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Systems
10-13 June 2014 IAEA Technical Meeting 1
SOL revised: a systemic and holistic approach
to event investigation
Babette Fahlbruch (TÜV NORD)
Juliane Jung (SOL-VE GmbH)
Hans Maimer (SOL-VE GmbH)
Systems
The structure of TÜV NORD
10-13 June 2014 2
TÜV Hannover/
Sachsen-Anhalt e.V. TÜV Nord e.V. RWTÜV AG
TÜV NORD AG
Business Unit
Mobility
• TN Mobilität
• MPI
• Companies
RWTÜV e.V. TÜV Thüringen
e.V.
Business Unit
Industry Services
• TN CERT
• TN Systems
• TN EnSys
• TN SysTec
• Companies
Business Unit
Training and
Human
Resources
• Academies
• Companies
• Nord-Kurs
Business Unit
Natural
Resources
• DMT
• Companies
Business Unit
International
• TN International
• Companies
Business Unit
Administration
• TN Service
IAEA Technical Meeting
Systems
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TÜV NORD Nuclear
Who we are
TÜV UK TÜV NORD
SysTec
TÜV NORD
EnSys Hannover
TÜV Czech
TÜV NORD
Sweden
TÜV NORD
Southern Africa
TÜV India
International network of TÜV NORD entities operating in
the nuclear market
provides full
range nuclear
services
worldwide
600 experts
worldwide
accumulated
technical
experience of
300 operational
years (NPP)
TÜV NORD
Korea
Systems
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TÜV NORD Nuclear
Our Competencies
TÜV NORD Nuclear provides Full-range Service in the Nuclear Field in the Areas
Civil engineering Electrical power supply
Strength design Nuclear fuel technology
System analysis and process engineering Control & instrumentation
Mechanical components Quality monitoring and assurance
Reactor physics and criticality safety Radiation protection and siting
Thermo-fluid dynamics Radioactive waste
Safety management and reliability analyses Non-destructive materials testing
Transport and handling Plant security
X-ray technology Licensing and Operation Supervision
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Event analysis - background
Systems
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Periods of Safety Research
Inter-organizational
period
Dysfunctional
relations
between
organizations as
source of
problems
Socio-technical
period
Interaction of
subsystems as
source of
problems
Human error
period
Individuals
as source of
problems
Technical
period
Technology
as source of
problems
1995 1990
Com
ple
xity o
f t
echnolo
gy
Time
1950
Expanded from Reason (1990)
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Environment Organisation
Team Individual
Technology
Systemic View on Safety
Systems
Cognitive problems for event analyses
Premature or insufficient generating of hypotheses, which can lead
to restricted information and factor search
Contributing factors being remote in time and space from the
occurrence of the event will not be recognized as such which can
lead to an over-weighting of close (time / space) factors
Mono-causal thinking / truncated search strategies lead(s) to the
identification of only one factor even if more contributed
Omission of factors which contributed by their absence as missing
inhibitory factors like barriers
Identification of contributing factors because of reference situations
(past events)
Omission of unreported factors (out of sight - out of mind)
Concentration on the individual human performance 10-13 June 2014 8 IAEA Technical Meeting
Systems
Event analysis for Organizational Learning
Qualitative, not quantitative approach
Not necessary to find “true” causes, but find and discuss possibilities
to improve the system
Focus on all factors which may contribute to an event – including
human and organizational factors
Analysis method should be applicable for company staff
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Development of SOL
Systems
History
Development and evaluation of SOL (paper pencil)
Development of SOL-VE (computer program)
Application in NPP
Application in other industries
SOL 3.0 (program and paper pencil)
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1992
1997
1999
2005
2014
more than 200
analyses in NPP
Systems
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Goals of the development
Method for identifying contributing factors
Method for use in plants by trained operators
Identification of human, organizational and environmental factors
Standardized process of analysis
Integration of expert knowledge for the identification of contributing
factors
Overcoming shortcomings in causal attribution
Systems
Definition
Event analysis is the social accepted reconstruction of the event to be
analyzed, i.e. the identification of what happened and why it happened.
For the what it is necessary to describe the course of the event
as detailed as possible.
For the why it is necessary to identify as much contributing
factors as possible.
The main problem according to these points is, that it is necessary to go
beyond the given information, i.e. to make causal inferences
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SOL 3.0
Systems
Requirements for change
Explicit presentation of the systemic model and integration of
aspects related to safety culture and safety management
Difficulties of practitioners to see differences between directly and
indirectly contributing factors
Comments from the nuclear industry
Author‘s experiences from more than 50 event investigations
16.05.2014 17. Plattform Jahresworkshop 15
Systems
Implemented changes in SOL 3.0
Actors can be categorized in different system levels
Possible interactions of contributing factors is explicit considered
New factors: decision making (factor 5) and leadership (factor 9)
No difference between directly and indirectly contributing factors
Factors can be better differentiated (distinctly classified), examples
are practitioner‘s language
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Systems
Process of event analysis
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Event
Information collection
Situational description
Identification of
contributing factors
• On-site inspection / fact
finding
• Document analyses
• Interviews
• Event building blocks
• Why-questions
• Factor questions
Corrective actions
Trend / pattern
analyses
yes
yes
no
no
Information collection
completed ?
