Cause Code Definitions

Possible entries for causes of reportable occurrences are classified into seven broad categories and various subcategories. These categories and their associated subcategories are listed below:

A1Design/Engineering ProblemAn event or condition that can be traced to a defect in design or other factors related to configuration, engineering, layout, tolerances, calculations, etc.
A1B1Design input LTAInput to a design was lacking adequate information that was necessary for the design.
A1B1C01Design input cannot be metWere the criteria and other requirements so stringent that they could not be met? Were there conflicting criteria? Were all of the necessary references included?
A1B1C02Design input obsoleteWere the criteria out-of-date? Was an old version of a requirement or specification used? Did process requirements/conditions change and the changes omitted from the input?
A1B1C03Design input not correctWere the wrong standards or requirements used? Were the requirements transcribed in error?
A1B1C04Necessary design input not availableWere the necessary requirements, codes, standards, etc. available to the designer?
A1B2Design output LTAInadequate design output that did not meet the customer's expectations or design requirements.
A1B2C01Design output scope LTADid the design consider all the possible scenarios? Were all the operating conditions, normal and emergency included in the design?
A1B2C02Design output not clearWere the drawings difficult to read? Were the specifications difficult to understand? Could the specification be interpreted in more than one way?
A1B2C03Design output not correctWere the drawings and other specifications incorrect? Did the final design output include all changes?
A1B2C04Inconsistent design outputWere there differences between different output documents? Did the drawings and other design documents agree?
A1B2C05Design input not addressed in design outputDid the specifications include all the requirements? Were some criteria left out of the design output?
A1B2C06Drawing, specification or data errorWas the latest drawing revision referenced? Was the latest vendor information included in the design documentation? Were the correct data noted on the design documentation request?
A1B2C07Error in equipment or material selectionWas the correct vendor identification number used for procurement of equipment? Was the correct grade of stainless steel specified for the material?
A1B2C08Errors not detectableWere personnel unable to detect errors [by way of alarms or instrument readings] during or after the occurrence? Did a serious error go unnoticed because there was no way to monitor system status?
A1B2C09Errors not recoverableWas the system designed such that personnel were unable to recover from error discovered before a failure occurred?
A1B3Design / documentation LTADesign or documentation that did not include all of the required information and did not comply with document control and record requirements.
A1B3C01Design/documentation not completeWere the designs and other documentation for equipment complete? Were items missing from the documentation? Did a complete baseline exist?
A1B3C02Design/documentation not up-to-dateWere drawings and documents updated when changes were made? Did documents/drawings reflect the current status?
A1B3C03Design/documentation not controlledWas the design documentation controlled per site requirements for document control and records?
A1B4Design/Installation verification LTA Design reviews, testing, independent inspections, and acceptance were not in compliance with customer expectations and/or site requirements.
A1B4C01Independent review of design/documentation LTAWas a review performed on the design? Was the review performed by an independent reviewer? Did the design have problems passing the functional testing? Were all of the Independent Inspection attributes acceptable? Did the customer accept the final design installation?
A1B4C02Testing of design/installation LTAWas testing included as part of the design acceptance process? Did the testing verify the operability of the design? Did design parameters successfully pass all testing criteria?
A1B4C03Independent inspection of design/installation LTAWere Independent Inspection attributes included in the design installation? Were required Hold/Witness points verified by Quality Assurance? Did Hold/Witness points pass the acceptance criteria? Was material Commercial Dedicated Grade and adequately documented?
A1B4C04Acceptance of design/installation LTADid the customer have problems with acceptance of the design, testing, and/or verification?
A1B5Operability of design/ environment LTAPersonnel or environmental factors were not considered as part of the design.
A1B5C01Ergonomics LTAErgonomics is defined as the science that seeks to adapt work or working conditions to suit the worker. The design should include provisions for eliminating problems encountered by personnel performing tasks. This may also include problems resulting from Physical or Environmental factors.
