Five types of factor building blocks with case study 2014.05.05.0730

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Factor Building blocks are the DNA of high hazard industry investigations.

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Five types of factor building blocks with case study 2014.05.05.0730

  1. 1. Factor Building Blocks (The DNA of the Problem) Factor Trees are made up of linked Factor Building Blocks (FBBs) W. R. Corcoran, Ph.D., P.E. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
  2. 2. Notices • This is part of The Phoenix Approach©. • It also applies to all other approaches to issue investigation (root cause analysis). • If your organization is licensed to use The Phoenix Approach© you may use this in accordance with the license. • If your organization is not licensed to use The Phoenix Approach© please call for permission. In the meanwhile you have permission to give this seminar once in-house, if you send me the workshop comments. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 2
  3. 3. Who Can Benefit • Investigators • Investigation Team Leaders • Investigation Team Sponsors • Investigation Report Reviewers/ Approvers • Investigation Report Inspectors • Managers whose success can be affected by Investigation Team Results © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 3
  4. 4. FBB Seminar Objectives 1. To explain a Factor Tree. 2. To explain a Factor Building Block (FBB). 3. To show how FBBs make up a Factor Tree. 4. To explain the five known types of FBBs. 5. To show that three of the five are rigorously capable of explaining the key attributes of the FBB’s “effect.” 6. To show that one can provide input for any of the first three. 7. To show that one can be convenient in some common situations. 8. To show how this fits into issue investigation in general. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 4
  5. 5. • State your name • State your position and affiliation • State (very briefly) your most memorable involvement with an event or an investigation • Tell us one or two things you would like to get out of this seminar. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 5
  6. 6. DNA? • DNA shows up in every cell of life. • The FBB shows up in every part of that which results in every harmful outcome. • DNA testing helps assure that you’re electrocuting the right suspect. • Using FBBs helps assure that you’re fixing the right problem right. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 6
  7. 7. Usual Investigation Objective To identify the factors that resulted in the adverse outcomes that are being investigated so that actions can be taken to avoid such outcomes in the future. 1. To have confidence in the above, the factors should explain the nature, the magnitude, the location, and the timing of the adverse outcome. 2. This involves tightly linked, evidence-based chains of factors from the adverse outcome to the deepest identified factors. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 7
  8. 8. Corrective Actions • The corrective actions for an adverse outcome address/ respond to/ relate to the factors that resulted in the adverse outcome. • If the factors do not explain the nature, the magnitude, the location, and the timing of the adverse outcome there must be one or more missing or erroneous factors. • Thus there can be a serious lack of confidence that the corrective actions are sufficient and appropriate. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 8
  9. 9. Causal Factor Analysis (Root Cause Analysis) Report Production/ Evaluation Corrective Actions Extent of Conditions & Causes Factors Extraneous CAQs Lessons-To- Be-Learned Consequences Evidence (data) © Drs. William Corcoran and Richard Hartley 8-21-07 Event Recognition Investigation (collect & organize evidence (data )) Culture Insight Convert Evidence (data) to Information Significance Characterization Human Behavior Technology Use Appropriate RCA Tools Lines of Inquiry The Fixes To Be Fixed To Be Prevented 9
  10. 10. Corrective Action Must Relate to Consequence Through Factor © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu Corrective Action Factor Consequence What factor does it address? What consequence did it affect? 10
  11. 11. This Seminar Begins to Address • The shape labeled “Consequences” • The shape labeled “Factors” • The shape labeled “Use Appropriate RCA Tools” • (The Big Picture Slide includes eleven other shapes!) © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 11
  12. 12. Flash Card Front • For confidence in the fixes, the items fixed must explain the _________. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 12
  13. 13. Flash Card Back •Effect(s) to be prevented, ie., the consequences. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 13
  14. 14. Affect and Effect • Affect (verb): to influence, change, modify…, e.g., The angle of the sun affects the length of shadows. • Effect (noun): A phenomenon. Something that happens, e.g., Einstein got his first Nobel Prize for the Photoelectric Effect. The Domino Effect was a Vietnam Era discussion topic. When one employee quits HR worries about the Bandwagon Effect. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 14
  15. 15. 15
  16. 16. Affect/Effect Hint 1. Use “affect” only as a verb. 2. Use “effect” only as a noun. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 16
  17. 17. Terminology • Factor-A factor of an effect is an item that affected the effect. • Effect-An identifiable phenomenon • Factor Tree-A linked structure that looks like an organization chart and represents the chains of factors that resulted in a defined adverse effect. • Factor Building Block-An effect linked to the factors that directly resulted in it. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 17
  18. 18. Aliases • There is great variation in investigative terminology. • Bad Factors (Harmful Factors) are often called “Causal Factors.” • Good Factors (Beneficial Factors) are often called “Mitigating Factors” and, in the case of a near miss, “Preventive Factors.” • Bad Effects (Adverse Outcomes) are often called “Consequences” when they are where an investigation starts. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 18
  19. 19. A Factor Can Be: • Condition, e.g., Bearing installed backwards • Behavior, e.g., Worker installs bearing backwards • Action, e.g., Pump starts automatically • Inaction, e.g., Plant staff does not sample lube oil • Note: The reality of a factor can often be expressed in more than one way. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 19
  20. 20. Not Wearing a Hard Hat Can Be: • Condition, e.g., Hard hat was not being worn. (Head exposed to impacts) • Behavior, e.g., Worker did not put hard hat on. • Action, e.g., Worker left hard hat in break room. • Inaction, e.g., Worker did not put hard hat on. • Note: The reality of a factor can often be expressed in more than one way. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 20
  21. 21. Direct Factor • A direct factor of an effect is a factor that affects the effect without any intermediate, or intervening, factors. • Aliases: Direct Cause, Immediate Cause, Proximate Cause… • Example: A direct factor of the Hartford Civic Center Roof Collapse was the snow load. • There are always more than one direct factor for an effect. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 21
  22. 22. Direct Factor Exercise • Conduct a thought experiment: – Wait until the hole tray in your three-hole puncher is almost full – Remove it from the three-hole puncher – Take it to an vacant room – Empty the hole tray on the floor – View the pattern of paper discs. • What are the factors that directly resulted in the nature, the magnitude, the location, and the timing of the pattern of paper discs? © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 22
  23. 23. Direct Factor Exercise Pattern of Paper Discs (NMLT) _________________________ Direct Factor 1: _____________ Direct Factor 2: _____________ Direct Factor 3: __________ Direct Factor 4: _____________ Add others as needed. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu Write on or near objects. 23
  24. 24. Direct Factor Exercise Potential Answer #1 Pattern of Paper Discs (NMLT) _________________________ Direct Factor 1: Number of Discs Direct Factor 2: Height of Drop Direct Factor 3: Air Movement Direct Factor 4: Stickiness of Discs © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 24
  25. 25. Effect • Death, Damage, Dose, Delay…. • Note: An effect can have an impact on a downstream effect, e.g., damage can result in delay. • Note: A factor is an effect of the deeper factors that resulted in it. • Note: The reality of an effect can often be expressed in more than one way. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 25
  26. 26. Factors and Effects Effect Factor / Effect Factor / Effect Factor / Effect Factor / Effect Factor / Effect Factor / Effect Factor / Effect Factor / Effect © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu An effect is the result of factors, which in turn are the effects that resulted from deeper factors……. (it ends when we decide to stop) 26
  27. 27. Flash Card Front • In Factor Trees (and Factor Building Blocks) the factors connected directly below an effect are always _________ factors of the effect. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 27
  28. 28. Flash Card Back •DIRECT © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 28
  29. 29. Block and Tree Legend Effect Direct Factor Direct Factor Direct Factor © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu The connecting lines always mean that the upper item is/was a result of the lower connected items. 29
  30. 30. A Factor Tree is • A graphic representation of the factors that resulted in an adverse effect. • A structure that has an adverse effect at the top and the terminal factors at the bottom. • An evidence-based unbroken logical set of chains of results from the top effect to the deepest factors. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 30
  31. 31. Factor Tree Example FT1 Harmful Effect: Factory Fire Direct Factor 1: Fuel Supply Direct Factor 2: Oxygen supply Direct Factor 3: Ignition Direct Factor 4:Suppression All Factor Trees are like this. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu The direct factors of an effect will explain the nature, the magnitude, the location, and the timing of the effect. 31
  32. 32. Factor Tree Example FT1.1 Harmful Effect: Factory Fire Direct Factor 1: Fuel Supply Factors Affecting NMLT of FS Direct Factor 2: Oxygen supply Factors Affecting NMLT of OS Direct Factor 3: Ignition Factors Affecting NMLT of Ignition Direct Factor 4:Suppression Factors Affecting NMLT of suppression All Factor Trees are like this. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu The direct factors of an effect will explain the nature, the magnitude, the location, and the timing (NMLT) of the effect. 32
