To save time on executing these routine reports every month, thetrend reports can be standardized and automated.

c. Conduct common cause analysis and trending of the data.

Filter and sort the data by the various trend codes and tabulate the number ofoccurrences in each category.

Chart the information using Pareto Charts for further evaluation.

Using Paretos Principle and applying it to CAP data, identify problem areaswhere approximately 20% of the causes are causing approximately 80% of theproblems. Using this same principle during problem solving efforts, by solvingthose 20% of causes, the majority of a problem area will be resolved, andresources should then be applied to other top problem areas rather thancontinuing to solve the last 20% of the problems (which are caused by 80% ofthe causes). By applying Paretos principle, the department stays focused on themost important contributors to adverse trends.



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EXAMPLE

In the example above, the first level Pareto for the Focus areas shows 50 CRs in thearea of Human Performance. The next step is to pull those 50 CRs and furtherevaluate the data associated with those 50.

The next level Pareto shows that the largest contributing cause of HumanPerformance issues was Procedure Adherence, with 25 CRs.

The analysis of the 25 procedure adherence CRs found that 15 were caused byinadequate procedures.

At the monthly DSEM, the department would pursue an ACE to evaluate the 15 CRsinvolving procedure quality.

d. Examples of data analysis tools are included in Attachment 1.

e. In addition, key performance indicators (KPIs) and other performance data for thedepartment should also be reviewed. These include:

Industrial Safety Data

Department KPIs

Human Performance Data: analyzed by the Human Performance DepartmentCoordinators (HUDCs)

Self-assessment Program Performance

Benchmarking information

Operating Experience Information

Corrective Action Program Performance

Department Budgets



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f. Below are suggestions for reviewing some of the more important areas.

Industrial Safety Program: collectively review applicable KPIs for industrial safetytogether with any available information from TeamTrack and analyze for adversetrends and common causes.

Human Performance Observations: trended in the same manner as CRs as

described herein. Corrective Action Program Indicators: collectively review the information from the

CR data base together with published Corrective Action Program KPIs andmetrics and analyze for adverse trends and common causes.

Self-assessment Program: review self-assessment reports that were completedin the past month and look for recurring problem areas where an escalated actionplan may be required.

Department Radiation Protection Indicators: collectively review the informationfrom TeamTrack together with Radiation Protection KPIs and metrics andanalyze for adverse trends and common causes.

Department Budget Indicators: review department Budget KPIs and metrics and

identify where actual budgets are more than 10% over the authorized budgets.Year end projection should be closely monitored, and ensure that recovery plansare in place if projections show the department will be over budget at years end.(Note: the current department indicators do not show year-end projections). Alsoidentify if the department is more than 10% under budget, such that managementcan discuss how the windfall could be used to offset other departments that areover budget, as well as to consider adjustments to future budgets.

Benchmarking information: review the departments benchmarking schedule andensure that completed trips were properly documented. Also review completedreports and check that any performance gaps that are to be addressed aretracked through the corrective action program.

Operating Experience: review the report of OE assignments for the department

and ensure that they are on track to be completed on time. Review completedreports and check that any performance gaps that are to be addressed aretracked through the corrective action program.

Miscellaneous Custom Department Indicators: review customized departmentKPIs and metrics, as well as the custom trend hot buttons and analyze foradverse trends and common causes.

13.0 Preparations for the Periodic Department Performance Improvement Meetings

13.1 Each period, the departments should hold a Performance Improvement meeting to reviewdepartment performance data.

13.2 The following guidance is provided for preparing a summary of the overall trending and analysis

to be discussed at the Department Performance Improvement Meetings.a. A list of root cause evaluations and apparent cause evaluations completed during the

previous month.

b. The list of top performance issues and adverse trends identified through data analysisand trending, and existing corrective actions.

c. The list of key performance indicators that are RED and existing recovery plans.

d. A list of department performance improvement items and associated action itemscompleted during the past month, such as:



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e. Operating experience reviews

f. Self-assessments

g. Benchmarking reports

h. Requests for support from other departments or industry peers.

i. Actions or projects that will require additional funding that need to be presented tomanagement.

j. The three best examples of improved performance in the department during the pastmonth and how the Performance Improvement Program and other performanceimprovement tools were used to achieve those improvements.

14.0 Department Performance Improvement Meetings

14.1 Attendance:

a. Department Managers determine the final list of attendees.

b. Department Managers lead the monthly meetings and are supported primarily by theDCACs and HUDCs.

c. DCACs are responsible for reserving a room and putting out the invitation to all attendeesusing Lotus Notes.

14.2 Agenda: there are many inputs to the self-evaluation meetings, and it is not possible to reviewthe associated information during that meeting. For example, an analysis of corrective actionprogram data for common causes and trends can take days. The majority of that informationshould be reviewed ahead of time by the DCACs and HUDCs, and those reviews can besummarized during the meeting.

