Post on 26-May-2015
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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
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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
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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
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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
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• 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
Exercise
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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
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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
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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
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Causal Factor Analysis (Root Cause Analysis) Report Production/ Evaluation
CorrectiveActions
Extent of Conditions &Causes
Factors Extraneous CAQs
Lessons-To-Be-Learned
Consequences
Evidence(data)
© Drs. William Corcoran and Richard Hartley 8-21-07
EventRecognition
Investigation (collect & organizeevidence (data ))
CultureInsight
Convert Evidence (data) toInformation
SignificanceCharacterization
HumanBehavior
Technology
Use AppropriateRCA Tools
Lines of Inquiry
The Fixes
To BeFixed
To BePrevented
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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?
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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
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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
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Flash Card Back
•Effect(s) to be prevented, ie., the consequences.
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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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
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Drag is
an effect.
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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
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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
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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
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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
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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
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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
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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
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Direct Factor Exercise
Pattern of Paper Discs (NMLT) _________________________Direct
Factor 1: ________
_____
DirectFactor 2:
_____________
DirectFactor 3:
__________
DirectFactor 4:
_____________
Add others as needed.
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
Write on or near objects.
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Direct Factor Exercise Potential Answer #1
Pattern of Paper Discs (NMLT) _________________________Direct
Factor 1: Number of
Discs
DirectFactor 2: Height of
Drop
DirectFactor 3: Air Movement
DirectFactor 4: Stickiness of Discs
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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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
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Factors and Effects
Effect
Factor / Effect
Factor / Effect Factor / EffectFactor / 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)
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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
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Flash Card Back
•DIRECT
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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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 itemis/was a result of the lower connected items.
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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
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Factor Tree Example FT1
HarmfulEffect: Factory Fire
DirectFactor 1: Fuel
Supply
DirectFactor 2: Oxygen supply
DirectFactor 3: Ignition
DirectFactor 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.
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Factor Tree Example FT1.1
HarmfulEffect: Factory Fire
DirectFactor 1: Fuel
SupplyFactors
Affecting NMLT of FS
DirectFactor 2: Oxygen
supplyFactors
Affecting NMLT of OS
DirectFactor 3: Ignition
Factors Affecting NMLT of Ignition
DirectFactor 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.
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Factor Tree Example FT1.4
DirectFactor 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.
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Factor Tree Example FT2
HarmfulEffect: Radiation DoseDirect
Factor 1: Source
Strength
DirectFactor 2: Time
of Exposure
DirectFactor 3:
Distance to Source
DirectFactor 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.
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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
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Flash Card Back
•DIRECT FACTORS
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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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
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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
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One Level Factor Tree Exercise
Consequence (NMLT) _________________________Direct
Factor 1: ________
_____
DirectFactor 2:
_____________
DirectFactor 3:
__________
DirectFactor 4:
_____________
Add others as needed.
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
Write on or near objects.
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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
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Flash Card Front
Multiple Choice:• Every factor tree branch ends in
A. The Root CauseB. A Root CauseC. A terminal (ending/last) factor D. None of the above
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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Flash Card Back
• Every factor tree branch ends inC. 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
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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
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Generic Factor Building Block (FBB)(Generic Direct Factors)
HarmfulEffect
DirectFactor 1
DirectFactor 2
DirectFactor…
DirectFactor…
DirectFactor…
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.
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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
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Generic Factor Building BlockNotes
• 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
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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
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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
HarmfulHazard
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
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How FBBs make up a Factor Tree
Harmful Effect
FBB1FBB1.1
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
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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
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
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Factor Building Block #1(Four Factor Types-STEM)
HarmfulEffect
DirectSet-up Factors
DirectTriggering
Factors
DirectExacerbating
Factors
DirectMitigating
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
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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
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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
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Factor Building Block Example STEM1(Four Factor Types-STEM)
HarmfulEffect is One House Burned Down
Direct Set-up Factors WereCombustible Construction,
etc.
