Five types of factor building blocks with case study 2014.05.05.0730

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

Notices
• This is part of The Phoenix Approach©.
• It also applies to all other approaches to issue
investigation (root cause analysis).
• If your organization is licensed to use The Phoenix
Approach© you may use this in accordance with the
license.
• If your organization is not licensed to use The
Phoenix Approach© please call for permission. In the
meanwhile you have permission to give this seminar
once in-house, if you send me the workshop
comments.
© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu 2

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

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.

• 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.

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.

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.

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.

Causal Factor Analysis (Root Cause Analysis) Report Production/ Evaluation
Corrective
Actions
Extent of Conditions &
Causes
Factors Extraneous CAQs
Lessons-To-
Be-Learned
Consequences
Evidence
(data)
© Drs. William Corcoran and Richard Hartley 8-21-07
Event
Recognition
Investigation
(collect & organize
evidence (data ))
Culture
Insight
Convert Evidence (data) to
Information
Significance
Characterization
Human
Behavior
Technology
Use Appropriate
RCA Tools
Lines of
Inquiry
The
Fixes
To Be
Fixed
To Be
Prevented
9

Corrective Action Must Relate to
Consequence Through Factor
Corrective Action
Factor
Consequence
What factor does it address?
What consequence did it affect?
10

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!)

Flash Card Front
• For confidence in the fixes, the items fixed
must explain the _________.

Flash Card Back
•Effect(s) to be prevented,
ie., the consequences.

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.

Affect/Effect Hint
1. Use
“affect” only
as a verb.
2. Use
“effect” only
as a noun.

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.

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.

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.

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

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.

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?

Direct Factor Exercise
Pattern of Paper Discs (NMLT)
_________________________
Direct
Factor 1:
_____________
Direct
Factor 2:
_____________
Direct
Factor 3:
__________
Direct
Factor 4:
_____________
Add others as
needed.
Write on or near objects.
23

Direct Factor Exercise
Potential Answer #1
Pattern of Paper Discs (NMLT)
_________________________
Direct
Factor 1: Number
of Discs
Direct
Factor 2: Height
of Drop
Direct
Factor 3: Air
Movement
Direct
Factor 4:
Stickiness
of Discs

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

Factors and Effects
Effect
Factor / Effect
Factor / Effect Factor / Effect
Factor / Effect
Factor / Effect
Factor / Effect
Factor / Effect
Factor / Effect
An effect is the result of factors, which in turn are the
effects that resulted from deeper factors……. (it ends
when we decide to stop)
26

Flash Card Front
• In Factor Trees (and Factor Building Blocks) the
factors connected directly below an effect are
always _________ factors of the effect.

Flash Card Back
•DIRECT

Block and Tree Legend
Effect
Direct Factor Direct Factor Direct Factor
The connecting lines always mean that the upper item
is/was a result of the lower connected items.
29

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.

Factor Tree Example FT1
Harmful
Effect: Factory Fire
Direct
Factor 1: Fuel
Supply
Direct
Factor 2: Oxygen
supply
Direct
Factor 3: Ignition
Direct
Factor
4:Suppression
All Factor Trees are like this.
The direct factors of an effect will explain the nature, the
magnitude, the location, and the timing of the effect.
31

Factor Tree Example FT1.1
Harmful
Effect: Factory Fire
Direct
Factor 1: Fuel Supply
Factors
Affecting NMLT
of FS
Direct
Factor 2: Oxygen supply
Factors
Affecting NMLT
of OS
Direct
Factor 3: Ignition
Factors
Affecting NMLT
of Ignition
Direct
Factor 4:Suppression
Factors
Affecting NMLT
of suppression
magnitude, the location, and the timing (NMLT) of the effect.
32

Factor Tree Example FT1.4
Direct
Factor 4:Suppression
NMLT of Installed
Suppression Systems
Performance
Deeper Factors
NMLT of External Fire
Company
Performance
Deeper Factors
magnitude, the location, and the timing (NMLT) of the effect.
33

Factor Tree Example FT2
Harmful
Effect: Radiation
Dose
Direct
Factor 1: Source
Strength
Direct
Factor 2: Time of
Exposure
Direct
Factor 3: Distance
to Source
Direct
Factor 4:Shielding
34

Flash Card Front
• The nature, the magnitude, the location, and
the timing of an effect are explained by the
_________ of the effect.

Flash Card Back
•DIRECT FACTORS

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

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

One Level Factor Tree Exercise
Consequence (NMLT)
_________________________
Direct
Factor 1:
_____________
Direct
Factor 2:
_____________
Direct
Factor 3:
__________
Direct
Factor 4:
_____________
Add others as
needed.
Write on or near objects.
39

Stopping Fact
• All factor tree branches must stop somewhere.
• There is a stopping decision on each branch.
• We’re not addressing that now.
40

Flash Card Front
Multiple Choice:
• Every factor tree branch ends in
A. The Root Cause
B. A Root Cause
C. A terminal (ending/last) factor
D. None of the above

Flash Card Back
• Every factor tree branch
ends in
C. A terminal (ending/last)
factor (But some terminal
factors can be “root
causes.”)

