Systematic Methods To

Address Root And

Contributing Causes
Expectations in
NRC Inspection Procedures 95001 and
95002
Frederick J. Forck
4Konsulting, LLC

Using Tools
USE A TOOL

USE A TOOL TO BUILD

Using Cause Analysis Tools

CAUSE ANALYSIS TOOLS
1. Fault

tree analysis
2. Critical incident techniques
3. Events & causal factors
analysis
4. Pareto Analysis
5. Change analysis
6. Barrier analysis
7. Management Oversight &
Risk Tree (MORT) analysis
8. Why Staircase
NRC IP 95001

USE TOOLS TO RECONSTRUCT

Systematic Evaluation Normally

Includes:

Clearly identify problem

State assumptions
Data

Timely collection
Verification

Preserve evidence
Document analysis so
Progression of the problem
is clearly understood
Any missing information or
inconsistencies are identified
Problem can be easily explained
and/or
understood by others
NRC IP 95001

Determine cause & effect

relationships resulting in
Identification of root and contributing
causes that
Consider the following types
of issues:
Hardware: design, materials, systems aging,

and environmental conditions;

Process: procedures, work practices,
operational policies, supervision and oversight,
preventive and corrective maintenance
programs, and quality control methods; and
Human performance: training, communications,
human-system interface, and fitness for duty
(which includes managing fatigue).

Basic Investigation Steps

Gather information
Reconstruct the incident.
Discover causes.
Recommend corrective actions

Continuous Performance
Improvement
Problem
Prevention

Symptom/Effect
Analysis

Cause
Analysis

Solution
Analysis

Problem
Prevention

Follow Up
Analysis

Solution
Analysis

Follow Up
Analysis

Symptom/Effe
ct Analysis

Cause
Analysis
Avatar International Inc., 1985

General Job/Task Analysis

Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis
Process

Instructions, Procedures, & Drawings

Criterion V of Appendix B to 10CFR50

Written
Followed
Include

Acceptance

Criteria

10CFR50, App. B
Callaway Plant Lead Auditor
Training

Steps with Acceptance Criteria

Issues that drove, influenced,
or allowed the incident
Accurate, factual
information

Scope The
Problem

Investigate
The Factors

Intervention(s) that improve

design or change behavior

Reconstruct
The Story

Establish
Contributing
Factors

Validate
Underlying
Factors

Progression of the
problem
Precise, complete, bounded
problem statement

Plan
Corrective
Actions

Report
Learnings

Auditable,
defensible record
Correctable root and
contributing causes

Overall Method Steps w.

Techniques

Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis
Process

SCOPE THE PROBLEM

(Step 1)
Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis
Process

Techniques
Deviation Statement
Difference Mapping
Problem Description
Extent of Condition
Review
Methodology Selection

Effective Problem Description

Identify the GAP: What is the Problem?
Method 1: Deviation Statement (noun/verb)
OBJECT: What is the item that is affected?
DEFECT: Identify the DEVIATION from the EXPECTED or
REQUIRED STANDARD of PERFORMANCE.
Example: Five gallons of oil spilled (defect)
on the B Emergency Diesel Generator room floor (object) .
OR Use:

Method 2: Expected vs. Actual Statement

Compare WHAT SHOULD BE*: Requirement, Standard, Norm, or Expectation
with
WHAT IS: The existing, as-found condition
*Sometimes the What Should Be is implied.
Kepner-Tregoe, The New Rational Manager
BPI Problem Solving-Decision Making-Planning

HOW: Extent of [Adverse]

Condition
Evaluate ONLY from Problem Description
Perspective
Deviation
Statement: Object
Application

Then evaluate various combinations

Same Same Same

Same Same Similar
Similar Same Same
Similar Similar Same
etc.

Document the basis for bounding with

the associated risk and consequence
Lewis Allen , STP, 15th Annual HPRCT

Defect

Same-Same-Same
An Identical Object
in an Equivalent Application
with a Matching Defect
Same-Same-Similar
An Identical Object
in an Equivalent Application
with a Related Defect
Similar-Same-Same
A Comparable Object
in an Equivalent Application
with a Matching Defect

How to do an Extent of Condition Review

Human Performance Tool

Peer Check

INVESTIGATE THE FACTORS

(Step 2)
Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis
Process

Techniques
Evidence Preservation
Interviewing (What & How)
Performance Analysis
Worksheet
Culpability Decision Tree
Substitution Test/Survey
SORTM questions

Information Gathering Strategy

1.

