defining investigation extent of condition/cause scope a new approach steve davis the excellence...
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Defining Investigation Defining Investigation Extent of Condition/Cause Extent of Condition/Cause
ScopeScopea New a New
Approach Approach
Steve DavisSteve Davis
The Excellence Engine, The Excellence Engine, LLCLLC
June 2010June 2010
Extent of Extent of Condition/CauseCondition/Cause
a.k.a. How big is this a.k.a. How big is this problem?problem?
Transportability of condition - determine Transportability of condition - determine whether the same problem/condition exists whether the same problem/condition exists elsewhere.elsewhere.
Is the extent to which the condition may Is the extent to which the condition may exist in other plant equipment, exist in other plant equipment, organizations, processes, or human organizations, processes, or human performance. performance.
Extent of ConditionExtent of Condition
Why Perform an Extent of Why Perform an Extent of Condition Review?Condition Review?
To identify down stream To identify down stream effects from the initial event.effects from the initial event.
To identify possible event To identify possible event initiators and correct them initiators and correct them prior to causing an additional prior to causing an additional event.event.
Extent of CauseExtent of Cause
Transportability of cause - determine Transportability of cause - determine whether the same root or underlying whether the same root or underlying causes of the problem/condition may be causes of the problem/condition may be affecting performance elsewhere (other affecting performance elsewhere (other plant processes, equipment, or human plant processes, equipment, or human performance).performance).
Why Perform an Why Perform an Extent of Cause Review?Extent of Cause Review?
To identify other places where To identify other places where this cause exists and correct this cause exists and correct them prior to causing an them prior to causing an additional event. additional event.
The ProblemThe Problem
Extent of Cause/Condition review too narrow.Extent of Cause/Condition review too narrow. Extent of Cause/Condition review too broad.Extent of Cause/Condition review too broad. Extent of Cause/Condition review just right Extent of Cause/Condition review just right
but is criticized as being too broad/narrow.but is criticized as being too broad/narrow. Extent of Cause/Condition review assesses Extent of Cause/Condition review assesses
the wrong areas.the wrong areas.
A Risk Based Approach to A Risk Based Approach to SettingSetting
Extent of Condition/Cause Extent of Condition/Cause Assessment ScopeAssessment Scope
The SolutionThe Solution
Risk Based Risk Based Three Step ApproachThree Step Approach
First, define other potential instances of First, define other potential instances of the same/similar condition/cause(s). the same/similar condition/cause(s).
Second, determine the risk of a similar Second, determine the risk of a similar event occurring with the same/similar event occurring with the same/similar condition/cause(s) by assigning a condition/cause(s) by assigning a probability of occurrence and level of probability of occurrence and level of consequence if no corrective or consequence if no corrective or preventive actions are taken.preventive actions are taken.
Third, decide if action is required.Third, decide if action is required.
Define Potential Define Potential Same/Similar ConditionsSame/Similar Conditions
Restate the Restate the event / problemevent / problem and and critical setup conditionscritical setup conditions Define Same/Similar using the following criteria.Define Same/Similar using the following criteria.
––Same - Same Same - Same SameSame Program [e.g., CAP] or Process [e.g., Surveillance Program [e.g., CAP] or Process [e.g., Surveillance
Scheduling] or System [Auxiliary Steam] with the Scheduling] or System [Auxiliary Steam] with the SameSame kind of kind of problem/error/failure or defect. problem/error/failure or defect. Same Object – Same DefectSame Object – Same Defect
––Same - SimilarSame - Similar SameSame Program [e.g., CAP vs. Self-Assessment] or Process [e.g., Program [e.g., CAP vs. Self-Assessment] or Process [e.g.,
Surveillance Scheduling vs. 13-Week Scheduling] or System Surveillance Scheduling vs. 13-Week Scheduling] or System [Auxiliary Steam vs. Heater Drains] with a [Auxiliary Steam vs. Heater Drains] with a SimilarSimilar kind of kind of problem/error/failure or defect. problem/error/failure or defect. Same Object – Similar DefectSame Object – Similar Defect
––Similar - SimilarSimilar - Similar SimilarSimilar Program [e.g., CAP vs. Self-Assessment vs. Management Program [e.g., CAP vs. Self-Assessment vs. Management
Oversight] or Process [e.g., Surveillance Scheduling vs. 13-Week Oversight] or Process [e.g., Surveillance Scheduling vs. 13-Week Scheduling vs. WM] or System [Auxiliary Steam vs. Heater Drains Scheduling vs. WM] or System [Auxiliary Steam vs. Heater Drains vs. Main Steam] with a vs. Main Steam] with a SimilarSimilar kind of problem/error/failure or kind of problem/error/failure or defect. defect. Similar Object – Similar DefectSimilar Object – Similar Defect
Define Potential Define Potential Same/Similar CausesSame/Similar Causes
Restate the Restate the problem statementproblem statement and and identified causeidentified cause.. (Typically just the Root Cause or principal Apparent Cause)(Typically just the Root Cause or principal Apparent Cause) Define Same/Similar using the following criteria.Define Same/Similar using the following criteria.