  33. 33. Factor Tree Example FT1.4 Direct Factor 4:Suppression NMLT of Installed Suppression Systems Performance Deeper Factors NMLT of External Fire Company Performance Deeper Factors All Factor Trees are like this. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu The direct factors of an effect will explain the nature, the magnitude, the location, and the timing (NMLT) of the effect. 33
  34. 34. Factor Tree Example FT2 Harmful Effect: Radiation Dose Direct Factor 1: Source Strength Direct Factor 2: Time of Exposure Direct Factor 3: Distance to Source Direct Factor 4:Shielding All Factor Trees are like this. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu The direct factors of an effect will explain the nature, the magnitude, the location, and the timing of the effect. 34
  35. 35. Flash Card Front • The nature, the magnitude, the location, and the timing of an effect are explained by the _________ of the effect. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 35
  36. 36. Flash Card Back •DIRECT FACTORS © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 36
  37. 37. Factor Tree Exercise I • Draw a one level Factor Tree for one of the following: – Fatigue Cracking – Stress Corrosion Cracking – Burned Out Lighting Device – Weak Vehicle Battery – Specific Procedure Defect – Unintended Contact with Live Conductor – Running Low on Fuel for Vehicle © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 37
  38. 38. Factor Tree Exercise II • Draw a one level Factor Tree for one of the following: – Foreign Material in Critical Component – Near Miss Asphyxiation – Hospital Drug Overdose – Checking Account Overdraft – Radioactive Material Uptake – Hole in Reactor Vessel Head – Crane Toppling © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 38
  39. 39. One Level Factor Tree Exercise Consequence (NMLT) _________________________ Direct Factor 1: _____________ Direct Factor 2: _____________ Direct Factor 3: __________ Direct Factor 4: _____________ Add others as needed. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu Write on or near objects. 39
  40. 40. Stopping Fact • All factor tree branches must stop somewhere. • There is a stopping decision on each branch. • We’re not addressing that now. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 40
  41. 41. Flash Card Front Multiple Choice: • Every factor tree branch ends in A. The Root Cause B. A Root Cause C. A terminal (ending/last) factor D. None of the above © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 41
  42. 42. Flash Card Back • Every factor tree branch ends in C. A terminal (ending/last) factor (But some terminal factors can be “root causes.”) © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 42
  43. 43. A Factor Building Block is • An effect connected to the factors that directly resulted in the effect. • A component/node/cell/module of a factor tree. • An evidence-based one-level explanation of the attributes of an effect. • A top, intermediate, or bottom part of a factor tree. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 43
  44. 44. Generic Factor Building Block (FBB) (Generic Direct Factors) Harmful Effect Direct Factor 1 Direct Factor 2 Direct Factor… Direct Factor… Direct Factor… All Factor Building Blocks are like this. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu The direct factors of an effect will explain the nature, the magnitude, the location, and the timing of the effect. 44
  45. 45. Caution • “Block” is just a metaphor. • A Factor Building Block would be the same even if it were called: – A Factor Building Component – A Factor Building Cell – A Factor Building Module – A Factor Building Node – A Factor Building “Whatever” © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 45
  46. 46. Generic Factor Building Block Notes • A harmful effect can be – A “consequence” (harmful outcome, harmful effect) – A factor of a harmful outcome • There is no upper limit on the number of direct factors. (There are seldom more than eight.) © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 46
  47. 47. Five Known Types of FBBs • There could be more than five. 1. Four Factor Types: Set-up, Trigger, Exacerbation, Mitigation (STEM) 2. Four Key Attributes: Nature, Magnitude, Location, Timing (NMLT) 3. Five Barrier Analysis Elements: Target, Hazard, Co- location, Simultaneity, Lack of Barrier, Limiting Barrier (THCSLL) 4. Existence: Creation, Persistence (CP) 5. Rollup/Breakdown: A greater effect can be the result of smaller effects. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 47
  48. 48. What About an Effect Needs Explaining? Perspective Needs Explaining Needs Explaining Needs Explaining Needs Explaining Needs Explaining Needs Explaining 1. Factor Involvement Set-up Trigger Exacerbation Mitigation 2. Key Attributes Nature Magnitude Location Timing 3. Barrier Analysis Elements Vulnerable Target Harmful Hazard Co-location Simultaneity Lack of Effective Barrier Limiting Barrier 4. Existence Creation Persistence 5. Rollup/ Breakdown Constituent Items © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 48
  49. 49. How FBBs make up a Factor Tree Harmful Effect FBB1 FBB1.1 FBB 1.1.1 FBB 1.1.3 FBB1.2 FBB1….. FBB2 FBB2.1 FBB2.2 FBB2... FBB… FBB… FBB… All Factor Trees are like this. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu FBB=Factor Building Block 49
  50. 50. Freedom • An analyst can use any of the five types of factor building blocks at any stage of the construction of a factor tree. • It is not necessary to pick one type of FBB and stick to it. • The circumstances of the investigation will often suggest one type of FBB rather than others. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 50
  51. 51. Factor Building Block #1 (Four Factor Types-STEM) Set-up: Trigger: Exacerbation: Mitigation © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
  52. 52. Factor Building Block #1 (Four Factor Types-STEM) Harmful Effect Direct Set-up Factors Direct Triggering Factors Direct Exacerbating Factors Direct Mitigating Factors The direct factors will explain the nature, the magnitude, the location, and the timing of the effect. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 52
  53. 53. FBB #1 (STEM) Notes • If there had not been a set-up the effect could not have happened. • If there had not been a trigger the set-up would have remained latent. • If there had not been exacerbation the effect would have been less severe. • If there had not been mitigation the effect would have been more severe. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 53
  54. 54. FBB #1 (STEM) Management Notes • If the investigation report does not give you the set-up it is probably missing important corrective actions. • If the investigation report does not give you the triggering it is probably missing important corrective actions. • If the investigation report does not give you the exacerbation it is probably missing important corrective actions. • If the investigation report does not give you the mitigation it is probably missing important corrective actions to make the fragile mitigators more robust. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 54
  55. 55. Factor Building Block Example STEM1 (Four Factor Types-STEM) Harmful Effect is One House Burned Down Direct Set-up Factors Were Combustible Construction, etc. Direct Triggering Factor Was Lightning Strike Direct Exacerbating Factor Was Time for Fire Fighters to Arrive Direct Mitigating Factor Was Distance to Other Combustibles © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 55
  56. 56. Notes for House Fire Example • If the house had been only partially destroyed the fire fighter involvement would be both exacerbating and mitigating. • This type of situation arises frequently in events whose consequences do not go to completion/exhaustion/annihilation. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 56
  57. 57. Factor Building Block Example STEM2 (Four Factor Types-STEM) Harmful Effect is 1/3 Core Overheated (TMI) Direct Set-up Factors are Decay Heat and Other Core Conditions Direct Triggering Factor Was Interruption of Injection Direct Exacerbating Factor was Time to Diagnose Direct Mitigating Factor Was Restoration Of Injection © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 57
  58. 58. Factor Building Block Example STEM3 (Four Factor Types-STEM) HPCI Inoperable for DD Days Bearing can go in Backwards Worker put Bearing in Backwards Bearing Damages Pump While Operating Damage Undiscovered Until Pump Inoperable Damage Undiscovered for DD More Days Damage Discovered Pump Restored to Operability © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu Set- up Trigger Exacerbation Mitigation Mitigation Exacerbation Exacerbation 58
  59. 59. Factors-consequences Matrix: STEM Actual Case 1 Case 2 Case 3 Case 4 FACTORS Set-up Yes No Yes Yes Yes Trigger Yes Yes No Yes Yes Exacerbating Yes Yes Yes No Yes Mitigating Yes Yes Yes Yes No CONSEQUENCES As they were None None Lesser Consequences Worse Consequences © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 59
  60. 60. Flash Card Front • A Factors-consequences Matrix shows how a change in a factor results in a change in the _________. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 60
  61. 61. Flash Card Back •Consequence(s) /harmful effect(s) © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 61
  62. 62. Factor Building Block Exercise -STEM • Draw a one level FBB for one of the direct factors of one of the following effects or an effect of your own choosing: – Fatigue Cracking – Stress Corrosion Cracking – Burned Out Lighting Device – Weak Car Battery – Specific Procedure Defect – Unintended Contact with Live Conductor – Running Low on Fuel for Vehicle © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 62
  63. 63. STEM FBB Exercise Factor _________________________ Direct Factor(s) S: _____________ Direct Factor(s) T: _____________ Direct Factor(s) E: __________ Direct Factor(s) M: _____________ © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu Write on or near objects. From Previous Exercise 63
  64. 64. The STEM FBB is good for • All types of consequences • All types of factors © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 64
  65. 65. Factor Building Block #2 (Attributes of Consequence- NMLT) Nature: Magnitude: Location: Timing © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
