Excellence in Causal Analysis

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

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

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

4. Personally Involved Leaders

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

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

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

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

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

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

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

12. Personally Involved Leaders

13. Questions