The following is a recommended agenda for periodic performance improvement meetings.

a. Review root cause evaluations and apparent cause evaluations completed during theprevious month and discuss:

Quality of the evaluations / grades and whether improvement is needed. Timeliness of the evaluations.

Recurrence of root causes and causal factors.

b. Review the results of the monthly self-evaluation trending and analysis conducted by theDCACs and the HUDCs.

Summarize the review of department key performance indicators. Summarizethe data analysis conducted prior to the meeting using charts, Pareto diagramsand other indicators. Highlight the departments top performance issues andDiscuss RED indicators in detail.

1) Industrial and Radiation Safety indicators.

2) Corrective Action Program Indicators.3) Human Performance Observation data, Management Work

Observations and Observations of Training.

4) Department Error Rate and Event Rate

Discuss Corrective Action Plans for identified problem areas:

1) Review of existing corrective actions for problem areas that havealready been documented on an CR.



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2) New Action Requests (CRs) needed to address top performanceissues and adverse trends that have not been previously addressedthrough the corrective action program.

3) Review of existing recovery plans for RED key performanceindicators to determine whether they are on track.

4) New recovery plans for RED key performance indicators that do nothave an action plan to restore the indicator to GREEN.

c. Review general reports and other department performance improvement itemscompleted during the past month such as the ones listed below to ensure that allcorrective actions or improvement initiatives are documented in the corrective actionprogram for tracking to completion. Also review the schedule of upcoming activities toensure they are on track.

Operating Experience Reviews

Self-assessments

Benchmarking reports

Reports from external agencies

Budget report

d. Identify the need for support from other departments such as Training and Engineering,any major support required from off-site peers, and any additional funding requests thatneed to be presented to management.

Training requests should be formally transmitted to the Training Manager.

Requests for engineering assistance should be filled out in accordance withexisting processes.

e. Identify the three best examples of improved performance in the department during thepast month and how the Performance Improvement Program and other performanceimprovement tools were used to achieve those improvements. Document those

examples in the periodic performance improvement meeting reports.

15.0 Communicating Results

15.1 Reports: following the performance improvement meetings, the departments are responsible forfilling out a report.

a. The summary report should clearly convey:

The top three problem areas for the department and ongoing corrective actionefforts.

The top three success stories in resolving identified problems.

Any additional support or funding required to resolve the problems.

Any feedback or requests for action being sent to other organizations such asTraining and Engineering.

b. Completed DEM summaries are forwarded to the CAP Manager.

15.2 Provide Results to Other Departments: the results of meetings are valuable inputs to otherprograms and organizations. The following are a few of the main functional areas that shouldbe provided with meeting results as appropriate.

a. Training Program training needs or requests

b. Station Trend Program inputs on adverse trends



18/41


c. Self-assessment Program inputs for future self-assessments

d. The Engineering Department feedback on equipment problems

16.0 Tracking Corrective Actions

Recognizing that every organization is challenged with managing their limited resources wisely,the following guidance is provided for problem solving efforts.

16.1 Establish and maintain an ongoing integrated list of department problems and update the list ona monthly basis.

a. Use the results of the monthly meetings to update the list of top problems. The reportscontain a list of the top problems identified for that month, based on a review of the pastsix months worth of performance data.

b. Also consider other adverse conditions and trends identified outside of the performanceimprovement process.

16.2 Grade each problem as it is placed on the list and keep the problems in order of relativeranking. Consider using formal criteria to rank the problems. For example, grade the relativesignificance of each problem with respect to:

Nuclear Safety

Industrial Safety

Radiological Safety


Plant Performance

Regulatory Impact or Commitments

16.3 The list should capture the following essential information.

a. Ranking

b. Overall Grade

c. Department

d. Date Identified

e. Corrective Action Tracking Number

f. Summary of Problem

g. Summary of Corrective Actions

h. Focus on Four Area

i. INPO Performance Objective

j. Significance Level

k. Assigned Priority

l. Assignee

m. Due Date

n. Date Closed

o. Key Performance Indicator Used to Track Performance Improvements

16.4 Assign actions to address those problems in order of priority and track those actions in thecorrective action program.



19/41


a. Take into consideration available resources and do not assign more actions than can becompleted in a high quality manner.

b. Issue apparent cause evaluations for adverse trends and significant issues.

c. Issue root cause evaluations when actions to prevent recurrence are required.

16.5 Update the list on a monthly basis to ensure that the departments keep their resources focused

on addressing their most important problems first.

16.6 Issues that do not get addressed one month may be addressed in subsequent months as thehigher priority problems are addressed and the remaining problem areas rise in the relativerankings.

16.7 By maintaining a list of ranked problems and following the above methodology, eachdepartment can demonstrate that it is using their available resources in the most effective andefficient manner by applying them to the most important problem areas first.