––Same - Same Same - Same SameSame SameSame Same Cause – Same ImpactsSame Cause – Same Impacts
––Same - SimilarSame - Similar SameSame SimilarSimilar Same Cause – Similar ImpactSame Cause – Similar Impact
––Similar - SimilarSimilar - Similar SimilarSimilar SimilarSimilar Similar Cause – Similar ImpactSimilar Cause – Similar Impact
Set the Scope Set the Scope of the Assessmentof the Assessment
Using the defined Same/Similar Using the defined Same/Similar conditions/conditions/cause(s):cause(s): Determine the consequences for Determine the consequences for eacheach
defined defined potentialpotential condition/cause. condition/cause. Evaluate the chance of occurrence for Evaluate the chance of occurrence for
eacheach defined defined potential potential condition/cause.condition/cause. Identify the Risk for Identify the Risk for eacheach defined defined
potential potential condition/cause.condition/cause. Bound the Extent of Condition evaluation Bound the Extent of Condition evaluation
based on the based on the defined riskdefined risk. . (e.g. No Risk = No (e.g. No Risk = No evaluation)evaluation)
Roofing NailsIn Driveway
Nails inTires
Roofer ForeignMaterial Mgt.
Roofing NailsIn Other Places
Other ForeignMaterial Problemswith the New Roof
© 2003, William R. Corcoran, NSRC Corp., 860-285-8779, [email protected]
Consequence
Extent of causeSame - Same
Similar - Similar Same - SimilarSame - Same
Suggested Extent of Condition Suggested Extent of Condition Analysis TemplateAnalysis Template
Set up Set up ConditionsConditions Problem / EventProblem / Event Extent of ConditionExtent of Condition
Potential SAME – SAME Potential SAME – SAME ConditionCondition
RISKRISK
MITIGATING ACTIONSMITIGATING ACTIONS
Potential SAME – SIMILAR Potential SAME – SIMILAR ConditionCondition
RISKRISK
MITIGATING ACTIONSMITIGATING ACTIONS
POTENTIAL SIMILAR - SIMILAR POTENTIAL SIMILAR - SIMILAR CONDITIONCONDITION
RISKRISK
MITIGATING ACTIONSMITIGATING ACTIONS
©2008 The Excellence Engine
Suggested Extent of Cause Suggested Extent of Cause Analysis TemplateAnalysis Template
Problem Problem StatementStatement
Apparent / Apparent / Root CauseRoot Cause Extent of CauseExtent of Cause
Potential SAME – SAME Potential SAME – SAME ImpactsImpacts
RISKRISK
MITIGATING ACTIONSMITIGATING ACTIONS
Potential SAME – SIMILAR Potential SAME – SIMILAR ImpactsImpacts
RISKRISK
MITIGATING ACTIONSMITIGATING ACTIONS
POTENTIAL SIMILAR - POTENTIAL SIMILAR - SIMILAR IMPACTSSIMILAR IMPACTS
RISKRISK
MITIGATING ACTIONSMITIGATING ACTIONS
©2008 The Excellence Engine
Extent of Condition/CauseExtent of Condition/CauseAssessment Definition MatrixAssessment Definition Matrix
©2008 The Excellence Engine
Definition Matrix
Extent of Condition/CauseExtent of Condition/CauseAssessment Risk MatrixAssessment Risk Matrix
©2008 The Excellence Engine
Risk Matrix
©2008 The Excellence Engine
Mitigating Actions Matrix
Extent of Condition/CauseExtent of Condition/CauseAssessment Mitigating Actions MatrixAssessment Mitigating Actions Matrix
Catastrophic Critical Marginal NegligibleFrequent / Probable High High Medium Medium
Occasional High High Medium Low
Remote High Medium Low Low
Improbable Medium Medium Low Low
ConsequencesRecurrence
Risk Matrix
Same ObjectSame Defect
Same ObjectSimilar Defect
Similar ObjectSimilar Defect
Same CauseSame Result
Same CauseSimilar Result
Similar CauseSimilar Result
Definition Matrix Mitigating Actions Matrix
SimilarSimilar
Evaluate & Correct as
needed.
ManagementDiscretion
NoAction
SameSimilar
Evaluate & Correct as
needed.
ManagementDiscretion
ManagementDiscretion
SameSame
Evaluate & Correct as
needed.
Evaluate & Correct as
needed.