DirectTriggering
FactorWas
Lightning Strike
DirectExacerbatingFactor Was
Time for Fire Fighters to
Arrive
DirectMitigating
FactorWas
Distance to Other
Combustibles
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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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
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Factor Building Block Example STEM2(Four Factor Types-STEM)
HarmfulEffect is 1/3
Core Overheated(TMI)Direct Set-up
Factors areDecay Heatand Other
Core Conditions
DirectTriggering
FactorWas
Interruption of Injection
DirectExacerbatingFactor was
Time toDiagnose
DirectMitigating
FactorWas
RestorationOf Injection
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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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 Inoperabl
e
Damage Undiscovered for DD
More Days
Damage Discovere
d
Pump Restored
to Operabilit
y
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
Set-up
Trigger ExacerbationMitigation
MitigationExacerbation
Exacerbation
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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
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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
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Flash Card Back
•Consequence(s) /harmful effect(s)
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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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
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STEM FBB Exercise
Factor_________________________Direct
Factor(s) S: ___________
__
DirectFactor(s) T:
_____________
DirectFactor(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
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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
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
Factor Building Block #2(Attributes of Consequence-NMLT)
HarmfulEffectDirect
Factors Affecting Nature
DirectFactors
Affecting Magnitude
DirectFactors
Affecting Location
DirectFactors
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
67
Factor Building Block Example NMLT1(Attributes of Consequence-NMLT)
HarmfulEffect: Glass Shards and Wine on Floor
DirectFactors
Affecting Nature:
Fragility of Bottle,
Hardness of floor, etc.
DirectFactors
Affecting Magnitude:
Size of Bottle , Amount of Contents
DirectFactors
Affecting Location:
Location of Fumbler
DirectFactors
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
68
Factor Building Block Example NMLT2(Attributes of Consequence-NMLT)
HarmfulEffect: 856 DeathsDirect
Factors Affecting Nature:
Collision of Two 747s
DirectFactors
Affecting Magnitude: # of Occupants,
etc.
DirectFactors
Affecting Location:
Location of Stationary
747
DirectFactors
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
69
Factor Building Block Example NMLT3(Attributes of Consequence-NMLT)
HarmfulEffect: HPCI Inop for DD DaysDirect
Factors Affecting Nature: Internal
Booster Pump Damage
DirectFactors
Affecting Magnitude: Severity of Damage,
Persistence Time
DirectFactors
Affecting Location:
Location of Bearing
DirectFactors
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
70
Factor Building Block Example NMLT3.1(Attributes of Consequence-NMLT)
HarmfulEffect: HPCI Inop for DD Days
DirectFactors Affecting Nature: Internal Booster Pump
Damage
Deeper FBBs
DirectFactors Affecting
Magnitude: Severity of Damage,
Persistence TimeDeeper FBBs
DirectFactors Affecting Location: Location
of Bearing
Deeper FBBs
DirectFactors 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
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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
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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
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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
74
NMLT FBB Exercise
Factor_________________________Direct
Factor(s) of N: ___________
__
DirectFactor(s) of
M: ___________
__
DirectFactor(s) of L: __________
DirectFactor(s) of T: _____________
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
Write on or near objects. From Previous Exercise
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
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
Barrier
THE BASICS OF BARRIER ANALYSIS
THREAT/ HAZARDTARGET
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
78
Factor Building Block #3(Barrier Analysis Elements-THCSLL)
HarmfulEffect
Vulnerable
Item (Target)
Hazard That
CouldHarm Target
Co-location
of Target
and Hazard
Simultaneityof Target
and Hazard
Lack of EffectiveBarrier
Between Targetand 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
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
80
Flash Card Back
•Not
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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
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
83
Flash Card Back
•Worse
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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
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
86
Factor Building Block Example THCSLL1(Barrier Analysis Elements-THCSLL)
HarmfulEffect was
Was Interruption of Injection for Some HoursVulnerable
Item (Target)
Was Injectio
nFlow
Hazard That
CouldHarm Target
was Operato
rAction
Co-location
of Target
and Hazard
was Operato
rAccess
toControls
They were there at the same time.
Lack of EffectiveBarrier
Between Targetand Hazard
Next Shift Restored Injection
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
87
Factor Building Block Example THCSLL2(Barrier Analysis Elements-THCSLL)
HarmfulEffect was
Was Bearing BackwardsVulnera
bleItem
(Target)Was
Bearing Would go in
Backwards
Hazard That
CouldHarm Target
was Worker
Error
Co-location
of Target
and Hazard
was WorkerAccess
toPump
They were there at the same time.
Lack of EffectiveBarrier
Between Targetand Hazard
There was only one
pump involved
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
88
Factor Building Block Example THCSLL2.1(Barrier Analysis Elements-THCSLL)
HarmfulEffect was
Was Lack of BarrierVulnerable
Item (Target)
Was Barrier Control
Hazard That
CouldHarm Target
was No Requirement for Barriers
Co-location
of Target
and Hazard
was Work
Control Informal
ity
They were
there at the
same time.