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.

Generic Factor Building Block (FBB)
(Generic Direct Factors)
Harmful
Effect
Direct
Factor 1
Direct
Factor 2
Direct
Factor…
Direct
Factor…
Direct
Factor…
All Factor Building Blocks are like this.
44

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”

Generic Factor Building Block
Notes
• A harmful effect can be
– A “consequence” (harmful outcome, harmful
effect)
– A factor of a harmful outcome
• There is no upper limit on the number of
direct factors. (There are seldom more than
eight.)

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.
47

What About an Effect Needs
Explaining?
Perspective Needs
Explaining
Needs
Explaining
Needs
Explaining
Needs
Explaining
Needs
Explaining
Needs
Explaining
1. Factor
Involvement
Set-up Trigger Exacerbation Mitigation
2. Key Attributes Nature Magnitude Location Timing
3. Barrier
Analysis
Elements
Vulnerable
Target
Harmful
Hazard
Co-location Simultaneity Lack of
Effective
Barrier
Limiting
Barrier
4. Existence Creation Persistence
5. Rollup/
Breakdown
Constituent
Items
48

How FBBs make up a Factor Tree
Harmful Effect
FBB1
FBB1.1
FBB 1.1.1
FBB 1.1.3
FBB1.2 FBB1…..
FBB2
FBB2.1
FBB2.2
FBB2...
FBB… FBB… FBB…
FBB=Factor Building Block
49

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.

Factor Building Block #1
(Four Factor Types-STEM)
Set-up: Trigger: Exacerbation:
Mitigation

Harmful
Effect
Direct
Set-up
Factors
Direct
Triggering
Factors
Direct
Exacerbating
Factors
Direct
Mitigating
Factors
The direct factors will explain the nature, the

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.

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.

Factor Building Block Example STEM1
Harmful
Effect is One
House Burned
Down
Direct Set-up
Factors Were
Combustible
Construction, etc.
Direct
Triggering
Factor
Was Lightning
Strike
Direct
Exacerbating
Factor Was
Time for Fire Fighters
to Arrive
Direct
Mitigating
Factor
Was
Distance to Other
Combustibles

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.

Harmful
Effect is 1/3
Core Overheated
(TMI)
Direct Set-up
Factors are
Decay Heat
and Other
Core Conditions
Direct
Triggering
Factor
Was Interruption
of Injection
Direct
Exacerbating
Factor was
Time to
Diagnose
Direct
Mitigating
Factor
Was
Restoration
Of Injection

HPCI Inoperable for DD Days
Bearing can go
in Backwards
Worker put
Bearing in
Backwards
Bearing Damages
Pump While
Operating
Damage
Undiscovered
Until Pump
Inoperable
Damage
Undiscovered
for DD More
Days
Damage
Discovered Pump Restored
to Operability
Set-
up
Trigger Exacerbation
Mitigation
Mitigation
Exacerbation
Exacerbation
58

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
59

Flash Card Front
• A Factors-consequences Matrix shows how a
change in a factor results in a change in the
_________.

Flash Card Back
•Consequence(s)
/harmful effect(s)

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:
– Weak Car Battery

STEM FBB Exercise
Factor
_________________________
Direct
Factor(s) S:
_____________
Direct
Factor(s) T:
_____________
Direct
Factor(s) E:
__________
Direct
Factor(s) M:
_____________
Write on or near objects. From Previous
Exercise
63

The STEM FBB is good for
• All types of consequences
• All types of factors

(Attributes of Consequence-
NMLT)
Nature: Magnitude: Location: Timing

(Attributes of Consequence-NMLT)
Harmful
Effect
Direct
Factors Affecting
Nature
Direct
Factors Affecting
Magnitude
Direct
Factors Affecting
Location
Direct
Factors Affecting
Timing

Factor Building Block Example NMLT1
Harmful
Effect: Glass Shards and Wine
on Floor
Direct
Factors Affecting
Nature: Fragility of
Bottle, Hardness
of floor, etc.
Direct
Factors Affecting
Magnitude: Size of
Bottle , Amount of
Contents
Direct
Factors Affecting
Location: Location
of Fumbler
Direct
Factors Affecting
Timing: Time of
Being Startled, etc.

Harmful
Effect: 856 Deaths
Direct
Factors Affecting
Nature: Collision
of Two 747s
Direct
Factors Affecting
Magnitude: # of
Occupants, etc.
Direct
Factors Affecting
Location: Location
of Stationary 747
Direct
Factors Affecting
Timing: Time of
Other 747 Takeoff,
etc.