Determine how best to fill your information needs.

(Information you have vs. Information you still need)
review of logsheets, charts, drawings, etc.
area walkdowns
interviews
Decide who to interview and what you hope to learn from them.

2.

Determine which information to pursue first.

Considerations:
Focus on issues that appear to be key.
Management Sponsor may need certain information first
(e.g. restart issues).
Interviewee availability may pose an impact.

3.

Determine who will obtain the information.

Divide responsibilities among team members
If no team, you can still seek assistance from cognizant parties
e.g. system engineer can research material history
Adapted from Incident Investigation Training, Callaway
Plant

How is Interviewing done?

Prepare
Open
Question
Close
IAEA-TECDOC-1600

TwoPronged
Approach to
Incident
Prevention

Md
System Factors Prong

Re
Human Factors Prong

Adapted from INPO 06003

Factor Tree

Phoenix Handbook, Corcoran

Dana Cooley

RECONSTRUCT THE STORY

(Step 3)
Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis
Process

Techniques
Fault Tree
Task Analysis
Critical Activity
Charting
Actions & Factors Chart

Human-Machine Interface

Adapted from Callaway Plant Fault Tree Analysis Training

8 Steps of Fault Tree

Analysis
Step 1:
Identify the
Undesirable
Incident

Step 2:
Identify
1st Level
Inputs

Step 3:
Link Using
Logic Gates

Step 4:
Identify
2nd Level
Inputs

Step 8:
Determine
Contributing
Factors
Physical
Roots

Step 7:
Investigate
Remaining
Inputs

Step 6:
Develop
Remaining
Inputs

Step 5:
Evaluate
Inputs

Fault Tree Analysis, Clemens

Callaway Plant Fault Tree Analysis Training

Factor
Flow
Equipment

Physical
Roots

Human-Machine
Interface
Response

Think (Operation)

Human

Stimulus

Roots

Defense-In-Depth
Latent
Organizational
Weaknesses

Latent
Roots

How is Task Analysis done?

Step 1:
Obtain
Preliminary
Information

Step 2:
Select
Task(s) of
Interest

Step 3:
Obtain
Background
Information

Step 4:
Prepare a Task
Performance
Guide

Paper & Pencil Phase

Step 8:
Evaluate &
Integrate
Findings

Step 7:
Reenact
Task
Performance
Step 7A:
Interview
Personnel
(Alternate
Method)

DOE-NE-STD-1004-92

Step 6:
Select
Personnel

Step 5:
Get Familiar
With the
Guide

Walk-Through Phase

Critical Human Action Concept

Note: Not all steps of a work activity
are equally important.
Critical Human Actions (steps) include:
Actions aimed at changing the state of

facility structures, systems, or components

Steps that are irrecoverable or
actions that cannot be reversed
Steps where the outcome of an error
is intolerable for personnel or facility safety
www.hanover.gov
NRC NUREG/CR-5455, NRC HPIP

A "Critical" Human Action IS:

A step in the activity that caused or could have
made the incident less severe.
It is a CHA if the step:
Might cause an incident if the step is not done
Might cause an incident if an error is made
Might cause an incident if done some other way
Makes incident less severe if done the right way.

Could be a Critical Step related to the incident

NRC NUREG/CR-5455, NRC HPIP

How is a
Critical Human Activity Table
done?
1. Identify the human actions to be analyzed.
(This may be all the human actions in the incident,
or it may be those that are believed to have been
responsible for the event's occurrence.)
2. Decide which human actions caused the

incident or, if they had been performed

correctly, could have prevented the incident or
made the incident less severe (Critical Human
Actions or CHAs).
3. Collect and record information about the CHAs.
Derived from:
1. NRC NUREG/CR-5455, NRC
HPIP
2. UE QIP

General Systems Analysis

Events & Causal Factors Charting
Action

Action

Action

How did the factors originate?

Action

Inciden
t

Factor
Factor

Why did this

Incident
happen?
What systems allowed
The Conditions to
exist?