Lack of EffectiveBarrier
Between Targetand Hazard (Ineffective Oversight)
Other Items not Involved
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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
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
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
Simultaneity
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.)©
201
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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
93
Flash Card Back
•Missing or ineffective
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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
95
Flash Card Back
•Worse
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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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
97
THCSLL FBB Exercise
Factor_________________________Direct
Factor(s) related
to T: _______
_____
DirectFactor(s) related
to H: _______
___
DirectFactor(s) related
to S: _______
__
DirectFactor(s) related to C: _____________
DirectFactor(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
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
Factor Building Block #4(Existence of Effect: [CP])
Creation & Persistence
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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
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
101
Factor Building Block #4(Existence of Effect: Creation & Persistence [CP])
HarmfulEffect
DirectFactors
of Creation
Direct Factors
of Persistence
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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Factor Building Block Example CP1.0(Existence of Effect: Creation & Persistence [CP])
HarmfulEffect : Bearing Backward 1.0DirectFactors
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
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
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Flash Card Back
•Created, persisted
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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Factor Building Block Example CP1.1(Existence of Effect: Creation & Persistence [CP])
HarmfulEffect : 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
106
Factor Building Block Example CP1.1(Existence of Effect: Creation & Persistence [CP])
HarmfulEffect : Bearing Backwards 2011 (1.0)
Worker Installed the Bearing Backward in 2005 (1.1)Pump
designed
such that
bearing can go in
backwards 1.1.1Deeper FBB
s
Ineffective traini
ng 1.1.2
Deeper FBB
s
Insufficient
experience 1.1.3
Deeper FBB
s
Ineffective supervision 1.1.4
Deeper FBB
s
Ineffective
use of instructions
, procedures, drawi
ngs 1.1.5Deeper FBB
s
Bearing Left Backwards Until 2011 (1.2)
Deeper FBBs
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
107
Factor Building Block Example CP1.2(Existence of Effect: Creation & Persistence [CP])
HarmfulEffect : 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
108
Factor Building Block Example CP1.2(Existence of Effect: Creation & Persistence [CP])
HarmfulEffect : 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 reve
al erro
r 1.2.
1
Deeper FBBs
Pump
runs with bearing backwards
1.2.2
Deeper FBBs
Lube oil
samplin
g not don
e 1.2.
3Deeper FBBs
Vibratio
n monitoring not
effective 1.2.
4
Deeper FBBs
Damage
insufficient to caus
e seve
re failu
re 1.2.
5
Deeper FBBs
Damage
insufficient to caus
e seve
re vibratio
n until 201
1 (1.2.
6)
Deeper FBBs
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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
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
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
112
Flash Card Back
•True
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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
114
Flash Card Back
•True
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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
116
CP FBB Exercise
Factor_________________________
DirectFactor(s) related to Creation:
_____________
DirectFactor(s) related to Persistence:
_____________
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
Write on or near objects. From Previous Exercise
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
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
5
119
Factor Building Block #5(Rollup/Breakdown-RB)
Greater HarmfulEffect
Lesser HarmfulEffect
Lesser HarmfulEffect
Lesser HarmfulEffect
Lesser HarmfulEffect
Lesser HarmfulEffect
Greater effects can result from lesser effects.
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
120
Factor Building Block #5 Example RB1.0(Rollup/Breakdown-RB)
Greater HarmfulEffect: No Effective Barrier
No Effective Work
Control BarrierDeeper
FBBs
No Effective Supervision
BarrierDeeper
FBBs
No Effective Procedural
BarrierDeeper
FBBs
No Effective Experience
BarrierDeeper
FBBs
No Effective Training BarrierDeeper
FBBs
Greater effects can result from lesser effects.
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
121
Factor Building Block #5 Example RB2.0(Rollup/Breakdown-RB)
Greater HarmfulEffect: No Effective Barrier
No Effective Barrier to Encourage
Appropriateness
Deeper FBBs
No Effective Barrier to
Discourage Inappropriatene
ssDeeper
FBBs
No Effective Barrier to Prevent
Inappropriateness
Deeper FBBs
No Effective Barrier to
Detect Inappropriatene
ssDeeper
FBBs
No Effective Barrier to
Compensate for Inappropriatene
ssDeeper
FBBs
When there is no effective barrier these aremissing or defective.
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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
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
124
Flash Card Back
•Five (5)!
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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.
126
Factor Building Block ExerciseRollup/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
127
RB FBB Exercise
Factor_________________________Compone
nt 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
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
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
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
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
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
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
Frequently Asked Questions
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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
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
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
138138
Behavior orCondition
Make the EventHappen?