Harmful
Effect: HPCI Inop for DD Days
Direct
Factors Affecting
Nature: Internal
Booster Pump
Damage
Direct
Factors Affecting
Magnitude:
Severity of
Damage,
Persistence Time
Direct
Factors Affecting
Location: Location
of Bearing
Direct
Factors Affecting
Timing: Times of
Error, Damage,
Discovery,
Restoration.

Factor Building Block Example NMLT3.1
Harmful
Direct
Factors Affecting
Nature: Internal
Booster Pump
Damage
Deeper FBBs
Direct
Factors Affecting
Magnitude:
Severity of
Damage,
Persistence Time
Deeper FBBs
Direct
Factors Affecting
Location: Location
of Bearing
Deeper FBBs
Direct
Factors Affecting
Timing: Times of
Error, Damage,
Discovery,
Restoration.
Deeper FBBs

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
71

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.)

-NMLT
choosing:

NMLT FBB Exercise
Factor
_________________________
Direct
Factor(s) of N:
_____________
Direct
Factor(s) of M:
_____________
Direct
Factor(s) of L:
__________
Direct
Factor(s) of T:
_____________
Exercise
74

The NMLT FBB is good for

(Barrier Analysis Elements-
THCSLL)
Target: Hazard: Co-location:
Simultaneity: Lack of (Effective)
Barrier: Limiting Barrier

Barrier
THE BASICS OF BARRIER ANALYSIS
THREAT/ HAZARD
TARGET
BARRIER:
Anything that has the effect of (or is intended to) reduce the
probability and/or consequences of the effect of a threat on a
target.
© 2014 W. R. Corcoran, William.R.Corcoran@1959.USNA.com 77

(Barrier Analysis Elements-THCSLL)
Harmful
Effect
Vulnerable
Item
(Target)
Hazard
That Could
Harm Target
Co-location
of Target
and Hazard
Simultaneity
of Target
and Hazard
Lack of Effective
Barrier
Between Target
and Hazard
Barrier That
Limits the
Harm

Flash Card Front
• If there had been an effective barrier the
target would _________ have been harmed as
it was.

Flash Card Back
•Not

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.

Flash Card Front
• If there had not been an effective barrier that
limited the harm the harm would have been
_________ it was.

Flash Card Back
•Worse

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.

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!!

Factor Building Block Example THCSLL1
Harmful
Effect was
Was Interruption of
Injection for Some
Hours
Vulnerable
Item
(Target)
Was
Injection
Flow
Hazard
That Could
Harm Target
was
Operator
Action
Co-location
of Target
and Hazard
was
Operator
Access to
Controls
They were
there at the
same time.
Lack of
Effective
Barrier
Between
Target
and Hazard
Next Shift
Restored
Injection

Harmful
Effect was
Was Bearing
Backwards
Vulnerable
Item
(Target)
Was
Bearing
Would go in
Backwards
Hazard
That Could
Harm Target
was Worker
Error
Co-location
of Target
and Hazard
was Worker
Access to
Pump
They were
there at the
same time.
Lack of
Effective
Barrier
Between
Target
and Hazard
There was
only one
pump involved

Factor Building Block Example THCSLL2.1
Harmful
Effect was
Was Lack of Barrier
Vulnerable
Item
(Target)
Was Barrier
Control
Hazard
That Could
Harm Target
was No
Requiremen
t for Barriers
Co-location
of Target
and Hazard
was Work
Control
Informality
They were
there at the
same time.
Lack of Effective
Barrier
Between Target
and Hazard
(Ineffective
Oversight)
Other Items
not
Involved

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

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
90

Direct Factors Matrix of Barrier Analysis and Factor Type
(THCSLL)
(This applies to harmful factors as well as harmful consequences.)
[Example for TMI-2 Accident: 1/3 Core Melt]
Every harmful EFFECT is the resultant of a hazard, a vulnerable target, co-location, simultaneity, lack of an effective
barrier to the harm, and an effective barrier that limited the harm..
Hazard Target Co-
location
Simultan
eity
Lacking
Barrier
Limiting
Barrier
Every
harmful
EFFECT is
the resultant
of factors
that resulted
in its nature,
its
magnitude/
intensity, its
location, and
its timing,
including set-
up,
triggering,
exacerbation,
and
mitigation.
(Set-up) Decay Heat Ceramic
pellet and Zr
clad
Decay heat
within fuel
Decay heat
within fuel
Trigger
(Initiator)
Interruption
of Cooling
Exacerba-
tion
Magnitude of
decay heat
Properties of
pellet and
clad
How long
the cooling
was off
Mitigation . . Cooling
Restored
when it was
(next shift)
Every harmful EFFECT will have at least one direct factor in each column and at least one in each row. (This applies
to harmful factors as well as harmful consequences.)
©2014,WilliamR.Corcoran,860-285-8779,firebird.one@alum.mit.edu
91

Flash Card Front
• If a worker is injured you know that all of the
barriers to that exact injury were _________
or _______.