A1B5C02Physical environment LTADid inadequate equipment controls or control systems [e.g., push-buttons, rotary controls, J-handles, key-operated controls, thumb-wheels, multiple switches, joysticks] contribute to the occurrence? Did the control fail to provide an adequate range of control for the function it performs? Was the control inadequately protected from accidental activation? Were similar controls indistinguishable from one another? Were controls in close proximity of each other? Did operating conditions [e.g. room temperature, work location, physical location, restricted vision, PPE, excessive noise, arrangement or placement of equipment] affect performance of task? Was lighting adequate? Was noise a factor?
A1B5C03Natural environment LTAWas exposure to heat, cold, wind, and rain included in the design. Were earthquake tested devices included in the design? Was system designed to withstand flooding, freezing, or high wind conditions? Were lightning suppressing devices included in the design? Was the event caused by excessive exposure of personnel to a hot or cold environment?
A2Equipment/ material problemIs defined as an event or condition resulting from the failure, malfunction, or deterioration of equipment or parts, including instruments or material.
A2B1Calibration for instruments LTADid the calibrations include all the essential elements? Was equipment as-found condition less than adequate? A2B1C01 Calibration LTA Was the equipment involved in the incident included in a routine calibration program? Were calibrations performed too infrequently? Did the calibration include all the essential elements?
A2B1C02Equip. found outside acceptance criteriaDid an event occur as a result of equipment that was found outside of the specified acceptance criteria? Did the instrument calibration drift outside of the acceptable range? Was process instrumentation outside of acceptable range criteria due to a standard that was out of calibration?
A2B2Periodic/Corrective Maintenance LTAWas periodic maintenance established for the equipment, instrument or component? Was the periodic maintenance adequate? Was corrective maintenance adequate to correct the problem? Did equipment history exist for the instrument or component? Was the equipment history complete?
A2B2C01Preventive maintenance for equipment LTAWas an equipment malfunction caused by a failure to carry out scheduled preventive maintenance? Was preventive maintenance established for the equipment or component that failed? Was preventive maintenance scheduled too infrequently? Was the preventive maintenance incomplete? Was it performed on some of the components but not others?
A2B2C02Predictive Maintenance LTAWas predictive maintenance established for the equipment? Was the established frequency adequate to prevent or detect equipment degradation? Was the established method used to prevent or detect equipment degradation adequate?
A2B2C03Corrective Maintenance LTAWas corrective maintenance performed but failed to correct the original problem? Was the equipment or component reassembled improperly during corrective maintenance? Were other problems noted during maintenance activities that were not corrected? Was the actual job of performing a maintenance activity complete, but was not performed correctly?
A2B2C04Equipment history LTADid equipment history / records exist for the equipment that malfunctioned? Was the history for the equipment that malfunctioned complete / adequate? Did the history contain all the information necessary to assure equipment reliability? Would knowledge of equipment history have prevented the incident or lessened its severity?
A2B3Inspection/ testing LTADid scheduled inspection/testing exist for the instrument or equipment? Was the inspection/testing adequate or performed as required? Did the inspection/testing include all the essential elements?
A2B3C01Startup testing LTADid functional testing exist for the equipment or system prior to placing it in service? Was start-up testing adequate for the equipment or system being placed into service?
A2B3C02Inspection/ testing LTAWas required testing / inspection established or performed for the equipment involved in the incident? Was the required testing / inspection performed at the correct frequency? Were the acceptance criteria for the required testing / inspection adequately defined? Were all essential components included in the required testing / inspection?
A2B3C03Post-maintenance/Post-modification testing LTAWas the post-maintenance or post-modification testing specified not performed or performed incorrectly? Was the post-maintenance or post-modification testing completed, but the testing requirements were less than adequate? Was the post-maintenance or post-modification testing performed in accordance with the schedule for testing?
A2B4Material control LTAWas the problem due to the inadequate handling, storage, packaging or shipping of materials or equipment? Was the shelf life for material exceeded? Was an unauthorized material or equipment substitution made? Were spare parts inadequately stored? Was there an error made in the labeling or marking?
A2B4C01Material handling LTAWas material / equipment damaged during handling? Was material / equipment "mixed up" during handling?