Adapted from DOE Accident Investigation Program

Contributing
Factor

Contributing
Factor

Contributing
Factor

Work
Activity
Causes
Proces
s
Causes
Institution
al
Causes

General Format

ESTABLISH CONTRIBUTING
FACTORS (Step 4)
Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis Process

Techniques
Change Analysis
Barrier Analysis
Production/Protection
Strategy (Defense-In-Depth)
Analysis
Factor Tree

How is Change Analysis

done?

Evaluate by asking these questions:

What was different about this time from all
the other times the same hardware
operated without a problem or the same
task or activity was carried out without
error?
Why now and not before?
Why here and not there?
Root Cause Analysis Training Course CAP-02, Palo Verde Nuclear Generating Station
Ammerman, The Root Cause Analysis Handbook

Identify Risk Defenses

(Barriers & Controls)
Local
Factor
Control

Engineere
d
Barriers

Admin
Control
s

Oversigh
t
Controls

Cultural
Controls

Eliminate task.
Prevent error.
Catch error.
Detect defect.
Mitigate harm.
Accept risk.
Carelessness and overconfidence are more dangerous than deliberately accepted risk.
Wilbur Wright, 1901 (www.faa.gov)
Muschara, Managing Critical Steps, HPRCT
2009
Muschara, Managing Defenses, HPRCT 2008

Systematic Barrier Analysis

Identify each Target of hazards/threats.

Identify each Hazard (adverse effect/consequence)
Identify Barriers that should have controlled Hazard
Prevented contact between Hazard and Target OR
Mitigated consequences of Hazard/Target contact

Assign a Safety Precedence Sequence # to each

Barrier
Assess HOW Barrier failed
not provided/missing (not in place)
not used/circumvented (but were in place)
ineffective

Determine WHY Barrier failed (Step 5)

Validate analysis results
Integrate this information in E & CF Chart
Ammerman, The Root Cause Analysis Handbook
ASQ

System Safety Design Order Of

Precedence
MOST
EFFECTIVE

LOW HUMAN
INTERFACE

1. Eliminate hazards through design selection

2. Incorporate Safety Devices
3. Provide Warning Devices

4. Use Procedures & Administrative Controls

5. Select, train, supervise, and motivate to work

safely
6. Accept risks at appropriate management level
LEAST
EFFECTIVE

MIL-STD882D

HIGH HUMAN
INTERFACE

Defense Analysis Form

EFFECT/
CONSEQUENCES
(What Happened)
List one at timesequential order
not required

BARRIER/CONTROL THAT
SHOULD HAVE PRECLUDED
THE INCIDENT
list all applicable physical and
administrative defenses for each
consequence

Ammerman, The Root Cause Analysis

Handbook
ASQ

Exampl
e
www.sandia.gov

www.sandia.gov

Contributing [Causal] Factor

Test
Identify Contributing Influences
Evaluate factors (ovals) and flawed defense (broken barriers) on the Actions & Factors Chart by asking:

If this factor had not existed, could this incident have occurred?
If the answer is no, then youre on your way toward finding a Contributing Factor!

NRC Inspection Procedure 95001

VALIDATE UNDERLYING FACTORS

(Step 5)
Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis
Process

Techniques
WHY Factor Staircase
A-B-C Analysis
HOW-To-WHY Matrix
Cause & Effect Tree
Root Cause Test
Root Cause Evaluation
Extent of Cause
Review
Common Factor
Analysis

The WHY Factor

Staircase

Incident

Execution
Preparation
Feedback

Outcomes
Methods
Resources

Plan/Do/Check/Act

Vision
Beliefs
Values

Phoenix Handbook, Corcoran

Root Cause, Martin, HPRCT 2006

Capabilities/Limitations
Task Demands/Environment

Culture

Re Active Error Analysis

Job
Performer
TW IN
Analysis

Goals &
Values

Task
Preview

Pre-Job
Brief

Post-Job
Review

Behavio
r

Business

Result
s
I

INPO Human Performance Fundamentals

Course

The A-B-Cs:
1st Occurrence
Desired behavior: Wear safety glasses

Safety policy
Safety signs
Safety procedure
Safety briefing
Just-in-time
training

Wear safety
glasses

C
Ears hurt
Cant see
clearly
Uncomfortable
Feel odd

Consequences for current or past behaviors have

the strongest influence on our future behavior.
Foundations of Behavioral Accident Prevention: Eagles Management Support Course,
Performance Management,
BST, Inc.
Daniels