  66. 66. Factor Building Block #2 (Attributes of Consequence-NMLT) Harmful Effect Direct Factors Affecting Nature Direct Factors Affecting Magnitude Direct Factors Affecting Location Direct Factors Affecting Timing The direct factors will explain the nature, the magnitude, the location, and the timing of the effect. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 66
  67. 67. Factor Building Block Example NMLT1 (Attributes of Consequence-NMLT) Harmful Effect: Glass Shards and Wine on Floor Direct Factors Affecting Nature: Fragility of Bottle, Hardness of floor, etc. Direct Factors Affecting Magnitude: Size of Bottle , Amount of Contents Direct Factors Affecting Location: Location of Fumbler Direct Factors Affecting Timing: Time of Being Startled, etc. The direct factors will explain the nature, the magnitude, the location, and the timing of the effect. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 67
  68. 68. Factor Building Block Example NMLT2 (Attributes of Consequence-NMLT) Harmful Effect: 856 Deaths Direct Factors Affecting Nature: Collision of Two 747s Direct Factors Affecting Magnitude: # of Occupants, etc. Direct Factors Affecting Location: Location of Stationary 747 Direct Factors Affecting Timing: Time of Other 747 Takeoff, etc. The direct factors will explain the nature, the magnitude, the location, and the timing of the effect. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 68
  69. 69. Factor Building Block Example NMLT3 (Attributes of Consequence-NMLT) Harmful Effect: HPCI Inop for DD Days Direct Factors Affecting Nature: Internal Booster Pump Damage Direct Factors Affecting Magnitude: Severity of Damage, Persistence Time Direct Factors Affecting Location: Location of Bearing Direct Factors Affecting Timing: Times of Error, Damage, Discovery, Restoration. The direct factors will explain the nature, the magnitude, the location, and the timing of the effect. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 69
  70. 70. Factor Building Block Example NMLT3.1 (Attributes of Consequence-NMLT) Harmful Effect: HPCI Inop for DD Days Direct Factors Affecting Nature: Internal Booster Pump Damage Deeper FBBs Direct Factors Affecting Magnitude: Severity of Damage, Persistence Time Deeper FBBs Direct Factors Affecting Location: Location of Bearing Deeper FBBs Direct Factors Affecting Timing: Times of Error, Damage, Discovery, Restoration. Deeper FBBs The direct factors will explain the nature, the magnitude, the location, and the timing of the effect. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 70
  71. 71. Factors-consequences Matrix: NMLT Actual Case 1 Case 2 Case 3 Case 4 FACTORS Affecting Nature of Effect Yes Different Same Same Same Affecting Magnitude of Effect Yes Same Different Same Same Affecting Location of Effect Yes Same Same Different Same Affecting Timing of Effect Yes Same Same Same Different CONSEQUENCES As they were Different Nature Different Magnitude Different Location Different Timing © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 71
  72. 72. Direct Factors Matrix (DFM)-NMLT&STEM (This applies to factors as well as consequences.) [Example for TMI-2 Accident: 1/3 Core Melt] Every EFFECT is the resultant of vulnerability factors, triggering factors, exacerbating factors, and mitigating factors. Set-up (Vulnerability) Trigger (Initiator) Exacerbator Mitigator Every EFFECT is the resultant of factors that resulted in its nature, its magnitude/ intensity, its location, and its timing. Nature (Core Melt) 1) Properties of fuel 2) Decay Heat Magnitude (One-third) Magnitude of Decay Heat Interruption of Cooling Amount of Time to Restore Cooling Cooling Restored Location (In reactor) Core located in reactor No melt- through Timing (3-29-79) Interruption of Cooling when it happened. Cooling Restored when it was. Every EFFECT will have at least one direct factor in each column and at least one in each row. (This applies to factors as well as consequences.) © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 72
  73. 73. Factor Building Block Exercise -NMLT • Draw a one level FBB for one of the direct factors of one of the following effects or an effect of your own choosing: – Fatigue Cracking – Stress Corrosion Cracking – Burned Out Lighting Device – Weak Car Battery – Specific Procedure Defect – Unintended Contact with Live Conductor – Running Low on Fuel for Vehicle © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 73
  74. 74. NMLT FBB Exercise Factor _________________________ Direct Factor(s) of N: _____________ Direct Factor(s) of M: _____________ Direct Factor(s) of L: __________ Direct Factor(s) of T: _____________ © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu Write on or near objects. From Previous Exercise 74
  75. 75. The NMLT FBB is good for • All types of consequences • All types of factors © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 75
  76. 76. Factor Building Block #3 (Barrier Analysis Elements- THCSLL) Target: Hazard: Co-location: Simultaneity: Lack of (Effective) Barrier: Limiting Barrier © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
  77. 77. Barrier THE BASICS OF BARRIER ANALYSIS THREAT/ HAZARD TARGET BARRIER: Anything that has the effect of (or is intended to) reduce the probability and/or consequences of the effect of a threat on a target. © 2014 W. R. Corcoran, William.R.Corcoran@1959.USNA.com 77
  78. 78. Factor Building Block #3 (Barrier Analysis Elements-THCSLL) Harmful Effect Vulnerable Item (Target) Hazard That Could Harm Target Co-location of Target and Hazard Simultaneity of Target and Hazard Lack of Effective Barrier Between Target and Hazard Barrier That Limits the Harm The direct factors will explain the nature, the magnitude, the location, and the timing of the effect. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 78
  79. 79. Flash Card Front • If there had been an effective barrier the target would _________ have been harmed as it was. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 79
  80. 80. Flash Card Back •Not © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 80
  81. 81. Failed, Missing, Ineffective Barriers • If the target was harmed there was no effective barrier protecting the target from the harm that did occur. • There is no upper limit on the number of failed, missing, and otherwise ineffective barriers. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 81
  82. 82. Flash Card Front • If there had not been an effective barrier that limited the harm the harm would have been _________ it was. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 82
  83. 83. Flash Card Back •Worse © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 83
  84. 84. Barriers That Limit • The harm is always finite, i.e., limited. • Something resulted in the limitation. • Sometimes it is an active barrier, e.g., fire fighters, well cappers, or rescuers. • Sometimes it is the lack of more victims or more harmful agent. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 84
  85. 85. Negative Factors • A positive factor consists of the presence or excess of something. • A negative factor consists of the absence or insufficiency of something. • A failed, missing, or ineffective barrier can be a negative factor. • Problem: There is no limit to the number of negative factors resulting in one adverse effect!! • Problem: A negative factor can be described positively and vice versa!! © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 85
  86. 86. Factor Building Block Example THCSLL1 (Barrier Analysis Elements-THCSLL) Harmful Effect was Was Interruption of Injection for Some Hours Vulnerable Item (Target) Was Injection Flow Hazard That Could Harm Target was Operator Action Co-location of Target and Hazard was Operator Access to Controls They were there at the same time. Lack of Effective Barrier Between Target and Hazard Next Shift Restored Injection © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 86
  87. 87. Factor Building Block Example THCSLL2 (Barrier Analysis Elements-THCSLL) Harmful Effect was Was Bearing Backwards Vulnerable Item (Target) Was Bearing Would go in Backwards Hazard That Could Harm Target was Worker Error Co-location of Target and Hazard was Worker Access to Pump They were there at the same time. Lack of Effective Barrier Between Target and Hazard There was only one pump involved © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 87
  88. 88. Factor Building Block Example THCSLL2.1 (Barrier Analysis Elements-THCSLL) Harmful Effect was Was Lack of Barrier Vulnerable Item (Target) Was Barrier Control Hazard That Could Harm Target was No Requiremen t for Barriers Co-location of Target and Hazard was Work Control Informality They were there at the same time. Lack of Effective Barrier Between Target and Hazard (Ineffective Oversight) Other Items not Involved © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 88
  89. 89. Factor Building Block Example THCSLL2.1.1 (Ineffective Barriers) • Use of Instructions, Procedures, and Drawings • Worker Performance – Experience – Training • Supervision • Pre-job Briefing • Work Planning • Prior QA Performance • Use of Operating Experience • Others © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 89
  90. 90. Factors-consequences Matrix: Barrier Analysis (THCSL)Actual Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 FACTORS Yes Yes Vulnerable Target Yes Invulnerable or No Target Yes Yes Yes Yes Yes Harmful Hazard Yes Yes No Hazard Yes Yes Yes Yes Co-location of Target & Hazard Yes Yes Yes Different Places Yes Yes Yes Simultaneity of Target & Hazard Yes Yes Yes Yes Different Times Yes Yes Lack of an Effective Barrier between Target & Hazard Yes Yes Yes Yes Yes Effective Barrier Yes Limiting Barrier Yes Yes Yes Yes Yes Yes Less Limiting Barrier CONSEQUENCES As they were No Harm No Harm No Harm No Harm No Harm Worse Harm © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 90
  91. 91. Direct Factors Matrix of Barrier Analysis and Factor Type (THCSLL) (This applies to harmful factors as well as harmful consequences.) [Example for TMI-2 Accident: 1/3 Core Melt] Every harmful EFFECT is the resultant of a hazard, a vulnerable target, co-location, simultaneity, lack of an effective barrier to the harm, and an effective barrier that limited the harm.. Hazard Target Co- location Simultan eity Lacking Barrier Limiting Barrier Every harmful EFFECT is the resultant of factors that resulted in its nature, its magnitude/ intensity, its location, and its timing, including set- up, triggering, exacerbation, and mitigation. (Set-up) Decay Heat Ceramic pellet and Zr clad Decay heat within fuel Decay heat within fuel Trigger (Initiator) Interruption of Cooling Exacerba- tion Magnitude of decay heat Properties of pellet and clad How long the cooling was off Mitigation . . Cooling Restored when it was (next shift) Every harmful EFFECT will have at least one direct factor in each column and at least one in each row. (This applies to harmful factors as well as harmful consequences.) ©2014,WilliamR.Corcoran,860-285-8779,firebird.one@alum.mit.edu 91