Flash Card Back
•Missing or ineffective

Flash Card Front
• If a worker is injured you know that some
barrier(s) limited the exact injury so it wasn’t
even _________ .

Flash Card Back
•Worse

-THCSLL
choosing:

THCSLL FBB Exercise
Factor
_________________________
Direct
Factor(s)
related to T:
____________
Direct
Factor(s)
related to H:
__________
Direct
Factor(s)
related to
S:
_________
Direct
Factor(s) related
to C:
_____________
Direct
Factor(s) related
to L:
_____________
Direct
Factor(s)
related to
Limiting
Barrier
__________
Exercise
97

The THCSLL FBB is good for

(Existence of Effect: [CP])
Creation & Persistence

Existence
• If something existed at a given time
– It must have been created and
– It must have persisted up to that time.
• Examples
– Apollo XIII-Defective O2 Tank wiring
– Columbia-Damaged wing tile
– Challenger-Hardened O-ring
– Davis-Besse-Crack in CRDM nozzle
100© 2014, William R. Corcoran, 860-285-8779, firebird.one@alum.mit.edu

(Existence of Effect: Creation &
Persistence [CP])
Harmful
Effect
Direct
Factors
of Creation
Direct
Factors
of Persistence

Factor Building Block Example CP1.0
(Existence of Effect: Creation & Persistence [CP])
Harmful
Effect : Bearing Backward 1.0
Direct
Factors
of Creation : Worker Installed
the Bearing Backward 1.1
Direct
Factors
of Persistence: Not
noticed, effects not
addressed, etc. 1.2

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.

Flash Card Back
•Created, persisted

Harmful
Effect : Bearing Backwards 2011 (1.0)
Worker Installed the Bearing Backward
in 2005 (1.1)
Pump designed such that
bearing can go in backwards
1.1.1
Ineffective training 1.1.2
Insufficient experience 1.1.3
Ineffective supervision
1.1.4
Ineffective use of instructions,
procedures, drawings 1.1.5
Bearing Left Backwards Until 2011 (1.2)
Deeper FBBs

Harmful
Worker Installed the
Bearing Backward in 2005
(1.1)
Pump designed
such that bearing
can go in backwards
1.1.1
Deeper
FBBs
Ineffective training
1.1.2
Deeper
FBBs
Insufficient
experience 1.1.3
Deeper
FBBs
Ineffective
supervision 1.1.4
Deeper
FBBs
Ineffective use of
instructions,
procedures,
drawings 1.1.5
Deeper
FBBs
Bearing Left Backwards Until
2011 (1.2)
Deeper
FBBs

Harmful
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)

Harmful
Effect : Bearing
Backwards 2011
(1.0)
Worker Installed
the Bearing
Backward in 2005
(1.1)
Deeper FBBs
Bearing Left Backwards
Until 2011 (1.2)
Record reviews do
not reveal error
1.2.1
Deeper
FBBs
Pump runs with
bearing backwards
1.2.2
Deeper
FBBs
Lube oil sampling
not done 1.2.3
Deeper FBBs
Vibration
monitoring not
effective 1.2.4
Deeper FBBs
Damage
insufficient to
cause severe
failure 1.2.5
Deeper
FBBs
Damage
insufficient to
cause severe
vibration until
2011 (1.2.6)
Deeper FBBs

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
109

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.)

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?

Flash Card Back
•True

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?

Flash Card Back
•True

-CP
choosing:

CP FBB Exercise
Factor
_________________________
Direct
Factor(s) related to
Creation:
_____________
Direct
Factor(s) related
to Persistence:
_____________
Exercise
116

The CP FBB is good for

(Rollup/Breakdown-RB)
Greater effects can result from lesser
effects.

Greater Harmful
Effect
Lesser
Harmful
Effect
Lesser
Harmful
Effect
Lesser
Harmful
Effect
Lesser
Harmful
Effect
Lesser
Harmful
Effect
Greater effects can result from lesser effects.

Factor Building Block #5 Example RB1.0
Greater Harmful
Effect: No Effective Barrier
No Effective
Work Control
Barrier
Deeper FBBs
No Effective
Supervision
Barrier
Deeper FBBs
No Effective
Procedural
Barrier
Deeper FBBs
No Effective
Experience
Barrier
Deeper FBBs
No Effective
Training
Barrier
Deeper FBBs

Greater Harmful
No Effective
Barrier to
Encourage
Appropriateness
Deeper FBBs
No Effective Barrier
to Discourage
Inappropriateness
Deeper FBBs
to Prevent
Inappropriateness
Deeper FBBs
to Detect
Inappropriateness
Deeper FBBs
to Compensate for
Inappropriateness
Deeper FBBs
When there is no effective barrier these are
missing or defective.