The A-B-Cs:
Subsequent Occurrence
Desired behavior: Wear safety glasses

Peers dont wear

Supervisors
occasionally dont
wear
Leave at home
Embarrassed to ask
for spare pair

Work w/o safety

glasses

C
Ears dont hurt
Can see clearly
Less bother

Consequences for current or past behaviors have

the strongest influence on our future behavior.
Foundations of Behavioral Accident Prevention: Eagles Management Support Course,
Performance Management,
BST, Inc.
Daniels

Md

Defense Management Analysis

Uneasy Attitude
Morale Written Instruction Quality
Job Performer Skill, Knowledge, Proficiency
Housekeeping
Equipment Labeling & Condition
Work-Arounds & Burdens
Tool Quality & Availability
Equipment Ergonomics
Lockout-Tagout
Fitness-For-Duty

Walk-downs
Task Preview
Pre-Job Brief
Turnover

Processes/
Practices

Walk-downs
Task qualifications
Performance Feedback
Task assignment

Tasks/
Behaviors

Leadership
Defense In Depth

Staffing
Continuous Learning
Clear Expectations
Change Management
Benchmarking
Problem-Solving
Reviews & Approvals
Communication Practices
Simple, Effective Processes Management Practices
Accountability Rewards & Reinforcement

Interlocks
Independent Verification
Personal Protective
Equipment
Alarms

Results/
Consequence
s

Goals/
Values

Handoffs

Questioning Attitude
Procedure Use
Procedure Adherence
Self-Check
Place-keeping Observations
Conservative Decision-Making
3 Part Communication
StopWhen Unsure
Peer Check

Post-Job Critiques
Root Cause Analysis
Independent Oversight
Performance Indicators
Task assignment

Berms
Redundant trains

Equipment Reliability
Containment
Equipment Protection Systems
Safeguards Equipment
INPO Human Performance Fundamentals
Course

Deeper Understanding

NRC: Safety Culture General

Tree

NRC IM Chapter 0305 Areas

Safety Culture
Analysis

Do Last!!!

Tasks/

Behavior
s
Processes
/
Practices

Goals/
Values

NRC IMC 0305

Root Cause Test

Adapted from work of Dr. William R. Corcoran, NSRC

Corp.

How to do an Extent of Cause

Review

Human Performance Tool

Peer Check

Common Factor Analysis Steps

Step 1
Determine the
Scope of
the CFA

Step 2
Gather
Data

Step 3
Determine Which
Information to
Evaluate

Step 4
Categorize
the Data

Step 5
Identify Areas
for Further
Analyses

Step 9
Report
Learnings

Step 8
Plan
Corrective
Actions

Step 7
Develop and
Validate Causal
Theories

Step 6
Analyze
Areas of
Interest

Adapted from Incident Investigation Training, Callaway

Plant

PLAN CORRECTIVE ACTIONS

(Step 6)
Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis
Process

Techniques
Action Plan
Solution Selection
Tree
Solution Selection
Matrix
Change Management
Active Coaching Plan
S.M.A.R.T.E.R.
Effectiveness Review
Contingency Plan
Communication Plan

Developing A Corrective Action Plan

To Prevent Recurrence
Develop alternative actions which address the underlying factors
[i.e. the root cause(s)].
Evaluate alternative courses of action.
Ensure corrective actions address the underlying factors [i.e. the
root cause(s)].
Decide which alternatives will be recommended to management.
Map out implementation of interventions/actions
that will prevent or mitigate recurrence.

Plan for contingencies.

The Success Cycle

Behavior Change
Institutionalization Plan
Factor/Cause
Being Addressed

2009 4Konsulting, LLC

Corrective
Action Step

1. Right
Picture

2. Communicate

3. Monitor

4. Feedback

Who
Owner

When
Due Date

www.hanford.gov

By Stakeholders? By Subject Matter Experts?

