Definitions - nst10040008

arrier Analysis. Barrier Analysis is a systematic process that can be used to identify

physical, administrative, and procedural barriers or controls that should have prevented

the occurrence.

anagement oversight and Risk Tree (MORT) Analysis. MORT and Mini-MORT are

used to identify inadequacies in barriers/controls, specific barrier and support functions,

and management functions. It identifies specific factors relating to an occurrence and

identifies the management factors that permitted these factors to exist.

uman Performance Evaluation. Human Performance Evaluation identifies those factors

that influence task performance. The focus of this analysis method is on operability, work

environment, and management factors. Man-machine interface studies to improve

performance take precedence over disciplinary measures.

epner-Tregoe Problem Solving and Decision Making. Kepner-Tregoe provides a

systematic framework for gathering, organizing, and evaluating information and applies to

all phases of the occurrence investigation process. Its focus on each phase helps keep

them separate and distinct. The root cause phase is similar to change analysis.

Phase III. Corrective Actions. Implementing effective corrective actions for each cause reduces

the probability that a problem will recur and improves reliability and safety.

Phase IV. Inform. Entering the report on the Occurrence Reporting and Processing System

(ORPS) is part of the inform process. Also included is discussing and explaining the results of the

analysis, including corrective actions, with management and personnel involved in the occurrence. In

addition, consideration should be given to providing information of interest to other facilities.

Phase V. Follow-up. Follow-up includes determining if corrective action has been effective in

resolving problems. An effectiveness review is essential to ensure that corrective actions have been

implemented and are preventing recurrence.

Management involvement and adequate allocation of resources are essential to successful

execution of the five root cause investigation and reporting phases.

See DOE Order 5000.3A, Section 5.

Facility. Any equipment, structure, system, process, or activity that fulfills a specific purpose.

Examples include accelerators, storage areas, fusion research devices, nuclear reactors, production or

processing plants, coal conversion plants, magnetohydrodynamics experiments, windmills, radioactive waste

disposal systems and burial grounds, testing laboratories, research laboratories, transportation activities,

and accommodations for analytical examinations of irradiated and unirradiated components.

Reportable Occurrence. An event or condition, to be reported according to the criteria defined in

DOE Order 5000.3A.

Occurrence Report. An occurrence report is a written evaluation of an event or condition that is

prepared in sufficient detail to enable the reader to assess its significance, consequences, or implications

and evaluate actions being employed to correct the condition or to avoid recurrence.

Event. A real-time occurrence (e.g., pipe break, valve failure, loss of power). Note that an event

is also anything that could seriously impact the intended mission of DOE facilities.