SAC Violation Reporting Failure Analysis

DOE-STD-1186-2004

SAC VIOLATION REPORTING AND FAILURE ANALYSIS

5.1

Notification Requirements for Violations of SACs

Violations of SACs in the TSRs must be reported to DOE in accordance with DOE O 231.1A,

Environment, Safety, and Health Reporting, and DOE M 231.1-2, Occurrence Reporting and

Processing of Operations Information.

5.2

Investigation and Reporting of Specific AC Violations

DOE G 231.1-2, Occurrence Reporting Causal Analysis Guide, provides guidance on how to

determine the Apparent Cause(s) of specific reportable occurrences including TSR violations,

and to explain the structure and nodes of the Causal Analysis Tree for use in occurrence

reporting and failure analysis.

Identifying the causes for Specific AC violations is often difficult. The identification of human

error as a root or contributing cause of violations provides little information about how to prevent

similar problems from recurring. Recognizing human performance problems when they occur

and accurately identifying their causes are necessary first steps to developing effective

corrective actions. The investigator(s) should be both experts in human performance and the

process or facility involved in the violation. See NUREG/CR-6751, The Human Performance

Evaluation Process: A Resource for Reviewing the Identification and Resolution of Human

Performance Problems.

TSR violations, including Specific AC violations, that may occur during operation of the facility,

must be investigated to determine their specific or generic cause(s) and generic implications,

corrective actions recommended, and those violations reported to the DOE as required by

10 CFR 830.205, DOE O 231.1A, and DOE M 231.1-2.