A2B4C02Material storage LTAWas the material, equipment or part stored improperly? Was the material, equipment, or part damaged in storage? Did the material, equipment, or part have weather damage? Was the material, equipment, or part stored in an environment [heat, cold, acid fumes, etc.] that damaged it? Was adequate preventive maintenance [cleaning, lubrication, etc.] performed on spare parts?
A2B4C03Material packaging LTAWas material or equipment packaged properly? Was the material or equipment damaged because of improper packaging? Was material or equipment exposed to adverse conditions because the packaging had been damaged? A2B4C04 Material shipping LTA Was the material / equipment transported properly? Was the material / equipment damaged during shipping?
A2B4C05Shelf life exceededWere materials, equipment, or parts that had exceeded the shelf life installed? Did materials continue to be used after the shelf life was exceeded?
A2B4C06Unauthorized material substitutionWere incorrect materials or parts substituted? Were materials or parts substituted without authorization? Did the requirements specify no substitution?
A2B4C07Marking/labeling LTAWas there an error made in the labeling or marking? Was equipment identification, labeling, or marking less than adequate?
A2B5Procurement control LTAWas the error due to inadequate control of changes to procurement specifications or purchase orders? Did a fabricated item fail to meet requirements or was an incorrect item received? Did product acceptance requirements fail to match design requirements or were they otherwise unacceptable?
A2B5C01Control of changes to procurement specification/ purchase order LTAWere changes made to purchase orders or procurement specifications without the proper review and approvals? Did the changes result in purchase of the wrong material, equipment, or parts?
A2B5C02Fabricated item does not meet requirementsWas the item of concern fabricated according to the requirements specified in the procurement specifications/purchase requisition?
A2B5C03Incorrect item receivedWas an item received not the one ordered? Was the inconsistency recognized? Was the item accepted rather than returned?
A2B5C04Product acceptance requirements LTAWere the product acceptance requirements complete? Did the product acceptance requirements address all the safety concerns for the item? Did the requirements address all the concerns for efficiency?
A2B6Defective/failed or contaminatedWas an event caused by a failed or defective part? Was the material used defective or flawed? Was the weld, braze or soldered joint defective? Did the component reach the end of its expected service life? Was there electrical or instrument noise interference or interaction? Did foreign material or contaminant cause the equipment or component to fail?
A2B6C01Defective or failed partA part/instrument that lacks something essential to perform its intended function.
A2B6C02Defective or failed materialA material defect or failure.
A2B6C03Defective weld, braze or soldering jointA specific weld/joint defect or failure.
A2B6C04End of life failureA failure where the equipment or material is run to failure and has reached its end of design life.
A2B6C05Electrical or instrument noiseAn unwanted signal or disturbance that interferes with the operation of equipment.
A2B6C06ContaminantFailure or degradation of a system or component due to foreign material (i.e., dirt, crud, impurities, trash in river intake, etc.) or radiation damage due to excessive radiation exposure. Can be related to any material in an unwanted location.
A3Human Performance LTAAn event or condition resulting from the failure, malfunction, or deterioration of the humans in the process.
A3B1Skill based errorWas there inattention or over-attention to performance of work?
A3B1C01Check of work was LTAIndividual(s) made an error that would have been detectable and correctable if a check of the completed work was performed. A3B1C02 Step was omitted due to distraction Attention was diverted to another issue during performance of the task and individual(s) committed an error in performance based on the distraction.
A3B1C03Incorrect performance due to mental lapseIndividual(s) knew appropriate action(s) to take, but failed to initiate the correct action(s) based on inattention/over-attention.
A3B1C04Infrequently performed steps are performed incorrectlyIndividual(s) are not completely familiar with the tasks required based on not frequently performing the tasks and not operating at a fluency level.
A3B1C05Delay in time cause LTA actionsIndividual(s) perform the wrong actions based on an extended length of time expiring between the time the task was defined and the time the task was completed.
A3B1C06Wrong action selected based on similarity with other actionsIndividual(s) select a wrong action out of a series of actions that appear to be the same, but are not.