  92. 92. Flash Card Front • If a worker is injured you know that all of the barriers to that exact injury were _________ or _______. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 92
  93. 93. Flash Card Back •Missing or ineffective © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 93
  94. 94. Flash Card Front • If a worker is injured you know that some barrier(s) limited the exact injury so it wasn’t even _________ . © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 94
  95. 95. Flash Card Back •Worse © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 95
  96. 96. Factor Building Block Exercise -THCSLL • Draw a one level FBB for one of the direct factors of one of the following effects or an effect of your own choosing: – Fatigue Cracking – Stress Corrosion Cracking – Burned Out Lighting Device – Weak Car Battery – Specific Procedure Defect – Unintended Contact with Live Conductor – Running Low on Fuel for Vehicle © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 96
  97. 97. THCSLL FBB Exercise Factor _________________________ Direct Factor(s) related to T: ____________ Direct Factor(s) related to H: __________ Direct Factor(s) related to S: _________ Direct Factor(s) related to C: _____________ Direct Factor(s) related to L: _____________ Direct Factor(s) related to Limiting Barrier __________ © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu Write on or near objects. From Previous Exercise 97
  98. 98. The THCSLL FBB is good for • All types of consequences • All types of factors © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 98
  99. 99. Factor Building Block #4 (Existence of Effect: [CP]) Creation & Persistence © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
  100. 100. Existence • If something existed at a given time – It must have been created and – It must have persisted up to that time. • Examples – Apollo XIII-Defective O2 Tank wiring – Columbia-Damaged wing tile – Challenger-Hardened O-ring – Davis-Besse-Crack in CRDM nozzle 100© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
  101. 101. Factor Building Block #4 (Existence of Effect: Creation & Persistence [CP]) Harmful Effect Direct Factors of Creation Direct Factors of Persistence © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 101
  102. 102. Factor Building Block Example CP1.0 (Existence of Effect: Creation & Persistence [CP]) Harmful Effect : Bearing Backward 1.0 Direct Factors of Creation : Worker Installed the Bearing Backward 1.1 Direct Factors of Persistence: Not noticed, effects not addressed, etc. 1.2 © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 102
  103. 103. Flash Card Front • The only harmful effects involved in the event being investigated are those that both were ______ at some time in the past and ______ until the event. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 103
  104. 104. Flash Card Back •Created, persisted © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 104
  105. 105. Factor Building Block Example CP1.1 (Existence of Effect: Creation & Persistence [CP]) Harmful Effect : Bearing Backwards 2011 (1.0) Worker Installed the Bearing Backward in 2005 (1.1) Pump designed such that bearing can go in backwards 1.1.1 Ineffective training 1.1.2 Insufficient experience 1.1.3 Ineffective supervision 1.1.4 Ineffective use of instructions, procedures, drawings 1.1.5 Bearing Left Backwards Until 2011 (1.2) Deeper FBBs © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 105
  106. 106. Factor Building Block Example CP1.1 (Existence of Effect: Creation & Persistence [CP]) Harmful Effect : Bearing Backwards 2011 (1.0) Worker Installed the Bearing Backward in 2005 (1.1) Pump designed such that bearing can go in backwards 1.1.1 Deeper FBBs Ineffective training 1.1.2 Deeper FBBs Insufficient experience 1.1.3 Deeper FBBs Ineffective supervision 1.1.4 Deeper FBBs Ineffective use of instructions, procedures, drawings 1.1.5 Deeper FBBs Bearing Left Backwards Until 2011 (1.2) Deeper FBBs © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 106
  107. 107. Factor Building Block Example CP1.2 (Existence of Effect: Creation & Persistence [CP]) Harmful Effect : Bearing Backwards 2011 (1.0) Worker Installed the Bearing Backward in 2005 (1.1) Deeper FBBs Bearing Left Backwards Until 2011 (1.2) Record reviews do not reveal error 1.2.1 Pump runs with bearing backwards 1.2.2 Lube oil sampling not done 1.2.3 Vibration monitoring not effective 1.2.4 Damage insufficient to cause severe failure 1.2.5 Damage insufficient to cause severe vibration until 2011 (1.2.6) © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 107
  108. 108. Factor Building Block Example CP1.2 (Existence of Effect: Creation & Persistence [CP]) Harmful Effect : Bearing Backwards 2011 (1.0) Worker Installed the Bearing Backward in 2005 (1.1) Deeper FBBs Bearing Left Backwards Until 2011 (1.2) Record reviews do not reveal error 1.2.1 Deeper FBBs Pump runs with bearing backwards 1.2.2 Deeper FBBs Lube oil sampling not done 1.2.3 Deeper FBBs Vibration monitoring not effective 1.2.4 Deeper FBBs Damage insufficient to cause severe failure 1.2.5 Deeper FBBs Damage insufficient to cause severe vibration until 2011 (1.2.6) Deeper FBBs © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 108
  109. 109. Factors-consequences Matrix: Creation & Persistence Actual Case 1 Case 2 FACTORS Factors Resulting in Creation of Effect Yes No creation factors Same Factors Resulting in Persistence of Effect Yes Yes No Persistence Factors CONSEQUENCES Effect as it was when it was No creation, thus no existence No Current Existence © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 109
  110. 110. Direct Factors Matrix (DFM) for CP FBB (This applies to factors as well as consequences.) [Example for TMI-2 Accident: Defective Operator Mental Model ] The current EXISTENCE of every EFFECT is the resultant of the factors that resulted in its creation and the factors that resulted in its persistence. Creation Persistence Every EFFECT is the resultant of factors that resulted in its nature, its magnitude/ intensity, its location, and its timing. Nature (Relationship of Pzr Level to RCS Inventory) Navy training on “Solid Operation-Brittle Fracture” No training by plant to replace or clarify Navy training Magnitude (One) Not counteracted by training on sub-cooled margin. Not counteracted by commercial nuclear training. Location (In Operator’s Mind) Operated was trained. Operator remembered. Timing (Created during naval service. Persisted until 3-29-79.) During naval service. Activated by high Pzr Level Every EFFECT will have at least one direct factor in each column and at least one in each row. (This applies to factors as well as consequences.) © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 110
  111. 111. Flash Card Front • If you know the factors that resulted in the creation of a harmful factor you may be able to prevent the creation of other harmful factors. • True or False? © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 111
  112. 112. Flash Card Back •True © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 112
  113. 113. Flash Card Front • If you know the factors that resulted in the persistence of a harmful factor you may be able to find and address other harmful factors sooner. • True or False? © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 113
  114. 114. Flash Card Back •True © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 114
  115. 115. Factor Building Block Exercise -CP • Draw a one level FBB for one of the direct factors of one of the following effects or an effect of your own choosing: – Fatigue Cracking – Stress Corrosion Cracking – Burned Out Lighting Device – Weak Car Battery – Specific Procedure Defect – Unintended Contact with Live Conductor – Running Low on Fuel for Vehicle © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 115
  116. 116. CP FBB Exercise Factor _________________________ Direct Factor(s) related to Creation: _____________ Direct Factor(s) related to Persistence: _____________ © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu Write on or near objects. From Previous Exercise 116
  117. 117. The CP FBB is good for • All types of consequences • All types of factors © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 117
  118. 118. Factor Building Block #5 (Rollup/Breakdown-RB) Greater effects can result from lesser effects. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
  119. 119. Factor Building Block #5 (Rollup/Breakdown-RB) Greater Harmful Effect Lesser Harmful Effect Lesser Harmful Effect Lesser Harmful Effect Lesser Harmful Effect Lesser Harmful Effect Greater effects can result from lesser effects. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 119
  120. 120. Factor Building Block #5 Example RB1.0 (Rollup/Breakdown-RB) Greater Harmful Effect: No Effective Barrier No Effective Work Control Barrier Deeper FBBs No Effective Supervision Barrier Deeper FBBs No Effective Procedural Barrier Deeper FBBs No Effective Experience Barrier Deeper FBBs No Effective Training Barrier Deeper FBBs Greater effects can result from lesser effects. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 120
  121. 121. Factor Building Block #5 Example RB2.0 (Rollup/Breakdown-RB) Greater Harmful Effect: No Effective Barrier No Effective Barrier to Encourage Appropriateness Deeper FBBs No Effective Barrier to Discourage Inappropriateness Deeper FBBs No Effective Barrier to Prevent Inappropriateness Deeper FBBs No Effective Barrier to Detect Inappropriateness Deeper FBBs No Effective Barrier to Compensate for Inappropriateness Deeper FBBs When there is no effective barrier these are missing or defective. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 121
  122. 122. Barrier Exercise Identify at least one barrier that would: 1.Encourage putting the bearing in correctly. 2.Discourage putting the bearing in backwards. 3.Prevent putting the bearing in backwards. 4.Detect that the bearing had been put in backwards. 5.Compensate for the bearing being in backwards. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 122
  123. 123. Flash Card Front • Whenever there is no effective barrier you know that in concept that all ____ types of barriers were missing or defective. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 123
  124. 124. Flash Card Back •Five (5)! © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 124