17.0 Problem Solving

17.1 There may be more than 10,000 action requests (CRs) written each year at a typical nuclearstation. Of the total CRs written in a year, approximately 30 to 50 may require Root CauseEvaluations (RCEs), and approximately 300 to 500 may require Apparent Cause Evaluations(ACEs). The remaining CRs are addressed individually or closed to actions taken, and trendedby the station trend programs. What is noteworthy about the thousands of conditions that didnot require RCEs and ACEs is that in many cases, their underlying causes are the same asthose that are causing the bigger events.

17.2 The Performance Improvement Program was written with the premise that there is great valuein analyzing those 10,000 lower level CRs for adverse trends and common causes, as theirunderlying causes can prevent larger events from taking place.

17.3 In previous sections of this Handbook, guidance was provided on how to identify problem areasfor analysis and resolution in an organized and prioritized manner. The following guidance isprovided to enhance the determination of underlying causal factors and establishingappropriate corrective actions.

a. When choosing a problem to solve, it is advantageous to have a set of data to evaluaterather than one occurrence. As described in earlier sections, binning problems andcharting them on Pareto diagrams provides a good method to determine the set of datato use.

b. Formal problem solving tools should be applied, such as:

Cause and Effect Analysis

Hazards / Barriers / Targets

Fault Tree Analysis

Events and Causal Factors Charting

Five Whys Analysis Matrix Diagram

c. The primary purpose of using formal tools is to identify the underlying causal factors thatare causing the steady stream of problems that show up every month as symptoms(performance issues). The following diagram shows how being good problem solversinvolves focusing on underlying causal factors and root causes, not on the symptoms.



20/41


#ofCond

itionReports

Month

Symptomatic Level

Underlying Causal Factors

Root Causes

d. A key to an effective Performance Improvement Program is that personnel across thestation use these tools in every day applications and are therefore better problem solvers,eliminating underlying causes and latent organizational weaknesses that were causingrepetitive problems.

e. Examples of some of the more effective and simple to use problem solving tools areincluded in Attachment 1.

18.0 Selecting Corrective Actions

18.1 Corrective Actions are the countermeasures put in place to address the identified causes andprevent similar problems from recurring. There is a vast range of corrective actions that can be

applied to any given set of causes, with varying degrees of effectiveness and cost. Thechallenge is to pick cost-effective solution as in every business there are limited resources.

18.2 A tool that can help organize potential corrective actions and help the evaluators decide whichones should be implemented is the Countermeasures Matrix. Once the corrective actions areselected, an Action Plan can be generated from the matrix to schedule the implementation andtrack the plan to conclusion

Focus on Problems vs. Focus on Solutions

When NASA began the launch of astronauts into space, they found out that pens

wouldn't work at zero gravity. In order to solve this problem, they hired AndersenConsulting (Accenture today). It took them one decade and 12 million dollars. Theydeveloped a pen that worked at zero gravity, upside down, under water, on practicallyany surface including crystal, and in a temperature range from below freezing to over300 C. The Russians used pencils.

18.3 The NASA example really drives home the possible range of corrective actions that could beused to solve a problem. In many cases there will be a range of ideas on how to solve a



21/41


particular problem, and the countermeasures matrix guides the team through a logicalapproach to select the solutions that are most in line with the companys goals.

18.4 Instructions for how to complete a countermeasures table are included in Attachment 1.

19.0 Monthly Alignment Meetings

19.1 Purpose: At least once a month the DCACs, HUDCs and the Station Trend Coordinator meetwith the Corrective Action Program Manager to share lessons learned and compare how thedepartments are implementing the Corrective Action Program and the DCAC functions suchthat a consistent approach is taken across the station. The meetings also serve as a forum todiscuss the top problem areas among the department to look for common causes and trendsacross the station.

19.2 Attendance: DCACs, HUDCs, the Station Trend Coordinator, the Human Performance andCorrective Action Program Supervisors and the CAP Manager. The meeting should befacilitated by one of the Supervisors.

19.3 Agenda: the following is a recommended agenda for the monthly DCAC Alignment Meetings.

a. Discuss difficulties in performing DCAC responsibilities, such as downloading and

analyzing data, applying trend codes and preparing for the monthly meetings.b. Discuss the top performance issues for each department. Look for any common set of

causal factors across the departments for possible station trends. If the same causalfactors are identified across multiple departments, the Station Trend Coordinator shoulddetermine whether a station level ACE should be issued to further evaluate the issuescollectively.

NOTE

When underlying causes show up in multiple departments, it is anindication that there are root causes at work generating problems across a

wider spectrum.

Similarly, when the same causes show up across the fleet, it is anindication of limiting weaknesses in the organization that are at the core ofthe companys business models.