For Unintended Consequences?
Degree of Dependability/Reliability
Leveraged solution w. Behavior Engineering Model
Should be completed before next shot on goal
If not, interim corrective actions are needed
Logical tie between the problem and cause(s)
Logical tie between cause(s) and corrective actions
Doable? Feasible? Realistic? Cost/Benefit?
Agreed to by Stakeholder? Good business?
Describes desired behaviors so an observer can compare
observed behavior to a desired behavior
What exactly needs to be done? Focus on results.
WHO does WHAT by WHEN

Reviewed
Effective
Time-sensitive
Related
Attainable
Measurable
Specific

S.M.A.R.T.E.R. Criteria

Institutionalization
Plan
Cause/Factor
Being
Addressed

Corrective Action Plan

To Prevent Recurrence

1. Right Picture

2. Communicate

3. Monitor

4. Feedback

S.M.A.R.T.E.R.
Specific

Measurable

Attainable

Related

Timely

Effective

WHO

Reviewed

Owne
r

WHEN
Due
Date

Corrective Action
Effectiveness Scale
MIL-STD-882D

Md

Effectiveness Review General

Flow

 Define the optimum time to

perform the effectiveness review.

Establish the acceptance criteria for the

attributes to be monitored or evaluated.

Describe the process characteristics

to be monitored or evaluated.
Describe the means that will be used to
verify that the actions taken had the
desired outcome.

Grand Gulf Nuclear Station

TIMELINESS
SUCCESS
S

ATTRIBUTE
METHOD

M.A.S.T. Effectiveness Plan

Performance Indicator Development

How is it done?

Improving Performance: How to Manage the White Space on the Organization Chart, Rummler & Brache

REPORT LEARNINGS
(Step 7)
Derived from
1. INPO 90-004
2. NUREG/CR-5455, NRC HPIP
3. Entergy Root Cause Analysis
Process

Forms
Report Template
Grade Cards/Scoresheets

Report Answers General Questions

The investigation will have determined the
following:
What was expected
(anticipated
consequences);
What has happened
(real
consequences);
What could have happened
(potential
consequences);
Cause-effect relations;
Faulty/failed technical elements
(structures, systems, or
IAEA-TECDOC-1600
components);
Inappropriate actions (human, management,
organizational);

Report Answers Specific Questions

What

was the Job Performer focused on?

Could they do the Job if their lives depended
on it?
Equally qualified person likely to make same
error?
What were the factors that directly resulted in
the nature, the magnitude, the location, and
the timing of the key consequences?
What happens to them when they do what
they do?
Mager & Pipe, Analyzing Performance Problems
Corcoran , Phoenix Handbook
Daniels, Performance Management

Report Answers Regulator Questions

Who identified issue (licensee? regulator? self-revealing?) under what conditions?

How long did issue exist? prior opportunities to identify?
Plant-specific risk consequences? individual & collective compliance concerns?
Systematic method used to identify underlying factors?
Evaluation detail commensurate with significance of the problem?
Evaluation considered prior occurrences? operating experience?
Extent of condition addressed? extent of cause?
Corrective actions for each underlying factor?
or adequate evaluation why no corrective actions are necessary?
Corrective action priority considers risk significance & regulatory compliance?
Schedule established for implementing and completing corrective actions?
Quantitative/qualitative effectiveness measures of actions to prevent recurrence?
Corrective actions adequately address Notice of Violation, if applicable?
NRC IP 95001
NRC IP 95002

Questions?

Later
Frederick J. Forck, CPT*
4Konsulting, LLC
2320 Knight Valley Drive
Jefferson City, Mo 65101-2253
Phone: 573-645-8854
Fax: 573-636-7734
Email: fforck@4konsulting.com
www.4konsulting.com
*International Society for Performance Improvement (ISPI) Certified Performance Technologist (CPT)

Extent of Condition
Review Criteria
Deviation Statement
Same-Same-Same
An Identical Object
in an Equivalent Application
with a Matching Defect.
Same-Same-Similar
An Identical Object
in an Equivalent Application
with a Related Defect.
Similar-Same-Same
A Comparable Object
in an Equivalent Application
with a Matching Defect.
Similar-Same-Similar
A Comparable Object
in an Equivalent Application
with a Related Defect.
Same-Similar-Same
An Identical Object
in a Corresponding Application
with a Matching Defect.
Similar-Similar-Same
A Comparable Object
in a Corresponding Application
with a Matching Defect.
Same-Similar-Similar
An Identical Object
in a Corresponding Application
with a Related Defect.