Description
comprehensive?
yes
no
All factors checked?
Systems
Step 1: Information collection
On-site inspections / observations
Analysis of documents
Procedures, protocols, mails, letters, regulations etc.
Interviews with
Involved personnel
Supervisors and managers
Not-involved persons with comparable tasks
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Systems
WHEN? Start/end of the event
Start/end of single event building blocks
WHERE?
Location of the event
Other locations of actions (control room, ...)
WHO? Function and qualification of involved persons (shift leader, fitter, ...), involvement of other departments, involvement of outside-companies
WHAT? Kind of work/tasks during the event (test, maintenance, ...), work process, operation scheduling (team work, co-operation, tasks, ...), operating instructions
HOW? Separate work or group work, allocation of tasks, used communication tools, disturbancies in the communication, status of involved systems/components/ tools (on/off, test, disturbancy, ...), automatic/manual operations during the event, working conditions (noise, temperature, wetness, ...)
Questions and clues for the collection of information
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Step 2: situational description
1. Decomposing
Decompose the event into event building blocks, i.e. into single action of different actors. An event building block contains information about one action of one actor. An actor can be a person or a technical component / system.
3. Recomposing
Recompose the event building blocks according to actors and time
Systems
No.:
Time:
Location:
Actor:
Action:
Remarks:
Decomposing the event into “event building blocks”
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Systems
Actors
Time
1
Actor 1
Action A
3
Actor 2
Action C
5
Actor 1
Action E
6
Actor 2
Action F
2
Actor 3
Action B
4
Actor 3
Action D
Recomposing: SOL time-actor diagram
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Systems
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Hints for compiling the event building blocks
Start with the actor (person or technical component) (avoid plural)
Continue with the action (avoid passive and denials)
Conditions should be written in remarks
Continue with location and time
Systems
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Hints: checking the time-actor-diagram
Are there event building blocks missing for the description of the
course of the event?
Are all involved actors (persons and components) covered by the
list of actors?
Is your diagram clear structured and understandable?
Are the single actions of each actor traceable?
Systems
10. Control and supervision
"Was the execution of work not controlled or supervised sufficiently?"
Examples are:
• Insufficient planning of control steps
• Missing control of work by supervisors or colleagues (peer checking)
• Missing control of work results by supervisors or colleagues
• Insufficient use of control principles, e. g. 4-eye-principle, STAR(K),
STOP
• Focus only on results of work, no attention to safe execution
• Inadequate arrangements against violation of independence of
control (signature by two persons)
Step 3: identification of contributing factors
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Systems
9. Leadership
“Could have aspects of leadership contributed?"
Examples are: • Missing prioritization of control tasks
• Missing role models
• Organization‘s policy and values are not lived credibly by supervisors and
managers (commitment)
• No expectations formulated by supervisors and managers
• To much production pressure by managers
• Missing feedback for performance
• Missing motivation of operators
• Tolerance of violations
• No open communication
Step 3: identification of contributing factors
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List of contributing factors
Technical component
Design
Ergonomic aspects of information
design
Working conditions
Decision making
Execution of work
Non-compliance with rules
Communication
Leadership
Control and supervision
Influence from team and
organizational culture
Operation scheduling and work
preparation
Rules, procedures and documents
Quality management
Accountability and responsibility
Organization und management
Feedback of experience
Qualification and training
Regulatory and consulting bodies
Environmental influence
16.05.2014 17. Plattform Jahresworkshop 28
Systems
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Instruction for the identification of contributing factors
4. Questioning
Ask „why“-questions for the first event building block. Use the information contained in the block. Use the identification aid to ask more questions
5. Categorizing / Identifying
Work through all contributing factors. If you can answer with yes one of the questions in the identification aid, write down the factor‘s name and its description
6. Repeat the above for all event building blocks
Systems
10-13 June 2014 IAEA Technical Meeting 30
SOL time-actor-diagram with contributing factors
1
actor 1
action A
3
actor 2
action C
5
actor 1
action E
6
actor 2
action F
2
actor 3
action B
4
actor 3
action D
3
Factor 6
description
5
Factor 3
description
5
Factor 2
description
6
Factor 18
description
6
Factor 19
description
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SOL time-actor-diagram with contributing factors
in SOL-VE OEM
Systems
First feedback on SOL 3.0
In an experimental condition more factors were identified than with
SOL (about 90-95%) by lay-persons
Positve feedback from NPP-analysts
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7 “golden” rules
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Systems
Rules for event analysis
1. Do not search for scape-goats and blame someone
2. Avoid typical errors in the analysis process
3. Analysts must be trained
4. Separate situational description and identification of factors strictly
5. Conduct an analysis always with a team (different backgrounds,
competences and experiences)
6. Be creative in the search for contributing factors
7. Get commitment of top level management
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