Problem Solving Tools

Transcription

1 Problem Solving Tools Report 162 Self Assessment of Radiation Safety Programs (2009) Report Investigation of Radiological Incidents (2012?) Mary L. Birch NC HPS Meeting October 4, 2012

2 Problem Solving Philosophy W. Edwards Deming in the 1950's proposed Continuous Process Improvement Finding and fixing small problems will prevent larger problems 10/4/2012 2

3 Self Assessment of Radiation Safety Programs Audit - a deliberate examination of the program to determine if it is effective. (Operational Radiation Safety Program, NCRP Report No.127, 1998) Self-Assessment process that an institution uses to critically review its own activities and performance in relation to regulations, standards, internal policy documents, implementing procedures, industry best practices, and goals. (Self Assessment of Radiation Safety Programs, NCRP Report No.162, 2009) 10/4/2012 3

4 Purpose of Self-Assessment Timely identification of deficiencies or weaknesses Ensures A safe working environment Regulatory compliance Conformance with program requirements Reaffirms workplace continuous improvement culture Reaffirms an atmosphere of caring Identifies noteworthy practices Identifies areas for further evaluation Provides an opportunity for learning 10/4/2012 4

5 Self Assessment Process establish an overall plan; assign responsibilities for implementing the program; identify the purpose of the selfassessment; identify the type of selfassessment to be performed (performance-, compliance-, or risk-based) identify the level of the selfassessment (i.e., task, process, or program); determine whether the selfassessment will be formal or informal. identify qualified individuals to conduct the self-assessment; review specific selfassessment methods and techniques; develop a specific selfassessment plan; conduct the self-assessment; document and report the results; determine the causes of any deficiencies; develop corrective actions; and implement and verify the implementation and effectiveness of corrective actions. 10/4/2012 5

6 Type of Self Assessment Performance-based how well does the radiation protection program maintain radiation exposures to workers and the public within regulatory limits and to levels that are ALARA? Risk-based have radiological risks been reduced to those deemed acceptable by the institution? Compliance-based - does the radiation protection program comply with applicable NRC, NRC agreement states, DOE, EPA, OSHA, FDA, DOT and other government agencies regulations? 10/4/2012 6

7 Level of Self Assessment Task - work activity that has a definite beginning and ending, consists of two or more steps, and leads to a product, service, or decision Process - series of actions that are taken to achieve a desired result and usually will include multiple tasks Program - integrated set of processes and other activities that are planned, initiated and managed in a coordinated way to achieve desired results. 10/4/2012 7

8 Sample Inquiry Effectiveness of Verbal Communications: Determine if the instructions provided to the interviewee were adequate to perform the assigned task. Determine if there have been any communication problems in the past as a result of inconsistent communication practices. If a facility communications policy exists, determine if it is followed. Determine if there were any problems encountered during the task or process with the communications equipment used. If another work group was involved with the performance of the task, determine if the communications with these other groups were adequate 10/4/2012 8

9 Documentation Report should be an impartial statement of the current health of the task, process, or program assessed Report should include: Scope and Objectives Methodology used Results Conclusions Recommendations Legal Considerations Be factual Be complete Protect sensitive information Avoid opinions and pejorative words Recommendations should be advisory rather than commanding 10/4/2012 9

10 Follow-Up Implement Corrective Actions, if any Verify that Corrective Actions have improved task, process or program Tracking/Trending Workplace observations Workplace interviews 10/4/

11 HPS Journal Book Review Reviewer, Mark Linsley, comments: HONESTLY, I actually enjoyed reading this report. As I read, I began to understand that my concept of an assessment was truly limited to only a compliance mindset. Two appendices, 21 pages, provide: An interview guide Examples of lines of inquiry Universal applicability - biological, chemical, electrical, hearing protection, laser, even food safety 10/4/

12 Prepare to Switch Gears 10/4/

13 Investigation of Radiological Incidents Initial Guidance in NCRP Report No. 127, Operational Radiation Safety Program (NCRP, 1998) Report Investigation of Radiological Incidents (2012?) provides more detailed guidance Purpose Determine what happened Determine the cause or causes of the incident Recommend corrective actions Radiological incident - an abnormal occurrence or sequence of occurrences that may adversely affect the health and safety of workers or the public, results in property damage, negatively impacts the environment, interrupts program activities, or results in non-compliance with regulations, or an occurrence or series of occurrences that could have led to adverse consequences if the circumstances had been slightly different (near miss) 10/4/

14 Incident Investigation Process Determine if an investigation is needed obtain information regarding the incident from the initial responder(s); evaluate the seriousness of the incident to determine if a formal incident investigation is warranted or required by regulatory requirements; Carry out the investigation select and appoint an individual or a team to perform the investigation; initiate investigation activities; conduct the investigation; perform a cause analysis; coordinate facility or institution recovery activities and the investigation; prepare the investigation report; develop corrective action recommendations Learn from the incident analyze and trend data from past incidents; follow-up on corrective actions; distribute lessons learned; 10/4/

15 Initial Response Incident Response Plan or Emergency Plan in place Initial responders may be personnel involved in the incident Should be well-trained to respond to the incident that has occurred Rescue victims Mitigate or stabilize the incident Preserve the incident scene Notify Management and Regulatory Agencies Transition to Investigation 10/4/

16 Incident Investigation Conduct the investigation select and appoint an individual or a team to perform the investigation; initiate investigation activities; conduct the investigation; perform a cause analysis; coordinate facility or institution recovery activities and the investigation; prepare the investigation report; develop corrective action recommendations 10/4/

17 Meet with Facility Representatives Entrance meeting Daily Briefings Exit meeting Collect Physical Evidence Interview Personnel Involved Establish an Incident Timeline Initiate and Conduct Investigation Activities 10/4/

18 Perform a Cause Analysis Goal is to answer WHY The basic steps in the cause analysis are: define the problem to be analyzed; gather the facts surrounding the incident and construct a timeline; determine the cause analysis method(s) to be used; analyze the facts using one or more cause analysis tools or techniques; identify the cause(s) of the incident; and determine the extent of condition and extent of cause, if appropriate. 10/4/

19 Levels of Cause Analysis Direct Cause determines the most likely reason for the failure or inappropriate action that immediately preceded the incident Apparent Cause - determines the reason for failure, inappropriate action or repetitive inappropriate actions based on readily available evidence and facts Root Cause - determines the most fundamental reason for an incident that, if corrected, will prevent recurrence of both the specific problem and similar incidents 10/4/

20 Examples 10/4/

21 Cause Analysis Methodology 10/4/

22 Incident Investigation Report Report Format Cover Page Table of Contents Executive Summary Body of report affected programmatic activity and equipment sequence of events barrier analysis inappropriate actions or equipment failures cause analysis Conclusions Minority Reports, if any Legal Considerations Be factual Be complete Protect sensitive information Avoid opinions and pejorative words Recommendations should be advisory rather than commanding If depositions taken, legal representation should be available 10/4/

23 Lessons Learned What is shared? Brief summary of the incident investigation report describing the institution, what happened, why it happened, an evaluation of the radiological consequences, and what was done to minimize the likelihood of reoccurrence of a similar incident. Who should see it? What mechanisms are available to share information? 10/4/

24 Summary Problem solving can be prospective or retrospective: Prospective guidance - Report 162 Self Assessment of Radiation Safety Programs (2009) Retrospective guidance - Report Investigation of Radiological Incidents (2012?) Goal Do the right things right the first time. 10/4/