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.

Flash Card Front
• Whenever there is no effective barrier you
know that in concept that all ____ types of
barriers were missing or defective.

Flash Card Back
•Five (5)!

(Rollup/Breakdown-RB) Notes
• A formula for investigation team trouble is to
attempt to explain a greater effect without
first explaining the lesser effects.
• Sometimes the factors that resulted in various
lesser effects are similar, if not identical.
125

Rollup/Breakdown-RB
choosing:
– Project Delay

RB FBB Exercise
Factor
_________________________
Component of
Factor:
_____________
Component of
Factor:
_____________
Component
of Factor:
__________
Component of
Factor:
_____________
Component of
Factor:
_____________
Write on or near objects. Factor amenable to
Rollup/Breakdown
From Previous
Exercise
127

The RB FBB is good for
• Consequences and factors that
– Are aggregations
– Are combinations
– Are divisible into chunks
– Are made up of multiple factors

The RB FBB is NOT good for
• Consequences and factors that
– Are unitary
– Are singular
– Are not aggregations
– Are not divisible into chunks

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.

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?

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.
132

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.
133

Frequently Asked Questions

FAQ Topics
• Root Cause
• Compliance
• Comparative TimeLine©
• Missed Opportunity Matrix
• The Investigation Report
• Glossary
• Corrective Action Matrix
• Extent
• Lines of Inquiry
• Stopping Rules
• Extent
• Charter
• Barrier Analysis Matrix
• Barrier Analysis Flow Chart
135

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.
136

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)?
137

138
Behavior or
Condition
Make the Event
Happen?
Make the
Consequences
Worse?
No
Is a Cause
Yes Yes
Is Something Else
Needed to Explain
the Cause or
Consequence?
Contributing
Cause
Cause is
Self-sufficient
YES
NO
Is not a CauseNo
© 2014, William R. Corcoran, 138

139
Behavior or
Condition
Make the Event
Happen?
Make the
Consequences
Worse?
No
Is a Cause
Yes Yes
Not a Root CauseRoot Cause
YESNO
Is Not a causeNo
© 2014, William R. Corcoran,
Is this cause
due to more
important
[underlying] factors?
139

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.
140

 A credible job on extent must be based on a
credible job on the basic investigation.
 The inferential extent of X is the answer to the
question, “If I see X what else should I expect to
see?”
 The X can be:
1. A harmful effect
2. A harmful factor (condition, behavior, action, or inaction)
3. A beneficial, but fragile, factor
141

 The What Else Besides X can be:
1. The same item (X) existing
a. At a different time
b. In a different place
2. A similar item (Ξ)existing
a. At a different time
b. In a different place
3. A factor affecting X
4. A result of X
Ξ is a Greek letter “Xi”,
a letter similar to the English
letter X. It is pronounced
“zigh” .
142

Systematic Approach to Extent
1. Do a good investigation.
2. Select important conditions, both consequences
and factors.
3. Select important factors, conditions, behaviors,
actions, and inactions.
4. Specify your qualitative/quantitative acceptance
criteria for extent.
5. Select or invent a tool for extent.
6. Determine probable extent.
7. Actually see if the extents are there.
© 2014 W. R. Corcoran, firebird.one@alum.MIT.edu
143

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.

Magnitudinal
Extent of X
(1.1)
Size of X
1.1
Number of
Xs 1.2
Intensity of
X 1.3
Severity of
X 1.4
Persistence
of X 1.5 Other
Magnitudinal
Properties of X
1.6

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 360 Degree Approach
• Is a nice way to comprehend inferential
extent.
• Can be explained in down home common
sense terms.

Roofing Nails
In Driveway
Nails in
Tires
Roofer Foreign
Material Management
Roofing Nails
In Other Places
Other Foreign
Material Problems
148

149
Termite in
Garage
Wood Structure
Damage
Termite Habitat
Nearby
Termites
In Other Places
Other
Wood-eating
Insects
© 2014, William R. Corcoran, 149

Problem That
Got Noticed
Downstream
Impact
Upstream
Causation
More of the
Same Item
More of the Same
Class of Issue
150

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.
151

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.
152

What about Lines of Inquiry(LOIs)?
(3)
• For transparency, the investigation report
should include lists of LOIs including
– LOIs pursued
– LOIs considered and dismissed
153

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.
154

The Tree of (Non)Compliance 1.0
Harmful Effect that Compliance Should Prevent (1.0)
And/Or
Noncompliance with
Requirement(s) (1.1)
See Tree of
(Non)Compliance 1.1
Defective Set of
Requirements(1.2)
See Tree of
(Non)Compliance
1.2
The connectors mean that the upper item is a result
of the lower items. The lower items are factors of the
upper item.

Flash Card Front
• If something happened that requirements
were intended to prevent and the
requirements were OK then there must have
been ______________.