  125. 125. Factor Building Block #5 (Rollup/Breakdown-RB) Notes • A formula for investigation team trouble is to attempt to explain a greater effect without first explaining the lesser effects. • Sometimes the factors that resulted in various lesser effects are similar, if not identical. 125
  126. 126. Factor Building Block Exercise Rollup/Breakdown-RB • Draw a one level FBB for one of the direct factors of one of the following effects or an effect of your own choosing: – Fatigue Cracking – Stress Corrosion Cracking – Burned Out Lighting Device – Weak Car Battery – Running Low on Fuel for Vehicle – Project Delay © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 126
  127. 127. RB FBB Exercise Factor _________________________ Component of Factor: _____________ Component of Factor: _____________ Component of Factor: __________ Component of Factor: _____________ Component of Factor: _____________ © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu Write on or near objects. Factor amenable to Rollup/Breakdown From Previous Exercise 127
  128. 128. The RB FBB is good for • Consequences and factors that – Are aggregations – Are combinations – Are divisible into chunks – Are made up of multiple factors © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 128
  129. 129. The RB FBB is NOT good for • Consequences and factors that – Are unitary – Are singular – Are not aggregations – Are not divisible into chunks © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 129
  130. 130. Recommendations for Investigators • Create a Factor Tree for your next investigation • Use FBB#1-STEM on your next investigation • Make the Factor Tree explain NMLT level by level. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 130
  131. 131. Recommendations for Investigation Report Reviewers/ Inspectors/ Auditors • Ask: What is the nature, the magnitude, the location, and the timing (NMLT) of the most important harmful effect? • Ask: Does the report explain the NMLT? • Ask: Do the corrective actions address that which explains the NMLT? • Ask: How does each corrective action affect the NMLT? © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 131
  132. 132. Conclusions 1.0 • There are at least five useful Factor Building Block models. • The following three are always useful: – STEM – NMLT – Barrier Analysis Elements (TBCSL) • The Existence (CP) FBB should be used as a check for missing Lines of Inquiry. • The Rollup/ Breakdown (RB) FBB should be used for multiple similar consequences and for failed/missing/ineffective barriers. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 132
  133. 133. Conclusions 2.0 • The FBB models provided can help in – Doing business issue investigations – Identifying weaknesses, shortfalls, and defects in investigation reports • Each of the five can be used to find the flaws in an analysis. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 133
  134. 134. Frequently Asked Questions © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
  135. 135. FAQ Topics • Root Cause • Compliance • Comparative TimeLine© • Missed Opportunity Matrix • The Investigation Report • Glossary • Corrective Action Matrix • Extent • Lines of Inquiry • Stopping Rules • Extent • Charter • Barrier Analysis Matrix • Barrier Analysis Flow Chart 135
  136. 136. What about Root Causes? (1) • The root causes will be at the bottom of the factor tree in the deepest factor building blocks. • They will be basic fundamental underlying harmful conditions, behaviors, actions, and/or inactions. • Their factors will be less important than they are. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 136
  137. 137. What about Root Causes? (2) If you have factors that are called root causes ask: 1. What are the other harmful factors that have equal or better claim to be called root causes? 2. What are the factors that directly resulted in each root cause? 3. What is the evidence that supports the facts alleged in statements of root cause? 4. How did this root cause impact the top level harmful effect (consequence)? 5. What other factors are necessary to explain the nature, the magnitude, the location, and the timing of the top level harmful effect (consequence)? © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 137
  138. 138. 138 Behavior or Condition Make the Event Happen? Make the Consequences Worse? No Is a Cause Yes Yes Is Something Else Needed to Explain the Cause or Consequence? Contributing Cause Cause is Self-sufficient YES NO Is not a CauseNo © 2014, William R. Corcoran, 138
  139. 139. 139 Behavior or Condition Make the Event Happen? Make the Consequences Worse? No Is a Cause Yes Yes Not a Root CauseRoot Cause YESNO Is Not a causeNo © 2014, William R. Corcoran, Is this cause due to more important [underlying] factors? 139
  140. 140. What about Extent? (1)  Every harmful effect, including those that are factors of higher level effects, have two types of extent:  Magnitudinal Extent (E.g., vibration amplitude)  Inferential Extent (E.g., other bearings with similar issues)  To appreciate the full importance of the issue you need to understand both as well as their causation. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 140
  141. 141. What about Extent? (2)  A credible job on extent must be based on a credible job on the basic investigation.  The inferential extent of X is the answer to the question, “If I see X what else should I expect to see?”  The X can be: 1. A harmful effect 2. A harmful factor (condition, behavior, action, or inaction) 3. A beneficial, but fragile, factor © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 141
  142. 142. What about Extent? (3)  The What Else Besides X can be: 1. The same item (X) existing a. At a different time b. In a different place 2. A similar item (Ξ)existing a. At a different time b. In a different place 3. A factor affecting X 4. A result of X © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu Ξ is a Greek letter “Xi”, a letter similar to the English letter X. It is pronounced “zigh” . 142
  143. 143. Systematic Approach to Extent 1. Do a good investigation. 2. Select important conditions, both consequences and factors. 3. Select important factors, conditions, behaviors, actions, and inactions. 4. Specify your qualitative/quantitative acceptance criteria for extent. 5. Select or invent a tool for extent. 6. Determine probable extent. 7. Actually see if the extents are there. © 2014 W. R. Corcoran, firebird.one@alum.MIT.edu 143
  144. 144. The Taxonomy of Extent 1.0 Extent of X (1.0) Magnitudinal Extent of X (1.1) See Taxonomy of Extent 1.1 Inferential Extent of X (1.2) See Taxonomy of Extent 1.2 The connectors mean that the upper item is comprised of the lower items. The lower items are part of the upper item. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 144
  145. 145. The Taxonomy of Extent 1.1 Magnitudinal Extent of X (1.1) Size of X 1.1 Number of Xs 1.2 Intensity of X 1.3 Severity of X 1.4 Persistence of X 1.5 Other Magnitudinal Properties of X 1.6 The connectors mean that the upper item is comprised of the lower items. The lower items are part of the upper item. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 145
  146. 146. The Taxonomy of Extent 1.2 Inferential Extent of X (1.2) More of X (1.2.1) See Taxonomy of Extent 1.2.1 Items Similar to X (1.2.2) See Taxonomy of Extent 1.2.2 Items that resulted in X (1.2.3) See Taxonomy of Extent 1.2.3 Items resulting from X (1.2.4) See Taxonomy of Extent 1.2.4 The connectors mean that the upper item is comprised of the lower items. The lower items are part of the upper item. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 146
  147. 147. The 360 Degree Approach • Is a nice way to comprehend inferential extent. • Can be explained in down home common sense terms. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 147
  148. 148. Roofing Nails In Driveway Nails in Tires Roofer Foreign Material Management Roofing Nails In Other Places Other Foreign Material Problems © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 148
  149. 149. 149 Termite in Garage Wood Structure Damage Termite Habitat Nearby Termites In Other Places Other Wood-eating Insects © 2014, William R. Corcoran, 149
  150. 150. Problem That Got Noticed Downstream Impact Upstream Causation More of the Same Item More of the Same Class of Issue © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 150
  151. 151. What about Lines of Inquiry? (1) • A Line of Inquiry (LOI) is an area, concept, issue, unanswered question or the like that the investigation team could consider. • LOIs drive the investigation after the topics in the five types of FBBs have been worked. • LOIs are very important to negative factors. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 151
  152. 152. What about Lines of Inquiry(LOI)? (2) • There are many pre-packaged LOI generating tools including picklist approaches, e.g., MORT, and assessment checklists. • LOI selection is often a knowledge-based activity. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 152
  153. 153. What about Lines of Inquiry(LOIs)? (3) • For transparency, the investigation report should include lists of LOIs including – LOIs pursued – LOIs considered and dismissed © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 153
  154. 154. What about Compliance? (1) • In a compliance-involved situation every harmful factor that requirements were intended to prevent is due either to – Noncompliance with a requirement or – A defect in the requirement. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 154
  155. 155. The Tree of (Non)Compliance 1.0 Harmful Effect that Compliance Should Prevent (1.0) And/Or Noncompliance with Requirement(s) (1.1) See Tree of (Non)Compliance 1.1 Defective Set of Requirements(1.2) See Tree of (Non)Compliance 1.2 The connectors mean that the upper item is a result of the lower items. The lower items are factors of the upper item. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 155
  156. 156. Flash Card Front • If something happened that requirements were intended to prevent and the requirements were OK then there must have been ______________. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 156
  157. 157. Flash Card Back •Noncompliance © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 157
  158. 158. What about the Barrier Analysis Matrix? (1) • Use it in conjunction with the THCSLL FBB • Use it independently to generate LOIs • Use it in conjunction with the FCM • Use it as input into the CTL © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 158