Evaluate & Correct as
needed.
High Medium Low
RiskApplicationExtent of Condit ion Extent of Cause
Application
Extent of Condition/Cause Extent of Condition/Cause Assessment Risk to Action MatrixAssessment Risk to Action Matrix
©2008 The Excellence Engine
Example ProblemExample Problem
A few gallons of hydrazine A few gallons of hydrazine contaminated with sodium hydroxide contaminated with sodium hydroxide waste was pumped from the waste was pumped from the secondary hydrazine addition tank to secondary hydrazine addition tank to the Auxiliary Feedwater Storage the Auxiliary Feedwater Storage Tank, which was being used to feed Tank, which was being used to feed the Steam Generators while the the Steam Generators while the plant was in Hot Standbyplant was in Hot Standby..
Set up Set up ConditionsConditions
Problem / Problem / EventEvent Extent of ConditionExtent of Condition
An empty hydrazine drum filled with sodium hydroxide waste was not labeled per station requirements.The waste drum was later mistaken for a new drum of hydrazine and its contents were added to the secondary hydrazine addition tank.
A few gallons of hydrazine contaminated with sodium hydroxide waste was pumped from the secondary hydrazine addition tank to the Auxiliary Feedwater Storage Tank, which was being used to feed the S/Gs while the plant was in Hot Standby.
Potential SAME – SAME ConditionPotential SAME – SAME Condition RISKRISK
What other systems or tanks are contaminated due to transfer from the secondary hydrazine addition tank or other direct transfers from the contaminated waste drum?
MITIGATING ACTIONSMITIGATING ACTIONS
Potential SAME – SIMILAR Potential SAME – SIMILAR ConditionCondition
RISKRISK
Are there any other mislabeled drums that could mistakenly be added to the same or other plant systems?
MITIGATING ACTIONSMITIGATING ACTIONS
POTENTIAL SIMILAR – SIMILAR POTENTIAL SIMILAR – SIMILAR CONDITIONCONDITION
RISKRISK
Are there any other chemical transfer tasks that could be mistakenly performed because of a labeling error?
MITIGATING ACTIONSMITIGATING ACTIONS
Extent of Condition Extent of Condition ExampleExample
©2008 The Excellence Engine
©2008 The Excellence Engine
Extent of Condition/CauseExtent of Condition/CauseAssessment Risk to Action MatrixAssessment Risk to Action Matrix
Catastrophic Critical Marginal NegligibleFrequent / Probable High High Medium Medium
Occasional High High Medium Low
Remote High Medium Low Low
Improbable Medium Medium Low Low
ConsequencesRecurrence
Risk Matrix
Same ObjectSame Defect
Same ObjectSimilar Defect
Similar ObjectSimilar Defect
Same CauseSame Result
Same CauseSimilar Result
Similar CauseSimilar Result
Definition Matrix Mitigating Actions Matrix
SimilarSimilar
Evaluate & Correct as
needed.
ManagementDiscretion
NoAction
SameSimilar
Evaluate & Correct as
needed.
ManagementDiscretion
ManagementDiscretion
SameSame
Evaluate & Correct as
needed.
Evaluate & Correct as
needed.
Evaluate & Correct as
needed.
High Medium Low
RiskApplicationExtent of Condit ion Extent of Cause
Application
Set up Set up ConditionsConditions
Problem / Problem / EventEvent Extent of ConditionExtent of Condition
An empty hydrazine drum filled with sodium hydroxide waste was not labeled per station requirements.The waste drum was later mistaken for a new drum of hydrazine and its contents were added to the secondary hydrazine addition tank.
A few gallons of hydrazine contaminated with sodium hydroxide waste was pumped from the secondary hydrazine addition tank to the Auxiliary Feedwater Storage Tank, which was being used to feed the S/Gs while the plant was in Hot Standby.
Potential SAME – SAME ConditionPotential SAME – SAME Condition RISKRISK
What other systems or tanks are contaminated due to transfer from the secondary hydrazine addition tank or other direct transfers from the contaminated waste drum?
Probable & Critical = Probable & Critical = HIGH RISKHIGH RISK
MITIGATING ACTIONSMITIGATING ACTIONS
Evaluate & CorrectEvaluate & Correct
Potential SAME – SIMILAR Potential SAME – SIMILAR ConditionCondition
RISKRISK
Are there any other mislabeled drums that could mistakenly be added to the same or other plant systems?
Probable & Critical = Probable & Critical = HIGH RISKHIGH RISK
MITIGATING ACTIONSMITIGATING ACTIONS
Evaluate & CorrectEvaluate & Correct
POTENTIAL SIMILAR – SIMILAR POTENTIAL SIMILAR – SIMILAR CONDITIONCONDITION
RISKRISK
Are there any other chemical transfer tasks that could be mistakenly performed because of a labeling error??