Flash Card Back
•Noncompliance

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
158

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
step done wrong.
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
factor.
Industry Operating
Experience Program
barriers.
Repeat missing and
factor.

What about the Investigation
Report?(1)
The report must be:
• Trustworthy
• Loyal to Principle
• Helpful
• (Reader) Friendly
• Courteous
• Kind to Victims
• Obedient to the Charter
• Cheerful as Appropriate
• Thrifty
• Brave
• Clean
• Reverent
160

The Case Study Begins
Real Life Application of the Principles
and Good Practices

(A case study using Factor Building
Blocks [FBBs])
For Training Only
W. R. Corcoran, Ph.D., P.E.

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.

Generic Factor Tree with FBBs
Harmful Effect
FBB1
FBB1.1
FBB 1.1.1
FBB 1.1.3
FBB1.2 FBB1…..
FBB2
FBB2.1
FBB2.2
FBB2...
FBB… FBB… FBB…
FBB=Factor Building Block
164

Bearing can go
in Backwards
Worker put
Bearing in
Backwards
Bearing Damages
Pump While
Operating
Damage
Undiscovered
Until Pump
Inoperable
Damage
Undiscovered
for DD More
Days
Damage
to Operability

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).

Some Terminology
• QA=Quality Assurance
• QAP=QA Program
• App B=10CFR50,
Appendix B
• VTM=Vendor Tech
Manual
• OE=Operating
Experience
• QC=Quality Control
• HPCI=High Pressure
Coolant Injection
• BP=Booster Pump
• Crit=Criterion, Criteria
• Crit IV (1,2), e.g.=
Sentences 1 and 2 of
Criterion IV
• PO=Purchase Order
167

Comparative TimeLine© [HPCI Inop for DD Days] Sheet 1 of N
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.

Notes
2005 or before HPCI BP needs
rebuild and
impeller mod
OK Work Process
Starts
Trigger
Upstream
issues?
2005 No QAP
required in PO
QAP required
in PO
No App B QA
applied
Crit IV (1, 2)
2005 No App B QA
applied
App B QA
applied
Many harmful
effects
Crit I (2)
2005 or before VTM leaves out
bearing
orientation
VTM specifies
bearing
orientation
None: Not used ECAQ
Crit V (2)
2005 VTM not used Should have
used VTM
None: It would
not have
helped
Separate ECAQ
Crit V (1)
2005 or before Defective VTM
accepted for
use
Defective VTM
should have
been rejected.
Defective VTM
in document
system
Separate ECAQ
Crit XVI (1)

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)

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

Notes
2005 and/or
before
Ineffective use
of OE on
bearing
orientation
Effective use of
OE
Missed
Opportunity
Crit XVI (1)
Programmatic
Issue
2005.03.16 Bearing
installed wrong
Bearing
installed wrong
HPCI BP
nonconforming
Tech Specs?
Crit V(2)
Physical Trigger
Begins NC Time
2005.03.16 Error not found
by QC
Error found by
QC
HPCI BP stays
nonconforming
Crit X (1, 2)
Crit XVI (1)
2005.03.16 Error not found
by Supervision
Error found by
Supervision
HPCI BP stays
nonconforming
Crit XVI (1)
2005.03.16 Orientation of
bearing not
recorded
Orientation of
bearing
recorded
Cannot ID prob
by record
review
Crit VII(2)
Crit XVII (1)

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

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)

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

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?)

Notes
2011.04.28 Temperature
data not taken
Temperature
data taken
ECAQ or
Missed
Opportunity
Crit XVI (1)
Programmatic
Issue (CAQ?)

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)

Notes
2011.07.21
(about)
Lube Oil
Samples Taken
& Analyzed
OK Contamination
reveals BP
Damage.
2011.07.27 Bearing
Replaced
OK Inop Ended About 68 Days
Inop
2012.08.24 and
before
None of the
following
effectively
identify any of
the above QA
weaknesses:
Nuclear
Assurance
Oversight,
NSRB, INPO
All of the
following
effectively
identify most
of the above
QA
weaknesses:
Nuclear
Assurance
Oversight,
NSRB, INPO
QA
Programmatic
breakdown not
identified.
Event allowed
to continue. No
subsequent
learning.
Crit II (9, 10)
Crit XVI (1, 2)
Crit XVIII (1)
180

Notes
2012.08.24 Revised RCAR
Issued
OK Over a year
between event
date and RCAR
issue date.
What’s the
real story?
181

Bearing can go
in Backwards
Worker put
Bearing in
Backwards
Bearing Damages
Pump While
Operating
Damage
Undiscovered
Until Pump
Inoperable
Damage
Undiscovered
for DD More
Days
Damage
to Operability
Set-
up
Trigger Exacerbation
Mitigation
Mitigation
Exacerbation
Exacerbation
182

Harmful
Direct
Factors Affecting
Nature: Internal
Booster Pump
Damage
Direct
Factors Affecting
Magnitude:
Severity of
Damage,
Persistence Time
Direct
Factors Affecting
Location: Location
of Bearing
Direct
Factors Affecting
Timing: Times of
Error, Damage,
Discovery,
Restoration.