22/41



Rob De La EspriellaDLE Total Quality Management, LLC

Attachment 1

Problem SolvingFundamentals

Closing the Gaps to Excellence


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Attachment 1

Problem Solving Fundamentals

I. Data Analysis Tools

There are numerous data analysis tools available from which to choose depending on the application,and some are listed below for your information. They each have their advantages and disadvantages.This Handbook contains a few of the more effective tools to analyze data that were carefully selectedfor their ease of use (noted by an *).

Data Analysis Tools

Tables & Spreadsheets*

Histogram*

Pareto Chart*

Process Map*

Task Analysis

Change Analysis*

Flowchart*

Spider Chart

Performance Matrix

Is / Is not Matrix

Sampling

Scatter Diagram

Problem Concentration Diagram

Affinity Diagram

Spaghetti Diagrams

A. Tables and Spreadsheets

One of the most basic and useful methods to display data is a table. Tables are extremely usefulbecause they form the basis for most charts. They are an excellent way to organize data and should

be used wherever possible.Most everyone should be familiar with tables, so we will not go into detail on how to construct one.However, not everyone is familiar with spreadsheets, which are an excellent tool to organize tablesand chart data.

Suggestions for improving your skills in using spreadsheets:

1. In the DATA menu, there is a SORT function. With this feature you can sort your data by rows orcolumns to arrange the data in ascending or descending order.



24/41


2. In the DATA menu, there is an AUTOFILTER function. With this function you can filter the data ina column by the pre-set criteria, or you can customize what specific information you want thespreadsheet to provide.

3. In the DATA menu, there is a VALIDATION function. This function allows you to create pull-downmenus for your data set. First you define a table of information to choose from, and then youformat a range of cells that will use a drop-down arrow that lets you choose the desired

information from the pre-defined table to place in that cell.

4. In the WINDOW menu, there is a FREEZE PANE function. By placing the cursor on a cell andclicking this function, it freezes every column to the left of the cell and every row above the cell.This feature is very useful for large tables where you want to keep the heading row and the firstcolumn in view as you scroll.

5. The CHCRT WIZCRD is a quick method to chart your data sets. The Wizard will guide you stepby step in selecting the right chart (there is a preview feature if you are not sure what it will looklike), and it prompts you to enter the necessary headings and axes labels.

6. The FUNCTION (fx) button allows you to put formulas in cells such as SUM and AVG, allowingthe spreadsheet to do calculations for you.

NOTE

Most programs come with a HELP menu that will guide you through setting up andusing these useful functions.

7. Using Spreadsheets to Analyze Data

a. By organizing data into a spreadsheet, you will be able to sort and filter the data such thatcommon causes and contributors can be counted.

b. The most important aspect of analyzing data is that you have as much information as

possible. Where data is missing, the DCACs will have to interface with the originators orsubject matter experts and fill in the missing blanks. This step is sometimes overlooked,which dilutes the accuracy of the analysis.

c. Once the data is organized into common causes and contributors, count the occurrences foreach area so that histograms and Pareto charts can be prepared.

d. The primary goal of this analysis is to prepare Pareto Charts that will pictorially show whichgroups of problems are causing the most CR within the department, such that they canreceive top priority.

B. Histograms

Once we have organized our information in a table or spreadsheet, it is often useful to view theinformation pictorially. Histograms, also called bar charts, are used to graphically represent thedistribution and variation of a data set because it is easier to see this variation in a chart than in atable. Histograms are a type of common cause analysis because causes can be grouped togetherand displayed in a histogram.



25/41


Below is an example of a table and its associated histogram.

Work Practices

Root Cause Subfactor #of CRs

Self-checking 38

procedure adherence 33

Intended/required verification notperformed 21

5 miscellaneous categories 14

Total 106

0

5

10

15

20

25

30

35

40

TotalCRsforWorkPractices

Subfactors

Work Practices Causal Factors

#of CRs 38 33 21 14

Self-checkingprocedure

adherence

Intended/required

verification notperformed

5 miscellaneous

categories



26/41


C. Pareto Charts

Vilfredo Pareto, an Italian mathematician in the 1800s, first developed the Pareto Principle. He wasconcerned with the distribution of riches in society and claimed that 80% of the wealth was owned by20% of the population.

In modern applications, Pareto charts help us prioritize the order in which problems should beaddressed. We can use this principle to focus our resources on eliminating 80% of the contributorsby only having to address 20% of the problems. Pareto charts are also one of the better methods tochart the results of common cause analysis.