A3B1C07Omission/repeating of steps due to assumptions for completionIndividual(s) based on lack of knowledge or assumptions conclude that activity steps are not completed or completed. Based on the perceptions, an error occurs because the incorrect decision or assumption was made.
A3B2Rule based errorWas there a misapplication of a good rule for behavior or application of a bad rule applied for behavior during the work process?
A3B2C01Strong rule incorrectly chosen over other rulesIndividual(s) chose behavior rules based on the number of times the rule(s) has been used successfully in the past. The more times the rule(s) have been used successfully, the stronger the desire to apply the rule(s) become.
A3B2C02Signs to stop are ignored and step performed incorrectly Error precursors to an event exist and, if recognized, can prevent the event. These precursors are grouped based on Task Demands, Work Environment, Individual Capabilities, and Human Nature.
A3B2C03Too much activity is occurring and error made in problem solvingThis error is initiated when the individual(s) committing the error experience information overload. The right set of decisions is not made based on too many details to process mentally.
A3B2C04Previous success in use of rule reinforces continued use of ruleIf a rule for behavior has been used successfully in the past, there is an overwhelming tendency to apply the rule again, even though circumstances no longer warrant the use of the rule.
A3B2C05Situation incorrectly identified or represented results in wrong rule usedIndividual(s) interpret facts based on training and experience that have helped form stored mental knowledge from which the individual(s) rely on to help interpret the facts. When the individual(s) use the stored knowledge, the right set of training and experience is sometimes not selected based on the existing facts. A broader search of the stored knowledge would have been necessary to explain the existing facts.
A3B3Knowledge based errorWas the problem solved without using stored rules for behavior? Were you in a problem solving/troubleshooting mode? A3B3C01 Attention given to wrong issues Selective mental processing of information is targeted at the wrong issues and is not focused on the right issues. Often the individual(s) focus is centered around what is psychologically important instead of targeted on what is logically important.
A3B3C02LTA conclusion based on sequencing of factsIndividual(s), when establishing a timeline or recalling step-by-step compilation of facts as they occur in an event sometimes reorder the sequence which affects the conclusion based on the facts.
A3B3C03Individual justifies action by focusing on biased evidence Individual(s) are overconfident in evaluating the correctness of their knowledge. The chosen course of action is selected based on evidence that favors it and contradictory evidence is overlooked.
A3B3C04LTA review based on assumption that process will not changeIndividual(s) believe that no variability exists in the process and overlook the fact that a change has occurred leading to differing results than normally realized.
A3B3C05Incorrect assumption that a correlation exists between two or more factsWrong assumptions are made based on the belief that two or more facts are related to each other and incorrect actions are taken based on the assumption.
A3B3C06Individual underestimates the problem by using past events as basisIndividuals tend to oversimplify events. Based on stored knowledge of past events, the individual(s) underestimates problems with the existing event and plans for fewer contingencies than will actually be needed.
A3B4Work practices LTAWas the capacity to perform work impaired? Was the act to incorrectly perform work deliberate?
A3B4C01Individual capabilities to perform work LTAa) Sensory/Perceptual Capabilities LTA - Was the problem due to less that adequate vision [e.g., poor visual acuity, color blindness, tunnel vision]? Was the problem due to some defect in hearing [e.g., hearing loss, tone deafness]? Was the problem due to some sensory defect [e.g., poor sense of touch or smell]?
b) Motor/Physical Capabilities LTA - Can the causal factor be attributed to trouble with inadequate coordination or inadequate strength? Was the problem due to inadequate size or stature of the individual involved? Did other physical limitations [e.g., shaking, poor reaction time] contribute to the problem?
c) Attitude/Psychological Profile LTA - Was the problem due to a poor attitude on the part of an individual? Did the individual involved show signs of emotional illness?
A3B4C02Deliberate violationWas the action on the part of the individual a deliberate action to commit human error?
A4Management ProblemAn event or condition that can be directly traced to managerial actions or methods. A "management" problem may be attributed to management methods (directions, monitoring, assessment, accountability, and corrective action), inadequate resource allocation, work organization and planning, supervisory methods and/or change management practices.