Factor Building Block Example NMLT3.1
Harmful
Direct
Factors Affecting
Nature: Internal
Booster Pump
Damage
Deeper FBBs
Direct
Factors Affecting
Magnitude:
Severity of
Damage,
Persistence Time
Deeper FBBs
Direct
Factors Affecting
Location: Location
of Bearing
Deeper FBBs
Direct
Factors Affecting
Timing: Times of
Error, Damage,
Discovery,
Restoration.
Deeper FBBs

Harmful
Effect was
Was Bearing
Backwards
Vulnerable
Item
(Target)
Was
Bearing
Would go in
Backwards
Hazard
That Could
Harm Target
was Worker
Error
Co-location
of Target
and Hazard
was Worker
Access to
Pump
They were
there at the
same time.
Lack of
Effective
Barrier
Between
Target
and Hazard
There was
only one
pump involved

Factor Building Block Example THCSL2.1
(Barrier Analysis Elements-THCSL)
Harmful
Effect was
Was Lack of Barrier
Vulnerable
Item
(Target)
Was
Barrier
Control
Hazard
That Could
Harm Target
was No
Requirement
for Barriers
Co-location
of Target
and Hazard
was Work
Control
Informality
They were
there at
the same
time.
Lack of Effective
Barrier
Between Target
and Hazard
(Ineffective
Oversight)
Limiting Barrier
was no worse
challenges

Factor Building Block Example CP1
(Existence of Effect: Creation & Persistence
[CP])
Harmful
Effect : Bearing
Backward
Direct
Factors
of Creation : Worker
Installed the Bearing
Backward
Direct
Factors
of Persistence: Not
noticed, effects not
addressed, etc.

Harmful
Effect : Bearing Backwards 2011
Worker Installed the Bearing Backward
in 2005
Pump designed such that
bearing can go in backwards
Insufficient experience
Ineffective supervision
Ineffective use of instructions,
procedures, drawings
Deeper FBBs

Harmful
Worker Installed the
Bearing Backward in 2005
Pump designed
such that bearing
can go in backwards
Deeper
FBBs
Deeper
FBBs
Insufficient
experience
Deeper
FBBs
Ineffective
supervision
Deeper
FBBs
Ineffective use of
instructions,
procedures,
drawings
Deeper
FBBs
Bearing Left Backwards Until
2011
Deeper
FBBs

Harmful
Worker Installed the Bearing
Backward in 2005
Deeper FBBs
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

Harmful
Effect : Bearing
Backwards 2011
Worker Installed
the Bearing
Backward in 2005
Deeper FBBs
Bearing Left Backwards
Until 2011
Record reviews do
not reveal error
Deeper
FBBs
Pump runs with
bearing backwards
Deeper
FBBs
Lube oil sampling
not done
Deeper FBBs
Vibration
monitoring not
effective
Deeper FBBs
Damage
insufficient to
cause severe
failure
Deeper
FBBs
Damage
insufficient to
cause severe
vibration until
2011
Deeper FBBs

Greater Harmful
Effect
Lesser
Harmful
Effect
Lesser
Harmful
Effect
Lesser
Harmful
Effect
Lesser
Harmful
Effect
Lesser
Harmful
Effect

Greater Harmful
No Effective
Work Control
Barrier
Deeper FBBs
No Effective
Supervision
Barrier
Deeper FBBs
No Effective
Procedural
Barrier
Deeper FBBs
No Effective
Experience
Barrier
Deeper FBBs
No Effective
Training
Barrier
Deeper FBBs

Factor Tree Example 1.0
(Begins with-STEM)
HPCI Inoperable for DD Days 1.0
Bearing can go in
Backwards 1.1
See Example
1.1
Worker put
Bearing in
Backwards
1.2
See example
1.2
Bearing
Damages Pump
While Operating
1.3
See Example
1.3
Damage
Undiscovered
Until Pump
Inoperable
1.4
See Example
1.4
Damage
Undiscovered
for DD More
Days 1.5
See Example
1.5
Damage
Discovered 1.6
See example
1.6
Pump
Restored to
Operability
1.7
See example
1.7

(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

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

(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

(Begins with-STEM)
Worker put
Bearing in
Backwards 1.2
Pump Rebuild in
2005 (1.2.1)
See Example
1.2.1
Defective
Instructions
1.2.2
See Example
1.2.2
25-75 Chance
Failed 1.2.3
END-Normal
No QA Hold
Point 1.2.4
See Example
1.2.4
Critical Step
Not Flagged
1.2.5
See Example
1.2.5
Workers not
qualified 1.2.6
See Example
1.2.6
No
Supervisory
Intervention
1.2.7
See Example
1.2.7
Orientations
1. Tandem (Left)
2. Tandem (right)
3. Back-to-back
4. Front-to-front
198