Remote & Critical =Remote & Critical =MEDIUM RISKMEDIUM RISK
MITIGATING ACTIONSMITIGATING ACTIONS
Mgmt. DiscretionMgmt. Discretion
Extent of Condition Extent of Condition ExampleExample
©2008 The Excellence Engine
Problem Problem StatementStatement
Apparent / Apparent / Root CauseRoot Cause Extent of CauseExtent of Cause
A few gallons of hydrazine contaminated with sodium hydroxide waste was pumped from the secondary hydrazine addition tank to the Auxiliary Feedwater Storage Tank, which was being used to feed the S/Gs while the plant was in Hot Standby.
Willful violation (i.e. shortcut taken) on the part of the individual responsible for labeling the waste drum.
Potential SAME – SAME ImpactsPotential SAME – SAME Impacts RISKRISK
Has the same individual taken shortcuts when labeling other waste drums? MITIGATING ACTIONSMITIGATING ACTIONS
Potential SAME – SIMILAR ImpactsPotential SAME – SIMILAR Impacts RISKRISK
Has the same individual taken any other safety significant shortcuts? MITIGATING ACTIONSMITIGATING ACTIONS
POTENTIAPOTENTIAL SIMILAR – SIMILAR L SIMILAR – SIMILAR IMPACTSIMPACTS
RISKRISK
Are other individuals in the same work group willfully violating labeling requirements? MITIGATING ACTIONSMITIGATING ACTIONS
Extent of Cause Extent of Cause ExampleExample
©2008 The Excellence Engine
©2008 The Excellence Engine
Extent of Condition/CauseExtent of Condition/CauseAssessment Risk to Action MatrixAssessment Risk to Action Matrix
Catastrophic Critical Marginal NegligibleFrequent / Probable High High Medium Medium
Occasional High High Medium Low
Remote High Medium Low Low
Improbable Medium Medium Low Low
ConsequencesRecurrence
Risk Matrix
Same ObjectSame Defect
Same ObjectSimilar Defect
Similar ObjectSimilar Defect
Same CauseSame Result
Same CauseSimilar Result
Similar CauseSimilar Result
Definition Matrix Mitigating Actions Matrix
SimilarSimilar
Evaluate & Correct as
needed.
ManagementDiscretion
NoAction
SameSimilar
Evaluate & Correct as
needed.
ManagementDiscretion
ManagementDiscretion
SameSame
Evaluate & Correct as
needed.
Evaluate & Correct as
needed.
Evaluate & Correct as
needed.
High Medium Low
RiskApplicationExtent of Condit ion Extent of Cause
Application
Problem Problem StatementStatement
Apparent / Apparent / Root CauseRoot Cause Extent of CauseExtent of Cause
A few gallons of hydrazine contaminated with sodium hydroxide waste was pumped from the secondary hydrazine addition tank to the Auxiliary Feedwater Storage Tank, which was being used to feed the S/Gs while the plant was in Hot Standby.
Willful violation (i.e. shortcut taken) on the part of the individual responsible for labeling the waste drum.
Potential SAME – SAME ImpactsPotential SAME – SAME Impacts RISKRISK
Has the same individual taken shortcuts when labeling other waste drums?
Probable & Critical = Probable & Critical = HIGH RISKHIGH RISK
MITIGATING ACTIONSMITIGATING ACTIONS
Evaluate & CorrectEvaluate & Correct
Potential SAME – SIMILAR ImpactsPotential SAME – SIMILAR Impacts RISKRISK
Has the same individual taken any other safety significant shortcuts?
Probable & Marginal = Probable & Marginal = MEDIUM RISKMEDIUM RISK
MITIGATING ACTIONSMITIGATING ACTIONS
Evaluate & CorrectEvaluate & Correct
POTENTIAPOTENTIAL SIMILAR – SIMILAR L SIMILAR – SIMILAR IMPACTSIMPACTS
RISKRISK
Are other individuals in the same work group willfully violating labeling requirements?
Improbable & Marginal Improbable & Marginal = = LOWLOW
MITIGATING ACTIONSMITIGATING ACTIONS
No ActionNo Action
Extent of Cause Extent of Cause ExampleExample
©2008 The Excellence Engine
Risk Based Approach to SettingRisk Based Approach to SettingExtent of Condition/Cause Extent of Condition/Cause
Assessment Scope Value-AddedAssessment Scope Value-Added
Provides standardized approach for Provides standardized approach for setting extent of condition/cause setting extent of condition/cause assessment scope.assessment scope.
Makes thinking visible.Makes thinking visible. Simplifies identifying appropriate Simplifies identifying appropriate
corrective actions. corrective actions.