  159. 159. Barrier Analysis Matrix (BAM) [HPCI Inop for DD Days] Sheet 1 of N Barrier Target Protected Threat Effectiveness in this case Significance Outsource QA Appendix B Compliance by Contractor Critical Noncompliance Ineffective. Contractor not in compliance with Criterion V and others,. Failed Barrier. Allowed nonconforming installation. Work Package Quality of Work Critical Work Defect Ineffective. Work had critical defect. Failed barrier. Defective installation. Pre-job brief for Booster Pump Work Work process integrity. Inadequate work process Did not identify critical step. Failed barrier. Missed Opportunity. Contractor Work Supervision Work process integrity. Inadequate work process Did not identify critical step done wrong. Failed barrier. Missed Opportunity. Vendor Technical Manual Work instructions Errors and omissions Not used.. Failed barrier. Missed Opportunity. Negative factor. In-house Operating Experience Program This barrier and other barriers. Repeat missing and ineffective barriers Not used effectively Failed barrier. Missed Opportunity. Negative factor. Industry Operating Experience Program This barrier and other barriers. Repeat missing and ineffective barriers Not used effectively Failed barrier. Missed Opportunity. Negative factor. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 159
  160. 160. What about the Investigation Report?(1) The report must be: • Trustworthy • Loyal to Principle • Helpful • (Reader) Friendly • Courteous • Kind to Victims • Obedient to the Charter • Cheerful as Appropriate • Thrifty • Brave • Clean • Reverent 160
  161. 161. The Case Study Begins Real Life Application of the Principles and Good Practices © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
  162. 162. HPCI Inoperable for DD Days (A case study using Factor Building Blocks [FBBs]) For Training Only W. R. Corcoran, Ph.D., P.E. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
  163. 163. Notices • This is part of The Phoenix Approach©. • It also applies to all other approaches to issue investigation (root cause analysis). • If your organization is licensed to use The Phoenix Approach© you may use this in accordance with the license. • If your organization is not licensed to use The Phoenix Approach© please call for permission. In the meanwhile you have permission to give this seminar once in-house, if you send me the workshop comments. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 163
  164. 164. Generic Factor Tree with FBBs Harmful Effect FBB1 FBB1.1 FBB 1.1.1 FBB 1.1.3 FBB1.2 FBB1….. FBB2 FBB2.1 FBB2.2 FBB2... FBB… FBB… FBB… All Factor Trees are like this. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu FBB=Factor Building Block 164
  165. 165. Factor Building Block Example STEM3 (Four Factor Types-STEM) HPCI Inoperable for DD Days Bearing can go in Backwards Worker put Bearing in Backwards Bearing Damages Pump While Operating Damage Undiscovered Until Pump Inoperable Damage Undiscovered for DD More Days Damage Discovered Pump Restored to Operability © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 165
  166. 166. The Comparative TimeLine©(CTL) • The CTL organizes the evidence. • It works with the other tools. • The information of all of the tools should be consistent (or explained). © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 166
  167. 167. Some Terminology • QA=Quality Assurance • QAP=QA Program • App B=10CFR50, Appendix B • VTM=Vendor Tech Manual • OE=Operating Experience • QC=Quality Control • HPCI=High Pressure Coolant Injection • BP=Booster Pump • Crit=Criterion, Criteria • Crit IV (1,2), e.g.= Sentences 1 and 2 of Criterion IV • PO=Purchase Order 167
  168. 168. Comparative TimeLine© [HPCI Inop for DD Days] Sheet n of N When What(Actual) What(Should) Result of Δ Impact and Notes © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 168
  169. 169. Comparative TimeLine© [HPCI Inop for DD Days] Sheet 1 of N When What(Actual) What(Should) Result of Δ Impact and Notes Before 2005 Pump design allows thrust bearing to be put in backwards OK Establishes vulnerability. Triggering Factor unless controlled in Instructions, Procedures, Drawings. Before 2005 Pump design allows pump to run with thrust bearing put in backwards OK Vulnerability not detectable in short term test. Set-up Factor unless controlled in Instructions, Procedures, Drawings. Note: 10CFR50, Appendix B, provides one way of controlling vulnerabilities such as this one. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 169
  170. 170. Comparative TimeLine© [HPCI Inop for DD Days] Sheet 2 of N When What(Actual) What(Should) Result of Δ Impact and Notes 2005 or before HPCI BP needs rebuild and impeller mod OK Work Process Starts Trigger Upstream issues? 2005 No QAP required in PO QAP required in PO No App B QA applied Crit IV (1, 2) 2005 No App B QA applied App B QA applied Many harmful effects Crit I (2) 2005 or before VTM leaves out bearing orientation VTM specifies bearing orientation None: Not used ECAQ Crit V (2) 2005 VTM not used Should have used VTM None: It would not have helped Separate ECAQ Crit V (1) 2005 or before Defective VTM accepted for use Defective VTM should have been rejected. Defective VTM in document system Separate ECAQ Crit XVI (1) © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 170
  171. 171. Comparative TimeLine© [HPCI Inop for DD Days] Sheet 3 of N When What(Actual) What(Should) Result of Δ Impact and Notes 2005 and before OE on defective VTM not applied OE on defective VTM applied Defective VTMs persist. No compensation for defective VTM Crit XVI (1) Programmatic Issue 2005 and before Ineffective requirements for VTMs Effective requirements for VTMs Defective VTMs accepted for use. Crit IV(1) Crit V (2) © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 171
  172. 172. Comparative TimeLine© [HPCI Inop for DD Days] Sheet 4 of N When What(Actual) What(Should) Result of Δ Impact and Notes 2005 and/or before QA Dept not effectively involved in work QA Dept effectively involved in work Above issues not identified Crit I(1,3) Crit II(4) Crit XVI (1) 2005 and/or before No Oversight Activity Notices any Programmatic Problems above Many Oversight Activities Notice some Programmatic Problems above Programmatic Issues remain Crit II (9.10) Crit XVI (1) Crit XVIII (1) 2005 and/or before Workers not qualified Workers effectively qualified Workers don’t know about bearings Crit II(8) 2005 and/or before Ineffective use of OE on worker qualification/trng Effective use of OE Missed Opportunity Crit XVI (1) Programmatic Issue © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 172
  173. 173. Comparative TimeLine© [HPCI Inop for DD Days] Sheet 5 of N When What(Actual) What(Should) Result of Δ Impact and Notes 2005 and/or before Ineffective use of OE on bearing orientation Effective use of OE Missed Opportunity Crit XVI (1) Programmatic Issue 2005.03.16 Bearing installed wrong Bearing installed wrong HPCI BP nonconforming Tech Specs? Crit V(2) Physical Trigger Begins NC Time 2005.03.16 Error not found by QC Error found by QC HPCI BP stays nonconforming Crit X (1, 2) Crit XVI (1) 2005.03.16 Error not found by Supervision Error found by Supervision HPCI BP stays nonconforming Crit XVI (1) 2005.03.16 Orientation of bearing not recorded Orientation of bearing recorded Cannot ID prob by record review Crit VII(2) Crit XVII (1) © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 173
  174. 174. Comparative TimeLine© [HPCI Inop for DD Days] Sheet 6 of N When What(Actual) What(Should) Result of Δ Impact and Notes 2009.09.09 (about) OE 29810 on Callaway TDAFP not applied OE 29810 on Callaway TDAFP not applied Misoriented bearing and defective LO Program not discovered. Crit XVI (1) Programmatic Issue 2009.10.22 (About) OE 30492 on Plant Hatch CRD Pump not applied OE 30492 on Plant Hatch CRD Pump applied Misoriented bearing and defective VTM not discovered. Crit XVI (1) Programmatic Issue 2010.01.20 (About) OE 30492 on different Plant Hatch CRD Pump not applied OE 30492 on Plant Hatch CRD Pump applied Misoriented bearing and defective VTM not discovered. Crit XVI (1) Programmatic Issue 2008.01.31 (about) This plant PER 133600 not applied This plant PER 133600 applied Misoriented bearing not discovered. Crit XVI (1) Programmatic Issue © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 174
  175. 175. Comparative TimeLine© [HPCI Inop for DD Days] Sheet 7 of N When What(Actual) What(Should) Result of Δ Impact and Notes Various OE on defective work instruction not applied OE on defective work instruction applied Defective work instruction not discovered. Crit XVI (1) Programmatic Issue 2010.01.20 and before None of the following effectively identify any of the above QA weaknesses: Nuclear Assurance Oversight, NSRB, INPO All of the following effectively identify most of the above QA weaknesses: Nuclear Assurance Oversight, NSRB, INPO QA Programmatic breakdown not identified. Event allowed to continue. Crit II (9, 10) Crit XVI (1, 2) Crit XVIII (1) © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 175
  176. 176. Comparative TimeLine© [HPCI Inop for DD Days] Sheet 8 of N When What(Actual) What(Should) Result of Δ Impact and Notes 2011.07.21 OE 30492 at Plant Hatch not applied to this plant. OE 30492 at Plant Hatch applied to this plant. Misoriented bearings not looked for. 2011.04.21 51 min run for surveillance OK Damage probably begins Normal Vib 2011.04.27 7h18m run (tornado) OK Damage probably increases Vib data not taken 2011.04.27 Vib data not taken Vib data taken ECAQ or Missed Opportunity Crit XVI (1) Programmatic Issue (CAQ?) 2011.04.28 4 runs ~6h (tornado) OK Damage probably increases © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 176
  177. 177. Comparative TimeLine© [HPCI Inop for DD Days] Sheet 9 of N When What(Actual) What(Should) Result of Δ Impact and Notes 2011.04.28 Vib data not taken Vib data taken ECAQ or Missed Opportunity Crit XVI (1) Programmatic Issue (CAQ?) 2011.05 (About) OE on Ft.Calhoun Screen Wash Pump not applied OE on Ft.Calhoun Screen Wash Pump applied Misoriented bearing and defective VTM not discovered. 2011.05.20 HPCI Discharge Check Valve fails to reseat HPCI Discharge Check Valve reseats HPCI Overpressure Triggering factor for Inop 2011.05.20 HPCI Overpressure Proper HPCI Pressure Damage increased Beginning of Inop Period 2011.05.20 and before and after Lube Oil Samples not Taken Lube Oil Samples Taken & Analyzed Missed LO Contamination. Damage not detected. Inop extended. Crit XVI (1) Programmatic Issue (CAQ?) © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 177
  178. 178. Comparative TimeLine© [HPCI Inop for DD Days] Sheet 10 of N When What(Actual) What(Should) Result of Δ Impact and Notes 2011.04.28 Temperature data not taken Temperature data taken ECAQ or Missed Opportunity Crit XVI (1) Programmatic Issue (CAQ?) © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 178