Object
(Person, Place, Thing)

Application
(Activity, Form, Fit, Function)

Defect
(Flaw, Failing, Deficiency)

Object
Extent of Condition
(Person, Place, Thing)
Review Criteria
Deviation Statement Drivers Side Front Tire on

Same-Same-Same
An Identical Object
in an Equivalent Application
with a Matching Defect.
Same-Same-Similar
An Identical Object
in an Equivalent Application
with a Related Defect.
Similar-Same-Same
A Comparable Object
in an Equivalent Application
with a Matching Defect.
Similar-Same-Similar
A Comparable Object
in an Equivalent Application
with a Related Defect.
Same-Similar-Same
An Identical Object
in a Corresponding Application
with a Matching Defect.
Similar-Similar-Same
A Comparable Object
in a Corresponding Application
with a Matching Defect.
Same-Similar-Similar
An Identical Object
in a Corresponding Application
with a Related Defect.

Application
(Activity, Form, Fit, Function)

Defect
(Flaw, Failing, Deficiency)

Parked in My Driveway

Flat

Rental Car
1. Other Tires on Rental Car
2. Tires on Pickup Truck

1. Parked in My Driveway
2. Parked in My Driveway

1. Flat
2. Flat

1. Other Tires on Rental Car

2. Tires on Pickup Truck

1. Parked in My Driveway
2. Parked in My Driveway

1. Low on Air
2. Low on Air

1. Tires on Boat Trailer

2. Tires on Bicycle

1. Parked in My Driveway
2. Parked in My Driveway

1. Flat
2. Flat

1. Tires on Boat Trailer

2. Tires on Bicycle

1. Parked in My Driveway
2. Parked in My Driveway

1. Low on Air
2. Low on Air

1.
2.
3.
1.

1.
2.
3.
1.

1.
2.
3.
1.

Car Spare Tire

Tires on Sons Vehicle
Tires on Spouses Vehicle
Garden Tractor

1. Car Spare Tire

2. Tires on Sons Vehicle
3. Tires on Spouses Vehicle

In Trunk as a Spare
Parked on the Street
Parked in the Garage
Parked Behind My House

1. In Trunk as a Spare
2. Parked on Street
3. Parked in the Garage

Flat
Flat
Flat
Flat

1. Low on Air
2. Low on Air
3. Low on Air

Fault Tree Form

O
R

O
R

O
R

O
R

O
R

Adapted from Callaway Plant Fault Tree Analysis

Training

Task Analysis Technique

(1)
Paper & Pencil Input
Steps in
Procedure
or Practice

(2)
Walk Through
by Analyst
or trained
individual.

(3)
Questions/
Conclusions about
how task
was/should be
performed.

WCNOC

Example: Task Analysis Technique

(1)
Paper & Pencil Input
Steps in
Procedure
or Practice
1. Locate proper pig trap.
2. De-pressurize line pressure.

3. Verify that the line has been

de-pressurized.
4. Open line.
5. Insert pig.
6. Close line.
7. Re-pressurize line.

(2)
Walk Through
by Analyst
or trained
individual.
Pig trap is not labeled.
Nearest pressure gauge is
up 2 flights of stairs about
50 away.
Other pig traps all have
pressure gauges near
opening.

(3)
Questions/
Conclusions about
how task
was/should be
performed.
Is there a requirement to label?
Why is the location without a
pressure gauge?
Has it been modified?
Steps are all very general.
How does the operator know how
to do them?

WCNOC

Example: Chlorine Tanker

Fill Critical Human Activity

Error Type: Wrong Information Obtained

Error Description: Wrong Weight Entered
Consequence: Alarm does not sound before tanker
overfills

Error Type: Check Omitted

Error Description: Tanker not monitored while
filling
Consequence: Leaks not detected early
Guidelines for Preventing Human Error in Process Safety, Center for Chemical Process Safety of the American Institute of
Chemical Engineers

Example
www.sandia.gov

A.

B.

C.

D.

E.

Factors
that Influence
Performance

Failed
Performance

Past
Successful
Performance

Difference
or Change

Contributing
Factor?
(Yes/No)

When

Supervision

Job Performer Job Performer

came in early to started day the
avoid the heat. same time as coworkers.
Employee did
not meet with
supervisor the
morning of the
accident.

Employee met with

supervisor to
discuss the days
work activities.

No co-workers
Yes. Worker
were available to came to work
help with the job. early, so was
working alone,
carrying tools.
Work activities
Yes. Because
were not
worker came to
discussed.
work early, job
hazards were not
discussed.

Events & Causal Factors Chart

after Change & Barrier Analysis

www.sandia.gov

Problem Correction Flowchart

Effectiveness Review Detailed

Flow