Assessment and Reporting Guidance

To perform the assessment and report the causal factors and corrective actions:

Analyze and determine the events and causal factor chain.

Any root cause analysis method that includes the following basic steps maybe used.

(a)

Identify the problem. Remember that actuation of a protective system constitutes the

occurrence but is not the real problem; the unwanted, unplanned condition or action that

resulted in actuation is the problem to be solved. For an example, dust in the air actuates

a false fire alarm. In this case, the occurrence is the actuation of an engineered safety

feature. The smoke detector and alarm functioned as intended; the problem to be solved

is the dust in the air, not the false fire alarm. Another example is when an operator

follows a defective procedure and causes an occurrence. The real problem is the defective

procedure; the operator has not committed an error. However, if the operator had been

correctly trained to perform the task and, therefore, could reasonably have been expected

to detect the defect in the procedure, then a personnel problem may also exist.

(b)

Determine the significance of the problem. Were the consequences severe? Could they

be next time? How likely is recurrence? Is the occurrence symptomatic of poor attitude,

a safety culture problem, or other widespread program deficiency? Base the level of effort

of subsequent steps of your assessment upon the estimation of the level of significance.

(c)

Identify the causes (conditions or actions) immediately preceding and surrounding the

problem (the reason the problem occurred).

(d)

Identify the reasons why the causes in the preceding identification step existed, working

your way back to the root cause (the fundamental reason that, if corrected, will prevent

recurrence of this and similar occurrences throughout the facility and other facilities under

your control). This root cause is the stopping point in the assessment of causal factors. It

is the place where, with appropriate corrective action, the problem will be eliminated and

will not recur.

Summarize findings, list the causal factors, and list corrective actions.

Summarize your findings using the worksheets in Appendix B, and classify each finding or cause by

the cause categories in Appendix A.

Select the one (most) direct cause and the root cause (the one for which corrective action will

prevent recurrence and have the greatest, most widespread effect). In cause selection, focus on

programmatic and system deficiencies and avoid simple excuses such as blaming the employee. Note that

the root cause must be an explanation (the why) of the direct cause, not a repeat of the direct cause. In

addition, a cause description is not just a repeat of the category code description; it is a description

specific to the occurrence. Also, up to three (contributing) causes may be selected. Describe the

corrective actions selected to prevent recurrence, including the reason why they were selected, and how

they will prevent recurrence. Collect additional information as necessary. Appendix B includes

instructions and worksheets that may be used to collect and summarize data. Appendix C contains

examples of root cause analyses.

Enter the occurrence report using ORPS.

Enter the occurrence report into ORPS, using the ORPS User's Manual as necessary. When

entering the cause code data using ORPS PC Software, match your direct cause, root cause, and each of