Steps for preparing a Pareto Chart

1. Capture the data on a table or spreadsheet

Equipment Failure Mode Count

Aging 7

Design 2

Environmental Protection 1

Fabrication 1

Foreign Material 1Installation 1

Lubrication 8

Operation 1

Pressure 4

Temperature 5

Total 31

2. Sort the data so that the causes are arranged from largest to smallest

Equipment Failure Mode Count

Lubrication 8

Aging 7

Temperature 5

Pressure 4

Design 2

Environmental Protection 1

Fabrication 1

Foreign Material 1

Installation 1

Operation 1

Total 31



27/41


3. Construct a Histogram

Equipment Failure Modes

0

1

2

3

4

5

6

7

8

9

Lubrica

tion Aging

Tempe

raturePr

essure

Design

Envir

onmentalP

rote

ctio

Fabrica

tion

Foreign

Mate

rial

Insta

llation

Operation

Modes

#ofEquipm

entFailures

4. Determine the % contribution of each failure mode to the total, and the cumulative % of thefailures when added from largest to smallest (a spreadsheet can do the calculations for you).

Equipment Failure Mode(Causes)

Count % of TotalCumulative

%

Lubrication 8 25.8% 25.8%

Aging 7 22.6% 48.4%

Temperature 5 16.1% 64.5%

Pressure 4 12.9% 77.4%

Design 2 6.5% 83.9%

Environmental Protection 1 3.2% 87.1%

Fabrication 1 3.2% 90.3%

Foreign Material 1 3.2% 93.5%

Installation 1 3.2% 96.8%

Operation 1 3.2% 100.0%Total 31



28/41


Following Vilfredo Paretos principle, select the first four failure modes for further evaluation andcorrective actions. In this case, 77.4% of the failures were caused by 40% of the causes.

Below is a representation of the Pareto, although due to the limitations of the software, thecumulative % (line graph) is not displayed in classic Pareto format. In a classic Pareto, theprimary Y axis (on the left) and the secondary Y axis (on the right) are set at the total number offailures (N=31), so that the 100% value corresponds to 31 failures.

Pareto of Equipment Failure Modes

0

2

4

6

8

10

Failure M odes

No.ofFailure

s

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

Count 8 7 5 4 2 1 1 1 1 1

Cumulative % 25.80% 48.40% 64.50% 77.40% 83.90% 87.10% 90.30% 93.50% 96.80% 100.00%

Lubric'n Aging Temp Press DesignEnviron

mentalFab

Foreign

MaterialIns tall'n Ops

N=31



29/41


D. Change Analysis

Change Analysis is the comparison of a successfully performed activity to the same activityperformed unsuccessfully. During the process of collecting information, all identified changes arewritten down. The differences are then analyzed for their effects in producing the inappropriate actionor adverse Event. Change Analysis is used to help you analyze a process and develop evaluationleads and questions on which to follow up in your search for causes.

The question the evaluator needs to ask is: What was different from all other times we carried out thesame task or activity without an inappropriate action or adverse event?

EXAMPLE

On your way to work you take the car out of the garage and notice oil on the floorwhere the car was parked. The car had never leaked oil before.

Right away you would ask yourself what has changed between yesterday andtoday. You quickly identify that yesterday you changed the oil in the car.

Although at this point you may not know exactly where the oil is coming from, youhave a good lead to follow-up on. When you check under the car, you notice thatthe oil is coming from the oil filter gasket and promptly correct the problem bytightening the filter.

The cause of the oil leak was a loose oil filter.

The underlying causal factor may be that you did not have the right level ofknowledge or all the appropriate tools, but you change the oil yourself tosave money.

The root cause might be that you are thrifty by nature and saving money is amajor factor in all your decisions.

In power plant applications, change analysis is useful in situations when a task or procedure hasbeen done successfully many times in the past, but the last time it resulted in an undesirableoutcome. The following are the general steps for conducting Change Analysis.

1. Obtain the help of subject matter experts who have done the task or evolution successfully in thepast, as well as the personnel who were involved in the latest attempt, to review the chronologyand available information.

2. Fill out the Change Analysis Worksheet to identify differences between the successful completionand the unsuccessful attempt, asking the five simple questions of What, Where, When, How and

Who.



30/41


Change FactorSuccessful

Outcome

What was

different this

time?

Adverse

Effect or

Consequences

Follow-up Questions

WHAT(Conditions,

activity, equipment)

Tag out thepump

breaker for

the 1A pump

for PM

Tagged thewrong breaker

(pump 1B)

1A Pump wasnot tagged and

started on a

demand signal

What barriers should have preventedthis from happening?

How did Operations conduct thetagging and verification?

Were the breakers properly labeled? Was the lighting adequate in the

breaker cubicle?

WHAT(Conditions,activity, equipment)

Mechanicsverify their

work are safeto start work

The tags werenot verified to

be hung on the1A breaker

Worked on thepump without aproper boundary

Why didnt the mechanics check thatthe tags were hung before startingwork?

What barriers should have preventedthis from happening?

WHEN (Occurrence, plantstatus, schedule)

The ShiftSupervisor

usually

approves thetag out by

0500 andtags are hung

by 0700

The ShiftSupervisor

approved the tag

out at 0700

Operators werein a hurry to getthe tags hung by

0800

How is scheduling done? Why did the SS not approve the tag

out by 0500?