Make theConsequences
Worse?No
Is a Cause
Yes Yes
Is Something ElseNeeded to Explain
the Cause or Consequence?
ContributingCause Cause is
Self-sufficient
YES
NO
Is not a CauseNo
© 2014, William R. Corcoran,
139139
Behavior orCondition
Make the EventHappen?
Make theConsequences
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?
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
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 effect2. 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
142
What about Extent? (3)
The What Else Besides X can be:1. The same item (X) existing
a. At a different timeb. In a different place
2. A similar item (Ξ)existing a. At a different timeb. In a different place
3. A factor affecting X4. 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” .
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
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
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 Magnitu
dinal 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
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
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
148
Roofing NailsIn Driveway
Nails inTires
Roofer ForeignMaterial Management
Roofing NailsIn Other Places
Other ForeignMaterial Problems
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
149149
Termite in Garage
Wood StructureDamage
Termite HabitatNearby
TermitesIn Other Places
Other Wood-eating
Insects
© 2014, William R. Corcoran,
150
Problem ThatGot Noticed
DownstreamImpact
UpstreamCausation
More of the Same Item
More of the SameClass of Issue
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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
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
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
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
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The Tree of (Non)Compliance 1.0
Harmful Effect that Compliance Should Prevent (1.0)
And/OrNoncompliance 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
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
157
Flash Card Back
•Noncompliance
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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
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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
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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
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
HPCI Inoperable for DD Days(A case study using Factor Building Blocks
[FBBs])
For Training OnlyW. R. Corcoran, Ph.D., P.E.
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
DD
IS AB
OU
T 68
CONTAINS NO
INFO IDENTIFYING
INVOLVED PLANT
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
164
Generic Factor Tree with FBBs
Harmful Effect
FBB1FBB1.1
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
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 Inoperabl
e
Damage Undiscovered for DD
More Days
Damage Discovere
d
Pump Restored
to Operabilit
y
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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
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
168
Comparative TimeLine© [HPCI Inop for DD Days] Sheet n of N
When What(Actual) What(Should) Result of Δ Impact and Notes
Template for CTL Slides
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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
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
TriggerUpstream 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 ECAQCrit V (2)
2005 VTM not used Should have used VTM
None: It would not have helped
Separate ECAQCrit V (1)
2005 or before Defective VTM accepted for use
Defective VTM should have been rejected.
Defective VTM in document system
Separate ECAQCrit XVI (1)
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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
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
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 TriggerBegins 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
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
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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
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
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
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
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
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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 BPDamage.
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
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
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 Inoperabl
e
Damage Undiscovered for DD
More Days
Damage Discovere
d
Pump Restored
to Operabilit
y
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
Set-up
Trigger ExacerbationMitigation
MitigationExacerbation
Exacerbation
183
Factor Building Block Example NMLT3(Attributes of Consequence-NMLT)
HarmfulEffect: HPCI Inop for DD DaysDirect
Factors Affecting Nature: Internal
Booster Pump Damage
DirectFactors
Affecting Magnitude: Severity of Damage,
Persistence Time
DirectFactors
Affecting Location:
Location of Bearing
DirectFactors
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
184
Factor Building Block Example NMLT3.1(Attributes of Consequence-NMLT)
HarmfulEffect: HPCI Inop for DD Days
DirectFactors Affecting Nature: Internal Booster Pump
Damage
Deeper FBBs
DirectFactors Affecting
Magnitude: Severity of Damage,
Persistence TimeDeeper FBBs
DirectFactors Affecting Location: Location
of Bearing
Deeper FBBs
DirectFactors 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
185
Factor Building Block Example THCSLL2(Barrier Analysis Elements-THCSLL)
HarmfulEffect was
Was Bearing BackwardsVulnera
bleItem
(Target)Was
Bearing Would go in
Backwards
Hazard That
CouldHarm Target
was Worker
Error
Co-location
of Target
and Hazard
was WorkerAccess
toPump
They were there at the same time.
Lack of EffectiveBarrier
Between Targetand Hazard
There was only one
pump involved
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
186
Factor Building Block Example THCSL2.1(Barrier Analysis Elements-THCSL)
HarmfulEffect was
Was Lack of BarrierVulnerable
Item (Target)
Was Barrier Control
Hazard That
CouldHarm Target
was No Requirement for Barriers
Co-location
of Target
and Hazard
was Work
Control Informal
ity
They were
there at the
same time.
