Phase V - Follow-Up

7. PHASE IV - INFORM

Electronic reporting to ORPS is part of the inform process for all occurrences. (For those

occurrences containing classified information, an unclassified version shall be entered into ORPS.)

Effectively preventing recurrences requires the distribution of these reports (especially the lessons learned)

to all personnel who might benefit. Methods and procedures for identifying personnel who have an

interest is essential to effective communications.

In addition, an internal self-appraisal report identifying management and control system defects

should be presented to management for the more serious occurrences. The defective elements can be

identified using MORT or Mini-MORT as described in Appendix G.

Consideration should be given to directly sharing the details of root cause information with similar

facilities where significant or long-standing problems may also exist.

Follow-up includes determining if corrective actions have been effective in resolving problems.

First, the corrective actions should be tracked to ensure that they have been properly implemented and are

functioning as intended. Second, a periodic structured review of the corrective action tracking system,

normal process and change control system, and occurrence tracking system should be conducted to ensure

that past corrective actions have been effectively handled. The recurrence of the same or similar events

must be identified and analyzed. If an occurrence recurs, the original occurrence should be re-evaluated to

determine why corrective actions were not effective. Also, the new occurrence should be investigated using

change analysis. The process change control system should be evaluated to determine what improvements

are needed to keep up with changing conditions. Early indications of deteriorating conditions can be

obtained from tracking and trend analyses of occurrence information. In addition, the ORPS database

should be reviewed to identify good practices and lessons learned from other facilities. Prompt corrective

actions should be taken to reverse deteriorating conditions or to apply lessons learned.

DOE Order 5000.3A, Occurrence Reporting and Processing of Operations Information, U.S.

Department of Energy, May 30, 1990.

User's Manual, Occurrence Reporting and Processing System (ORPS), Draft, DOE/ID-10319, EG&G

Idaho, Inc., Idaho Falls, ID, 1991.

Accident/Incident Investigation Manual, SSDC 27, DOE/SSDC 76-45/27, November 1985, second

edition, U.S. Department of Energy.

D. Fillmore and A. Trost, Investigating and Reporting Accidents Effectively, SSDC-41,

DOE-76-45/41, EG&G Idaho, Inc.

J. L. Burton, "Method Identifies Root Causes of Nuclear Reactor Scrams," Power Engineering,

October 1987.

D. L. Gano, "Root Cause and How to Find It," Nuclear News, August 1987.