How long does it usually take to hangthese tags?

Was there inordinate time pressure?

WHERE (physicallocations, environmental

conditions, step ofprocedure)

Componentsto be tagged

out areproperly

labeled andthe area is

well lit

The 1A and 1Bbreakers forthese pumps

were not

labeled.

The area was

well lit.

Operator went tothe wrongbreaker

Why were the breakers not labeled? How many other components are not

labeled?

What is the status of the plant labelingprogram?

Was the Operator properly trained onthis equipment?

What was his level of experience? Why did the second verification not

catch the error?

Were the standards for hanging and

verifying tags clear and were theyfollowed?

HOW (work practice,omission, extraneous

actions, out of sequence,poor procedure)

Independent

verificationsare

conductedwhen

hanging tags

The operators

worked togetherand did not

independentlyverify tag

placement

Wrong breaker

was tagged What did the Operators use to verify

they were on the right breaker?

Is the guidance clear for howverification is to be done?

Are the Operators trained on V&V?

HOW (work practice,omission, extraneous

actions, out of sequence,

poor procedure)

Mechanicswalk downthe tag out

prior tostarting the

job

Mechanics senta mechanic

apprentice to

check tags

Mechanicapprentice sawthe tag but did

not recognize itwas on the

wrong breaker

Who is responsible for ensuring thearea is safe to start work?

Is the guidance clear for verifyingwork areas are safe prior to startingwork?

WHO (personnel involved(by job title, not name),

supervision)

QualifiedMechanics

verify area is

safe beforestarting work

A mechanicapprentice

verified the tags

were hung

Mechanicapprentice sawthe tag but did

not recognize itwas on the

wrong breaker

Was the apprentice qualified to do tagverification?

3. Use the information gained from the change analysis to pursue the causal factors.



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E. Flowchart / Process Maps

Many of the problems at the station involve processes and procedures. In many cases it would beadvisable to prepare a flowchart of the process (or a segment of the process).

Flowcharts and process maps can be used:

1. To provide an understanding of the process and help pinpoint the problem area in support ofcause evaluations.

2. To conduct a gap analysis between the existing process or procedure and industry standards ofexcellence for the same process.

3. To evaluate the process flow and look for opportunities to make the process more efficient.

4. To identify where a procedure is missing key steps or critical guidance.

NOTE

One of the most effective methods for writing a new procedure orrevising an existing process is to first prepare a detailed flowchart of theprocess, and then use the steps in the flowchart as the basis for thenecessary guidance.

(Section III of this Handbook was prepared using a detailed processmap shown below).



32/41



Steps for preparing a flowchart

1. Flowcharts can be created on a single page or on a large whiteboard using post-it notes,

2. The basic shapes used in flowcharts are as follows.

red level of

ocess interface with

f the flowchart, establish columns for each group or function

left margin of the flowchart, establish rows for each phase or segment of the

e columns and rows to separate the groups and

umn containing the steps that the group isvolved down through all the phases of the process.

Keep in mind that there are usually three versions of a flowchart:

depending on the complexity.

3. The shapes are connected in the sequence dictated by a procedure or a process. If there is noprocedure, subject matter experts can be used to lay out the process. Build in the desidetail, starting with a high level view of the process.

4. A more sophisticated method to map out a process is the Cross-Functional Flowchart. This

method can be used to show how each group or persons involved in the prthe process, and different process phases or segments can also be shown.

a. Along the top margin oinvolved in the process.

b. Along theprocess.

c. When preparing the chart, follow thphases of the process as applicable.

This degree of sophistication is particularly useful when preparing multiple procedures for acomplex process involving different organizations. For example, to prepare a specific procedurefor one of the groups or functional areas, follow the colin

5.

Step 3.2.1

?

Start and Stop

Points

Process Step

Decision Point

YES

NO

START

Documents


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STEP

What You Think

STARTDOCUMENT

STOP

STEP

STEP ?

YES

NO

STARTDOCUMENT

STOPSTEP

STEP ?

YES

NO

STARTDOCUMENT

STOPSTEP

STEP

STEP STEP

STEP

STEP

STEP STEP STEP

What It Really Is

What You Want it to Be



34/41


II. Tools for Identifying Causal Factors

A. Cause and Effect Analysis (Fishbone Diagrams)

PROBLEM

ProgramProcess

ProcedurePersonnel

Also known as the Fishbone Diagram or Ishikawa after Mr. Kaoru Ishikawa, the JapaneseQuality Management expert who created it.