  179. 179. Comparative TimeLine© [HPCI Inop for DD Days] Sheet 11 of N When What(Actual) What(Should) Result of Δ Impact and Notes 2011.05.20 before QA Auditing, Self- assessment, OE and Oversight do not find LO Program Weakness QA Auditing, Self- assessment, OE and Oversight all find LO Program Weakness LO Program weakness not found. Inop extended. Crit XVI (1) Programmatic Weaknesses (LOP, CAP, OEP, QAP) 2011.07.20 Surveillance Test OK Vibration in Alert Range Inop Discovered 2011.05.20 before QA Auditing, Self- assessment, OE and Oversight do not find Vib Program Weakness QA Auditing, Self- assessment, OE and Oversight all find Vib Program Weakness Vib Program weakness not found. Inop extended. Crit XVI (1) Programmatic Weaknesses (VMP, CAP, OEP, QAP) © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 179
  180. 180. Comparative TimeLine© [HPCI Inop for DD Days] Sheet 12 of N When What(Actual) What(Should) Result of Δ Impact and Notes 2011.07.21 (about) Lube Oil Samples Taken & Analyzed OK Contamination reveals BP Damage. 2011.07.27 Bearing Replaced OK Inop Ended About 68 Days Inop 2012.08.24 and before None of the following effectively identify any of the above QA weaknesses: Nuclear Assurance Oversight, NSRB, INPO All of the following effectively identify most of the above QA weaknesses: Nuclear Assurance Oversight, NSRB, INPO QA Programmatic breakdown not identified. Event allowed to continue. No subsequent learning. Crit II (9, 10) Crit XVI (1, 2) Crit XVIII (1) © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 180
  181. 181. Comparative TimeLine© [HPCI Inop for DD Days] Sheet 13 of N When What(Actual) What(Should) Result of Δ Impact and Notes 2012.08.24 Revised RCAR Issued OK Over a year between event date and RCAR issue date. What’s the real story? © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 181
  182. 182. Factor Building Block Example STEM3 (Four Factor Types-STEM) HPCI Inoperable for DD Days Bearing can go in Backwards Worker put Bearing in Backwards Bearing Damages Pump While Operating Damage Undiscovered Until Pump Inoperable Damage Undiscovered for DD More Days Damage Discovered Pump Restored to Operability © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu Set- up Trigger Exacerbation Mitigation Mitigation Exacerbation Exacerbation 182
  183. 183. Factor Building Block Example NMLT3 (Attributes of Consequence-NMLT) Harmful Effect: HPCI Inop for DD Days Direct Factors Affecting Nature: Internal Booster Pump Damage Direct Factors Affecting Magnitude: Severity of Damage, Persistence Time Direct Factors Affecting Location: Location of Bearing Direct Factors Affecting Timing: Times of Error, Damage, Discovery, Restoration. The direct factors will explain the nature, the magnitude, the location, and the timing of the effect. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 183
  184. 184. Factor Building Block Example NMLT3.1 (Attributes of Consequence-NMLT) Harmful Effect: HPCI Inop for DD Days Direct Factors Affecting Nature: Internal Booster Pump Damage Deeper FBBs Direct Factors Affecting Magnitude: Severity of Damage, Persistence Time Deeper FBBs Direct Factors Affecting Location: Location of Bearing Deeper FBBs Direct Factors Affecting Timing: Times of Error, Damage, Discovery, Restoration. Deeper FBBs The direct factors will explain the nature, the magnitude, the location, and the timing of the effect. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 184
  185. 185. Factor Building Block Example THCSLL2 (Barrier Analysis Elements-THCSLL) Harmful Effect was Was Bearing Backwards Vulnerable Item (Target) Was Bearing Would go in Backwards Hazard That Could Harm Target was Worker Error Co-location of Target and Hazard was Worker Access to Pump They were there at the same time. Lack of Effective Barrier Between Target and Hazard There was only one pump involved © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 185
  186. 186. Factor Building Block Example THCSL2.1 (Barrier Analysis Elements-THCSL) Harmful Effect was Was Lack of Barrier Vulnerable Item (Target) Was Barrier Control Hazard That Could Harm Target was No Requirement for Barriers Co-location of Target and Hazard was Work Control Informality They were there at the same time. Lack of Effective Barrier Between Target and Hazard (Ineffective Oversight) Limiting Barrier was no worse challenges © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 186
  187. 187. Factor Building Block Example CP1 (Existence of Effect: Creation & Persistence [CP]) Harmful Effect : Bearing Backward Direct Factors of Creation : Worker Installed the Bearing Backward Direct Factors of Persistence: Not noticed, effects not addressed, etc. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 187
  188. 188. Factor Building Block Example CP2 (Existence of Effect: Creation & Persistence [CP]) Harmful Effect : Bearing Backwards 2011 Worker Installed the Bearing Backward in 2005 Pump designed such that bearing can go in backwards Ineffective training Insufficient experience Ineffective supervision Ineffective use of instructions, procedures, drawings Bearing Left Backwards Until 2011 Deeper FBBs © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 188
  189. 189. Factor Building Block Example CP2.1 (Existence of Effect: Creation & Persistence [CP]) Harmful Effect : Bearing Backwards 2011 Worker Installed the Bearing Backward in 2005 Pump designed such that bearing can go in backwards Deeper FBBs Ineffective training Deeper FBBs Insufficient experience Deeper FBBs Ineffective supervision Deeper FBBs Ineffective use of instructions, procedures, drawings Deeper FBBs Bearing Left Backwards Until 2011 Deeper FBBs © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 189
  190. 190. Factor Building Block Example CP3 (Existence of Effect: Creation & Persistence [CP]) Harmful Effect : Bearing Backwards 2011 Worker Installed the Bearing Backward in 2005 Deeper FBBs Bearing Left Backwards Until 2011 Record reviews do not reveal error Pump runs with bearing backwards Lube oil sampling not done Vibration monitoring not effective Damage insufficient to cause severe failure Damage insufficient to cause severe vibration until 2011 © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 190
  191. 191. Factor Building Block Example CP3.1 (Existence of Effect: Creation & Persistence [CP]) Harmful Effect : Bearing Backwards 2011 Worker Installed the Bearing Backward in 2005 Deeper FBBs Bearing Left Backwards Until 2011 Record reviews do not reveal error Deeper FBBs Pump runs with bearing backwards Deeper FBBs Lube oil sampling not done Deeper FBBs Vibration monitoring not effective Deeper FBBs Damage insufficient to cause severe failure Deeper FBBs Damage insufficient to cause severe vibration until 2011 Deeper FBBs © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 191
  192. 192. Factor Building Block #5 (Rollup/Breakdown-RB) Greater Harmful Effect Lesser Harmful Effect Lesser Harmful Effect Lesser Harmful Effect Lesser Harmful Effect Lesser Harmful Effect Greater effects can result from lesser effects. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 192
  193. 193. Factor Building Block #5 Example RB1.0 (Rollup/Breakdown-RB) Greater Harmful Effect: No Effective Barrier No Effective Work Control Barrier Deeper FBBs No Effective Supervision Barrier Deeper FBBs No Effective Procedural Barrier Deeper FBBs No Effective Experience Barrier Deeper FBBs No Effective Training Barrier Deeper FBBs Greater effects can result from lesser effects. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 193
  194. 194. Factor Tree Example 1.0 (Begins with-STEM) HPCI Inoperable for DD Days 1.0 Bearing can go in Backwards 1.1 See Example 1.1 Worker put Bearing in Backwards 1.2 See example 1.2 Bearing Damages Pump While Operating 1.3 See Example 1.3 Damage Undiscovered Until Pump Inoperable 1.4 See Example 1.4 Damage Undiscovered for DD More Days 1.5 See Example 1.5 Damage Discovered 1.6 See example 1.6 Pump Restored to Operability 1.7 See example 1.7 © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 194
  195. 195. Factor Tree Example 1.1 (Begins with-STEM) Bearing can go in Backwards 1.1 Reduces Spare Parts Inventory 1.1.1 END for now Missed/Dismissed in FMEA1.1.2 END for now Done on Previous Designs 1.1.3 END for now Mistake Proofing not a Design Consideration 1.1.3 See Example 1.1.3 Ineffective Application of App B, Crit. XVI, Sentence 1 (1.1.4) See Example 1.1.4 © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 195
  196. 196. Factor Tree Example 1.1.3 (Begins with-STEM) Mistake Proofing not a Design Consideration 1.1.3 Ineffective Use of Operating Experience 1.1.3.1 END for now Other 1.1.1.3.2 END for now © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 196
  197. 197. Factor Tree Example 1.1.4 (Begins with-STEM) Ineffective Application of App B, Crit. XVI, Sentence 1 (1.1.4) App B did not exist at original design 1.1.4.1 END for now App B not effectively applied to modified design 1.1.4.2 END for now Ineffective use of OE related to design for mis- orientation 1.1.4.3 END for now Ineffective Licensee QA Oversight END for now © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 197
  198. 198. Factor Tree Example 1.2 (Begins with-STEM) Worker put Bearing in Backwards 1.2 Pump Rebuild in 2005 (1.2.1) See Example 1.2.1 Defective Instructions 1.2.2 See Example 1.2.2 25-75 Chance Failed 1.2.3 END-Normal No QA Hold Point 1.2.4 See Example 1.2.4 Critical Step Not Flagged 1.2.5 See Example 1.2.5 Workers not qualified 1.2.6 See Example 1.2.6 No Supervisory Intervention 1.2.7 See Example 1.2.7 © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu Orientations 1. Tandem (Left) 2. Tandem (right) 3. Back-to-back 4. Front-to-front 198
  199. 199. Factor Tree Example 1.2.2 (Begins with-STEM) Defective Instructions 1.2.2 Non-plant Procedures used in turnkey work 1.2.2.1 See Example 1.2.2.1 Purchasing failed to apply App B, Crit. I, Sentence 2 (1.2.2.2) See Example 1.2.2.2 Plant failed to apply App B, Crit. II, Sentence 5(1.2.2.3) See Example 1.2.2.3 Plant failed to apply App B, Crit. V, Sentence 1(1.2.2.4 See Example 1.2.2.4 Ineffective Pre-job Brief 1.2.2.5 See Example 1.2.2.5 © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 199
  200. 200. Factor Tree Example 1.2.6 (Begins with-STEM) Workers not qualified 1.2.6 Failure to apply App B, Crit. II, Sentence 8 (1.2.6.1) See Example 1.2.6.1 Safety Related Work Assigned to Unqualified Contractor 1.2.6.2 BREAKDOWN OF QA PROGRAM 1.2.6.2.1 See Example 1.2.6.2.1 Defective Contract 1.2.6.3 Failure to apply App B, Crit. IV, Sentence 1 & 2 (1.2.6.3.1) See Example 1.2.6.3.1.1 © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 200