Lack of EffectiveBarrier
Between Targetand Hazard (Ineffective Oversight)
Limiting Barrier was no worse
challenges
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
187
Factor Building Block Example CP1(Existence of Effect: Creation & Persistence [CP])
HarmfulEffect : Bearing BackwardDirect
Factorsof 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
188
Factor Building Block Example CP2(Existence of Effect: Creation & Persistence [CP])
HarmfulEffect : 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
189
Factor Building Block Example CP2.1(Existence of Effect: Creation & Persistence [CP])
HarmfulEffect : Bearing Backwards 2011
Worker Installed the Bearing Backward in 2005Pump design
ed such that
bearing can go in
backwardsDeeper FBB
s
Ineffective traini
ng
Deeper FBB
s
Insufficient
experience
Deeper FBB
s
Ineffective supervision
Deeper FBB
s
Ineffective
use of instructions
, procedures, drawi
ngsDeeper FBB
s
Bearing Left Backwards Until 2011
Deeper FBBs
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
190
Factor Building Block Example CP3(Existence of Effect: Creation & Persistence [CP])
HarmfulEffect : 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
191
Factor Building Block Example CP3.1(Existence of Effect: Creation & Persistence [CP])
HarmfulEffect : Bearing Backwards 2011
Worker Installed the Bearing Backward in 2005
Deeper FBBs
Bearing Left Backwards Until 2011Reco
rd reviews do not reve
al erro
rDeeper FBBs
Pump
runs with bearing backwardsDeeper FBBs
Lube oil
samplin
g not don
eDeeper FBBs
Vibratio
n monitoring not
effectiveDeeper FBBs
Damage
insufficient to caus
e seve
re failu
re
Deeper FBBs
Damage
insufficient to caus
e seve
re vibratio
n until 201
1
Deeper FBBs
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
192
Factor Building Block #5(Rollup/Breakdown-RB)
Greater HarmfulEffect
Lesser HarmfulEffect
Lesser HarmfulEffect
Lesser HarmfulEffect
Lesser HarmfulEffect
Lesser HarmfulEffect
Greater effects can result from lesser effects.
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
193
Factor Building Block #5 Example RB1.0(Rollup/Breakdown-RB)
Greater HarmfulEffect: No Effective Barrier
No Effective Work
Control BarrierDeeper
FBBs
No Effective Supervision
BarrierDeeper
FBBs
No Effective Procedural
BarrierDeeper
FBBs
No Effective Experience
BarrierDeeper
FBBs
No Effective Training BarrierDeeper
FBBs
Greater effects can result from lesser effects.
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
194
Factor Tree Example 1.0(Begins with-STEM)
HPCI Inoperable for DD Days 1.0
Bearing can go in
Backwards 1.1
See Exampl
e 1.1
Worker put
Bearing in Backwards
1.2
See exampl
e 1.2
Bearing Damages
Pump While
Operating 1.3
See Exampl
e 1.3
Damage Undiscovered Until
Pump Inoperabl
e 1.4
See Exampl
e 1.4
Damage Undiscovered for DD
More Days 1.5
See Exampl
e 1.5
Damage Discovere
d 1.6
See exampl
e 1.6
Pump Restored
to Operabilit
y 1.7
See exampl
e 1.7
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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
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
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
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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 Supervisor
y Intervention 1.2.7
See Example 1.2.7
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
Orientations1. Tandem (Left)2. Tandem (right)3. Back-to-back4. Front-to-front
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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Missed Opportunity Matrix (MOM) [HPCI Inop for DD Days] Sheet n of N
Who Situation Opportunity Expected Result
Impact and Notes
Template for MOM Slides
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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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
R/R=Restart/
Recovery
211
Barrier Analysis Matrix (BAM) [HPCI Inop for DD Days] Sheet n of N
Barrier Target Protected
Threat Effectiveness in this case
Significance
Template for BAM Slides
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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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
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FACTOR-CONSEQUENCE MATRIX 1.0FACTOR Actual
CaseCase 1
Can’t go in wrong
Case 2 Right Guess
Case 3Effective 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
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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
Template for PFM Slides
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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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
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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
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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
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Problem ThatGot Noticed
DownstreamImpact
UpstreamCausation
More of the Same Item
More of the SameClass of Issue
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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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
Template for CAM Slides
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu
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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
End of Case Study
Comments? Questions?
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Thanks for Your Participation
• Questions?• Comments?• Differing Professional Opinions?• Next Steps for Your Organization?
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Questions?
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