(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

(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

(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

(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

(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

(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

(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

(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

(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.
207

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.
208

Missed Opportunity Matrix (MOM) [HPCI Inop for DD Days] Sheet n of N
Who Situation Opportunity Expected
Result
Impact and
Notes

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

Barrier Analysis Matrix (BAM) [HPCI Inop for DD Days] Sheet n of N
Barrier Target
Protected
in this case
Significance

Barrier Analysis Matrix (BAM) [HPCI Inop for DD Days] Sheet 1 of N
Barrier Target
Protected
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
step.
Opportunity.
Contractor Work
Supervision
Work process
integrity.
Inadequate work
process
step done wrong.
Opportunity.
Vendor Technical
Manual
Work instructions Errors and omissions Not used.. Failed barrier. Missed
factor.
In-house Operating
Experience Program
barriers.
Repeat missing and
factor.
Industry Operating
Experience Program
barriers.
Repeat missing and
factor.

FACTOR-CONSEQUENCE MATRIX 1.0
FACTOR Actual
Case
Case 1
Can’t go in
wrong
Case 2 Right
Guess
Case 3
Effective
Plant QAP
Case 4
Effective
Contractor
QAP
Case 5
Effective
Procedure
Case 6
Effective
Training
Case 7
Effective
QC
Case 8
Accident
Needing HPCI
Brg Can Go In Wrong Yes Brg in
Properly
Yes Yes Yes Yes Yes Yes Yes
Worker Guesses
Wrong
Yes Could not
happen
Brg in
Properly
Could not
happen
Could not
happen
Could not
happen
Could not
happen
Would be
caught
Yes
Lack of Effective Plant
QAP
Yes Would not
matter
Would not
matter
Brg in
Properly
Would not
matter
Would not
matter
Would not
matter
Would not
matter
Yes
Lack of Effective Plant
QAP
Yes Would not
matter
Would not
matter
Could not
happen
Brg in
Properly
Would not
matter
Would not
matter
Would not
matter
Yes
Lack of Effective
Procedure
Yes Would not
matter
Would not
matter
Could not
happen
Could not
happen
Brg in
Properly
Would not
matter
Would not
matter
Yes
Lack of Effective
Training
Yes Would not
matter
Would not
matter
Could not
happen
Could not
happen
Would not
matter
Brg in
Properly
Would not
matter
Yes
Lack of Effective QC Yes Would not
matter
Would not
matter
Could not
happen
Could not
happen
Would not
matter
Would not
matter
Brg in
Properly
Yes
No accident needing
HPCI
Yes Would not
matter
Would not
matter
Would not
matter
Would not
matter
Would not
matter
Would not
matter
Would not
matter
Accident
Needing HPCI
Consequences
HPCI Inop DD Days None None None None None None None Not
Applicable
Actual Fuel
Damage Increase
None None None None None None None None Yes
HPCI BP Inop
213

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

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

Extent
• Magnitudinal Extent
– Causation of Magnitudinal Extent
• Inferential Extent
– Causation of Inferential Extent

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

Problem That
Got Noticed
Downstream
Impact
Upstream
Causation
More of the
Same Item
More of the Same
Class of Issue
218

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

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

End of Case Study
Comments? Questions?

Thanks for Your Participation
• Questions?
• Comments?
• Differing Professional Opinions?
• Next Steps for Your Organization?
222

Questions?
223

INSTRUCTOR FEEDBACK
Please fill out the following table and return the form to me. Put a number from 0 (needs a lot of
help) to 10 (world class-on target) in the right hand column.
Appropriateness of the topics to your job.
The value of the topics to your career.
The instructor's command of the subject matter.
The instructor's presentation skills.
The instructor's ability to engage the participants.
The instructor's handling of questions and comments.
The helpfulness of the visual aides.
The helpfulness of the handout materials.
The overall quality of the training experience.
Your ability to apply at least 10% of the material in your job tomorrow.
Please also answer the following questions.
What suggestions do you
have to make the
presentation more valuable
to a person in your
situation?
How can you use one idea
out of the presentation to
improve your contribution
to your organization?
If you would like a free complimentary subscription to The Firebird Forum e-newsletter send an
e-mail to firebird.one@alum.MIT.edu including the word “subscribe”. 224

Five types of factor building blocks with case study 2014.05.05.0730

Recommandé

Recommandé

Contenu connexe

Similaire à Five types of factor building blocks with case study 2014.05.05.0730

Similaire à Five types of factor building blocks with case study 2014.05.05.0730 (20)

Dernier

Dernier (20)

Five types of factor building blocks with case study 2014.05.05.0730