Once a clearly defined problem has been selected from the data analysis, cause and effectanalysis can be used to:

Help the evaluators push past the symptoms and systematically evaluate potentialcauses and determine which are most likely to be root causes

Provide a structured method to ensure that a balanced list of potential causes hasbeen generated and that possible causes are not overlooked

Provide a pictorial representation that shows the relationship between the problemand the underlying causes

Steps for conducting Cause and Effect Analysis

1. Gather a facilitator familiar with the process and a group of subject matter experts in theproblem area.

2. Write the specific problem statement to be evaluated at the head of the fishbone, and beas specific as possible. For example:

Procedure adherence contributed to 50% of the 50 CR in the OperationsDepartment for the period of May to October 2006.

3. Construct the major bones of the fishbone. They can vary and are determined basedon the area to be evaluated. Typical major bones to choose from are listed below.

Man, Method, Management, Material, Machine, Measurement

Personnel, Processes, Procedures, Standards/Expectations & Policies, PlantEquipment & Facilities, Tools

4. Considering each of the major categories, brainstorm a list of all the possible first levelcauses and write them on the branches that apply.

5. For each of the possible causes in the major categories, ask why these causes existuntil the answer is no longer actionable or reasonable.



35/41


Example

Problem: Procedure adherence contributed to 50% of the 50 CR in theOperations Department for the period of May to October 2006

1. Procedures Category:

Why were there 25CR on procedure adherence in Ops? Becauseoperating procedures are less than adequate.

Why are operating procedures less than adequate? Because theyare outdated.

Why are they outdated? Because they have not been upgradedsince they were originated.

Why havent they been upgraded since they were originated?Because major procedure upgrades have not been funded.

Why has a procedure upgrade project not been funded? Because aproject proposal has not been submitted to the annual station

budget. Why has a project proposal not been submitted? Because of unclear

standards and expectations in this area.

Taking the evaluation to a cause that is not actionable is not sensible and can lead tofrustration. For example: gravity, the earths rotation or the annual budget for the NuclearBusiness Unit.

NOTE

In the above example, the evaluators drilled down on the Procedurescategory and asked why each time. One thing to note is that eachquestion can have more than one possible answer, creating manybranches for the same question.

The strength of the Fishbone diagram is that it keeps all these causalrelationships in order and represents them pictorially in an easy tounderstand format.



36/41


6. Once the diagram is complete, look for the lowest level causes that have come uprepeatedly in different parts of the Fishbone. Those are the most likely underlying causesof the problem. Cloud these underlying causes on the diagram.

NOTE

There are usually several underlying causes for any given problem. If theanalysis only identified one possible cause, consider adding additionalmajor categories and continuing the analysis

7. Confirm theses causes using a simple screening.

a. If these causes never existed, would the problem still have occurred?

b. If these causes are eliminated, would the problem completely go away?

8. Causes that have been confirmed as the most likely causes or root causes are assignedcorrective actions using a countermeasures matrix.

B. Hazards / Barriers / Targets (HBT) Analysis

HBT analysis is used to identify barriers that should have prevented the problem fromoccurring. The analysis identifies where barriers were missing, weak or ineffective, and whatnew barriers might be needed.

At nuclear plants, there are many threats (hazards) to the safe and reliable operation of thestation. Examples include:

Radiation

Electricity

High energy systems

Aging equipment

Heavy loads

Confined spaces

The targets that the barriers are designed to protect are usually employees and the generalpublic, as well as plant equipment that is required for either the safe operation of the plant orto mitigate the consequences of design basis events.

Nuclear plants employ a defense-in-depth concept, and for every potential hazard there arenumerous barriers in place that were designed to prevent it. There are two general types of

barriers, Physical and Administrative in nature.1. Physical barriers include:

Automatic shutdown devices

Safety and relief devices

Conservative design margins

Engineered safety features

Radiation shielding



37/41


Redundant equipment

Locked doors and valves

Fire barriers and seals

2. Administrative barriers include:

Regulations Technical Specifications

Training and qualification programs

Operating and maintenance procedures

Programs, policies and practices

Management & supervisory oversight

Steps for conducting HBT analysis:

1. The problem being evaluated is regarded as the threat or hazard, and the target is

usually personnel or equipment.

TargetsBarriers

Hazards

SSCs

PostingsDoorsLocks

InsulationShieldingStandardsProcedures

TrainingExperienceSupervisionOversight

RegulationsBest Practices

SteamElectricityRadiation

Heavy LoadsConfined Spaces

Hot SurfacesExtreme Temperatures

Rotating Equipment

2. For the identified problem, prepare a list of barriers that were put in place to protect thetarget from the hazard.

3. Place the identified barriers in a Barrier Analysis Worksheet and analyze each barrier todetermine to what extent each barrier failed and why. Failed barriers should be assignedcorrective actions.

4. Similarly, identify potential new barriers that, had they existed, may have prevented theproblem from occurring. Potential new barriers are also considered for action in acountermeasures matrix.



38/41


Barrier Analysis Worksheet

Hazard / Problem/ Consequence

Barriers That Should HavePrevented the Problem, or

New Barriers that CanWhy Did the Barrier Fail?

