ALBA PS5B4 PROJECT

Incident Reporting and Investigation Procedure - Attachment 5

Root Cause Tree Basic Cause Categories

PROCEDURES TRAINING QUALITY CONTROL

Not Used/ Wrong Followed Incorrectly No Training Understanding No QC NI

Not Followed NI Inspection

Format Confusing Task not Learning Inspection

No Procedure Typo Inspection
Analysed Objective Not
Sequence wrong > 1 Action/Step Instructions
NI Required NI
Procedure not Decided not
Excess references to Train
available or Facts wrong Lesson Plan
Multi Unit references No Hold Inspection
inconvenient Situation not No Learning NI Point
Limits NI Techniques
for use covered Objective Instruction NI
Procedure Wrong revision Details NI
Data/Computations NI
difficult to use used Missed Hold
wrong or incomplete Practice/ Foreign
Required Point
Procedure use Second checker Repetition material
Graphics NI Training Not
not required but needed NI Exclusion
No Check Off Performed during work
should be
Check Off misused Testing NI NI
Misused Second Check Continuous
Ambiguous Instructions Training NI
Equipment
Indentification NI

COMMUNICATIONS MANAGEMENT SYSTEM

No Communication Turnover Misunderstood Standards, SPAC Oversight/ Corrective

or Not Timely NI Verbal Comm Policies, or Not Used Employee Action
Admin Controls Relations
No Standard Standard (SPAC) NI Communication Corrective
Turnover of SPAC NI Infrequent Audits Action NI
Communication Terminology
System NI Process NO SPAC & Evaluations
Not Used Recently (A&E)
Standard Changed Corrective Action
Turnover Not Strict Enough A&E Lack Depth
Process Terminology NI Not Yet
Late Enforcement NI Implemented
Not Used Repeat Back Confusing or A&E Not
Communication
Not Used Incompatible Independant Trending
Turnover No Way to NI
Process Long Message Technical Error Implement Employee
NI Communications NI
Drawings/ Prints Accountability
Noisy NI
Environment NI Employee
Feedback
NI

HUMAN ENGINEERING WORK DIRECTION

Human-Machine Work Complex Non - Fault Preparation Selection of Supervision

Interface Environment System Tolerant System Worker During Work

Labels NI Housekeeping NI Knowledge Based Errors No Preparation No Supervision

Not Qualified
Arrangements/ Decision Not
Hot/ Cold Detectable Work Package/
Placement Required Fatigued
Permit NI
Displays NI Wet/ Slick
Errors Pre Job Briefing NI Upset
Lighting NI Monitoring Too Crew Teamwork NI
Controls NI Many Items Not
Recoverable Walk Through NI Substance Abuse
Noisy
Monitoring
Alertness NI Scheduling NI Team Selection NI
Obstruction
Plant/Unit Cramped Work Space Lock Out/ Tag Out
Differences (LOTO) NI
Equipment Guards NI
Excessive Fall Protection NI
Lifting High Radiation
Contamination
Tools or
Instruments NI

NI = NEEDS IMPROVEMENT
May also substitute LTA (Less Than Adequate or PIO (Potential Improvement Opportunity