Phase II - Assessment

Operational Safety Requirements

Safety Performance Measurement System/Occurrence Reporting

and Processing System (SPMS/ORPS) Reports

Trend charts and graphs

Facility parameter readings

Sample analysis and results (chemistry, radiological, air, etc.)

Work orders.

Acquiring related information - Some additional information that an evaluator should

consider when analyzing the causes includes the following:

Evaluating the need for laboratory tests, such as destructive/nondestructive failure

analysis

Viewing physical layout of system, component, or work area; developing layout

sketches of the area; and taking photographs to better understand the condition

Determining if operating experience information exists for similar events at other

facilities

Reviewing equipment supplier and manufacturer records to determine if

correspondence has been received addressing this problem.

The assessment phase includes analyzing the data to identify the causal factors, summarizing the

findings, and categorizing the findings by the cause categories specified in DOE Order 5000.3A (see

Appendix A). The major cause categories are:

Equipment/Material Problem

Procedure Problem

Personnel Error

Design Problem

Training Deficiency

Management Problem

External Phenomena.

These categories have been carefully selected with the intent to address all problems that could

arise in conducting DOE operations. Those elements necessary to perform any task are

equipment/material, procedures (instructions), and personnel. Design and training determine the quality

and effectiveness of equipment and personnel. These five elements must be managed; therefore,

management is also a necessary element. Whenever there is an occurrence, one of these six program

elements was inadequate to prevent the occurrence. (External phenomena beyond operational control

serves as a seventh cause category.) These causal factors specified in DOE Order 5000.3A can be

associated in a logical causal factor chain as shown in Figure 1. (Note that a direct, contributing, or root

cause can occur any place in the causal factor chain; that is, a root cause can be an operator error while a

management problem can be a direct cause, depending on the nature of the occurrence.) These seven

cause categories are subdivided into a total of 32 subcategories. The direct cause, contributing causes, and

root cause are all selected from these subcategories (see Appendix A).