  201. 201. Factor Tree Example 1.3 (Begins with-STEM) Bearing Damages Pump While Operating 1.3 Bearing Rubs if Backwards 1.3.1 END Normal Pump Operated HH Hours1.3.2 See Example 1.3.2 © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 201
  202. 202. Factor Tree Example 1.4 (Begins with-STEM) Damage Undiscovered Until Pump Inoperable 1.4 Ineffective Vibration Monitoring 1.4.1 See Example 1.4.1 Ineffective Lube Oil Purity Monitoring 1.4.2 See example 1.4.2 © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 202
  203. 203. Factor Tree Example 1.4.1 (Begins with-STEM) Ineffective Vibration Monitoring 1.4.1 Ineffective Use of OE Related to Vibration Monitoring 1.4.1.1 See Example 1.4.1.1 Failure to Consider Vibration Monitoring as Required by App B, Crit. XVI, Sentence 1 ( 1.4.1.2) See example 1.4.1.2 © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 203
  204. 204. Factor Tree Example 1.4.2 (Begins with-STEM) Ineffective Lube Oil Purity Monitoring 1.4.2 Ineffective Use of OE Related to Vibration Monitoring 1.4.2.1 See Example 1.4.2.1 Failure to Consider Lube Oil Purity Monitoring as Required by App B, Crit. XVI, Sentence 1 ( 1.4.2.2) See example 1.4.2.2 © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 204
  205. 205. Factor Tree Example 1.5 (Begins with-STEM) Damage Undiscovered for DD More Days 1.5 Pump Performs with Bearing in Backwards 1.5.1 END for now Ineffective Vibration Monitoring 1.5.2 See example 1.4.1 Ineffective Lube Oil Purity Monitoring 1.5.2 See Example 1.4.2 © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 205
  206. 206. Factor Tree Example 1.6 (Begins with-STEM) Damage Discovered 1.6 Surveillance Test Run 1.6.1 END for now Vibration Exceeds Alert Level 1.6.2 See Example 1.6.2 Staff Notices Excessive Vibration 1.6.3 See Example 1.6.3 © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 206
  207. 207. Factor Tree Example 1.7 (Begins with-STEM) Pump Restored to Operability 1.7 Damage Discovered 1.7.1 See example 1.6 Parts Available 1.7.2 END for now. Pump Repaired 1.7.2 END for now. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 207
  208. 208. Missed Opportunities • The situations in which ordinary people or groups could have done ordinary things ordinarily well that would have resulted in reduced or eliminated harmful outcomes. • Expect to see many missed opportunities. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 208
  209. 209. Missed Opportunity Matrix (MOM) [HPCI Inop for DD Days] Sheet n of N Who Situation Opportunity Expected Result Impact and Notes © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 209
  210. 210. Missed Opportunity Matrix (MOM) [HPCI Inop for DD Days] Sheet 1 of N Who Situation Opportunity Expected Result Impact and Notes Highest Mgt Planning for R/R Apply App B to ITS/SR work 18 Criteria Applied No event, Not a root cause Purchasing Mgt Writing Purchasing Policy Apply App B to ITS/SR work 18 Criteria Applied No event, Not a root cause QA Audit of Planning for R/R Find that App B is left out of Planning for R/R 18 Criteria Applied No event, Not a root cause Work Planner Planning for HPCI BP Rebuild Apply App B to ITS/SR work 18 Criteria Applied No event, Not a root cause Supervisor of HPCI BP Rebuild Pre-job Brief Call out bearing installation as critical step Bearing installed right No event, Not a root cause © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 210
  211. 211. Barrier Analysis Matrix (BAM) [HPCI Inop for DD Days] Sheet n of N Barrier Target Protected Threat Effectiveness in this case Significance © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 211
  212. 212. Barrier Analysis Matrix (BAM) [HPCI Inop for DD Days] Sheet 1 of N Barrier Target Protected Threat Effectiveness in this case Significance Outsource QA Appendix B Compliance by Contractor Critical Noncompliance Ineffective. Contractor not in compliance with Criterion V and others,. Failed Barrier. Allowed nonconforming installation. Work Package Quality of Work Critical Work Defect Ineffective. Work had critical defect. Failed barrier. Defective installation. Pre-job brief for Booster Pump Work Work process integrity. Inadequate work process Did not identify critical step. Failed barrier. Missed Opportunity. Contractor Work Supervision Work process integrity. Inadequate work process Did not identify critical step done wrong. Failed barrier. Missed Opportunity. Vendor Technical Manual Work instructions Errors and omissions Not used.. Failed barrier. Missed Opportunity. Negative factor. In-house Operating Experience Program This barrier and other barriers. Repeat missing and ineffective barriers Not used effectively Failed barrier. Missed Opportunity. Negative factor. Industry Operating Experience Program This barrier and other barriers. Repeat missing and ineffective barriers Not used effectively Failed barrier. Missed Opportunity. Negative factor. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 212
  213. 213. FACTOR-CONSEQUENCE MATRIX 1.0 FACTOR Actual Case Case 1 Can’t go in wrong Case 2 Right Guess Case 3 Effective Plant QAP Case 4 Effective Contractor QAP Case 5 Effective Procedure Case 6 Effective Training Case 7 Effective QC Case 8 Accident Needing HPCI Brg Can Go In Wrong Yes Brg in Properly Yes Yes Yes Yes Yes Yes Yes Worker Guesses Wrong Yes Could not happen Brg in Properly Could not happen Could not happen Could not happen Could not happen Would be caught Yes Lack of Effective Plant QAP Yes Would not matter Would not matter Brg in Properly Would not matter Would not matter Would not matter Would not matter Yes Lack of Effective Plant QAP Yes Would not matter Would not matter Could not happen Brg in Properly Would not matter Would not matter Would not matter Yes Lack of Effective Procedure Yes Would not matter Would not matter Could not happen Could not happen Brg in Properly Would not matter Would not matter Yes Lack of Effective Training Yes Would not matter Would not matter Could not happen Could not happen Would not matter Brg in Properly Would not matter Yes Lack of Effective QC Yes Would not matter Would not matter Could not happen Could not happen Would not matter Would not matter Brg in Properly Yes No accident needing HPCI Yes Would not matter Would not matter Would not matter Would not matter Would not matter Would not matter Would not matter Accident Needing HPCI Consequences HPCI Inop DD Days None None None None None None None Not Applicable Actual Fuel Damage Increase None None None None None None None None Yes HPCI BP Inop © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 213
  214. 214. Problem Finding Matrix (PFM) [HPCI Inop for DD Days] Sheet n of N Harmful Factor/Effect How Found Earlier, better, safer… Missed Opportunities Measures to assure prompt ID © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 214
  215. 215. Problem Finding Matrix (PFM) [HPCI Inop for DD Days] Sheet 1 of N Harmful Factor/Effect How Found Earlier, better, safer… Missed Opportunities Measures to assure prompt ID No QA for Safety-related Job Event Investigation of Inop HPCI QA Audit of Purchasing Audit Planning Audit Planning Check List No QA for Safety-related Job Event Investigation of Inop HPCI QA Department Review of Work Order Work Order Review Procedure Work Planning Check List No QA for Safety-related Job Event Investigation of Inop HPCI Engineering Department Review of Work Order Conduct of Engineering Procedure Work Planning Check List © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 215
  216. 216. Extent • Magnitudinal Extent – Causation of Magnitudinal Extent • Inferential Extent – Causation of Inferential Extent © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 216
  217. 217. The Taxonomy of Extent 1.2 Inferential Extent of X (1.2) More of X (1.2.1) See Taxonomy of Extent 1.2.1 Items Similar to X (1.2.2) See Taxonomy of Extent 1.2.2 Items that resulted in X (1.2.3) See Taxonomy of Extent 1.2.3 Items resulting from X (1.2.4) See Taxonomy of Extent 1.2.4 The connectors mean that the upper item is comprised of the lower items. The lower items are part of the upper item. © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 217
  218. 218. Problem That Got Noticed Downstream Impact Upstream Causation More of the Same Item More of the Same Class of Issue © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 218
  219. 219. Corrective Action Matrix (CAM) [HPCI Inop for DD Days] Sheet n of N Harmful Factor/Effect Corrective Actions Expected Effectiveness Effect if Pre- implemented Short Term/ Long Term/ Comments © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 219
  220. 220. Corrective Action Matrix (CAM) [HPCI Inop for DD Days] Sheet 1 of N Harmful Factor/Effect Corrective Actions Expected Effectiveness Effect if Pre- implemented Short Term/ Long Term/ Comments No QAP required in PO Adhere to App. B, Criterion IV QAP Applied No event No App B QA applied Adhere to App. B, Criterion II QAP Applied No event VTM leaves out bearing orientation Adhere to App. B, Criterion V VTM includes instructions for installing bearings No event VTM not used Adhere to App. B, Criterion IV VTM used in preparing work order Would not have mattered unless VTM had been right. Defective VTM accepted for use Adhere to App. B, Criterion XVI VTM rejected, then fixed No event © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 220
  221. 221. End of Case Study Comments? Questions? © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
  222. 222. Thanks for Your Participation • Questions? • Comments? • Differing Professional Opinions? • Next Steps for Your Organization? © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 222
  223. 223. Questions? © 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 223
  224. 224. INSTRUCTOR FEEDBACK Please fill out the following table and return the form to me. Put a number from 0 (needs a lot of help) to 10 (world class-on target) in the right hand column. Appropriateness of the topics to your job. The value of the topics to your career. The instructor's command of the subject matter. The instructor's presentation skills. The instructor's ability to engage the participants. The instructor's handling of questions and comments. The helpfulness of the visual aides. The helpfulness of the handout materials. The overall quality of the training experience. Your ability to apply at least 10% of the material in your job tomorrow. Please also answer the following questions. What suggestions do you have to make the presentation more valuable to a person in your situation? How can you use one idea out of the presentation to improve your contribution to your organization? If you would like a free complimentary subscription to The Firebird Forum e-newsletter send an e-mail to firebird.one@alum.MIT.edu including the word “subscribe”. 224

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