Worker receivedelectrical shock

Industrial Safety ProgramGuidelines for checking work

area not followed

Human Performance ProgramDid not self-check, peercheck, no questioning attitude

Worker PracticesGuidelines for working onenergized systems notfollowed

Tagging ProgramTags were hung on wrongcomponent

NEW: Live-Dead-Live ChecksAdd new requirement to workpractices Handbook

C. Fault Tree Analysis

Fault tree analysis is a systematic approach to identify potential causal factors. It provides anexcellent representation of the problem and its potential causes, and is most useful forequipment problems because they have a finite possible number of causes that can beidentified and validated through a process of elimination. Fault tree analysis is an excellenttroubleshooting tool as well.

Steps for preparing a Fault Tree

1. Fault trees can be created on a single page or on a large whiteboard using post-it notes,

depending on the complexity.

2. The basic shapes used in Fault Trees are as follows.

EVENT

BASIC

EVENT

AND gate

OR gate

CAUSES

LOWEST

POSSIBLE

CAUSE

3. Write the specific problem statement to be evaluated at the top of the Fault Tree.

4. Using available information such as drawings, wiring diagrams and procedures, constructthe fault tree using AND gates when all of the underlying causes have to occur to trigger



39/41



the higher level event, and OR gates when any one of the causes can trigger the higherlevel event.

5. The last possible cause in the series is depicted by a circle. The fault tree charting iscomplete when the lowest causes shown on the diagram are all circles.

6. Once all the possible causes are charted, begin a process of elimination based on actualpath to the problem is evaluated and verified to exist or not.

ses the potential fault

nd as many

data or expertise. Each faultThis may involve one or more of the following.

a. Equipment testing

b. Preventive maintenance that exerci

c. Physical inspections

d. Review of event chronology

e. Review of governing procedures

f. Personnel interviews and eye witness accounts

7. The process ends when all of the potential fault paths have been evaluated, aof the fault paths ruled out. The remaining basic events that cannot be eliminated will

require corrective actions to ensure that the fault path has been addressed.

COMPONENT COOLING

WATER PP WILL NOT

START

NO BUS

POWER

NO CONTROL

POWER

START LOGIC

NOT

SATISFIED

SUCTION VLV

CLOSED

EDG PWR

OOS

OFFSITE

PWR OOS

DC BKR

OPEN

CONTRL

PWR

FUSES

BLOWN

LOW

BEARING

WATER

FLOW

XFER SW

NOT

SELECTED

TO CONTROL

ROOM

PP START

NOT

SELECTEDON CONTROL

SW

VALVE NOT

FULL OPEN

LIMIT SW

DEFECT


40/41



III. Eva

A.

sures Matrix should be used for evaluating proposed corrective actions thatevaluate adverse trends identified through the DSEMs. In

sed to evaluate proposed corrective actions that are

s

oes the following:

After the decision is made on what is to be implemented, it also documents what was

questions.

st effective score). Examples of scoring factors:

luating and Implementing Corrective Actions

Countermeasures Matrix

A Countermeacome out of the ACEs used toaddition, this useful tool can be u

generated by: Root cause evaluation

Apparent cause evaluations

Self-assessments

A Countermeasures Matrix d

Graphically shows the relationship between the likely causes and the proposedcorrective actions.

It helps the team select the countermeasures that best address those cases usingformal screening criteria.

It provides management with a prioritized list of corrective actions such that decisionscan be made based on station budgets, resources, etc.

not implemented to understand the risk of recurrence.

Below are the steps for filling out a Countermeasures Matrix.

a. Problem: the problem statement used at the start of the analysis.

b. Most Likely Causes: the list of most likely causes that were identified through theevaluation process. To help zero in on most likely causes, ask the following

1) If this cause never existed, would the problem still have occurred?

2) If this cause is eliminated, would the problem completely go away?

c. Corrective Actions: the big picture corrective actions that will address the problem area.

d. Implementation Details: the main tasks needed to implement each of the correctiveactions. Providing this next level of detail helps in the analysis by identifying majorhurdles to implementing a corrective action.

e. Scoring: the team can select any number of factors to score the proposed list ofcorrective actions. Scoring can be done on any desired scale (1 to 5 or 1 to 10, with thehighest value being the mo

PROBLEMMost Likely

Causes

Corrective

Act ion s

Implementation

DetailsFeasability Effectiveness

Cost

Effective

Other

Factors

Overall

ScoreRanking

Selected for

Implementation

A

BCD

EFGH

IJK -

CAUSES

1

2

4

SCORING (1=LOW 5=HIGH)

ProblemStatement

2

1

34

SELECTION

1

2

3

CORRECTIVE ACTIONS

-5

4

3

1

2

4

5

7

8

11

135

-

-

4

3

2

1

NO