A4B1Management methods LTAThis evaluates the processes used to control or direct work-related plant activities, including how manpower and material is allocated for a particular objective. Management is considered to be any individual above the immediate supervision. This cause section addresses management-controlled practices and policies and requires that the investigator gain familiarity with the standards or expectations that exist for performing work. Examples of standards are: using required procedures, using signature and check-off blanks in a step-by-step fashion and N/A or N/R as required, using work control and tag-out systems when performing work and repeat-backs during communications, etc. Recurring events may indicate a problem in this area since this implies either living with known problems or that previously implemented corrective actions were inadequate or were not implemented in a timely manner.
A4B1C01Management policy guidance/expectations not well-defined understood or enforcedPersonnel exhibited a lack of understanding of existing policy and/or expectations, or policy/expectations were not well-defined or complete.
A4B1C02Job performance standards not adequately definedMeasurement of effectiveness could not be performed for specific job functions due to lack of defined standards.
A4B1C03Personnel exhibited insufficient awareness of impact of actions on safety/reliabilityManagement failed to provide direction regarding safeguards against non-conservative actions by personnel concerning nuclear safety or reliability.
A4B1C04Management follow-up or monitoring of activities did not identify problemsManagement's methods for monitoring the success of initiatives were ineffective in identifying shortcomings in the implementation.
A4B1C05Management assessment did not determine cause of previous event or known problemAnalysis methods failed to uncover the causal factors of consequential or non-consequential events.
A4B1C06Previous industry or in-house experience was not effectively used to prevent recurrenceIndustry or in-house experience relating to a current problem existed prior to the problem, but was not assimilated by the organization.
A4B1C07Responsibility of personnel not well defined or personnel not held accountableResponsibility for process elements (procedures, engineering, training, etc.) was not placed with individuals or accountability for failures of those process elements was not placed with individuals.
A4B1C08Corrective action responses to a known or repetitive problem was untimelyCorrective action for known or recurring problems was not performed at or within the proper time.
A4B1C09Corrective action responses to a known or repetitive problem was not adequate to prevent recurrenceManagement failed to take meaningful corrective action for consequential or non-consequential events.
A4B2Resource management LTAEvaluation of the processes whereby manpower and material are allocated to successfully perform assigned tasks. B2 serves as an expansion to B1, Management Methods, since both B1 and B2 are important inter-related factors. B2 provides more in-depth causal nodes for evaluating manpower and material issues impacting performance of work-related activities, including work-related activities performed under a procurement action such as contract services.
A4B2C01Too many administrative duties assigned to immediate supervisorThe administrative load on immediate supervisors adversely affected their ability to supervise ongoing activities.
A4B2C02Insufficient supervisory resources to provide necessary supervisionSupervision resource is less than that required by task analysis considering the balance of procedures, supervision and training.
A4B2C03Insufficient manpower to support identified goal/objective Personnel were not available as required by task analysis of goal/objective.
A4B2C04Resources not provided to ensure adequate training is provided/maintainedTraining resources were not available as required by task analysis.
A4B2C05Needed resource changes not approved/fundedCorrective actions for existing deficiencies that were previously identified were not approved or funded.
A4B2C06Means not provided to ensure procedures/documents/records are of adequate quality and up to dateA process for changing procedures or other work documents to assure quality and timeliness was nonexistent or inadequate.
A4B2C07Means not provided for assuring adequate availability of appropriate materials/toolsA process for supplying personnel with appropriate materials or tools did not exist.
A4B2C08Means not provided for assuring adequate equipment quality, reliability, or operabilityA process for assuring personnel's equipment was satisfactory did not exist.
A4B2C09Personnel selection did not ensure match of worker motivations/job descriptionsPersonnel selection processes failed to determine a mismatch between motivation and job description prior to task.
A4B2C10Means/method not provided for ensuring adequate services contract qualityA process for assuring quality contract services was being provided was nonexistent or inadequate.
A4B3Work organization & planning LTAThis category considers problems in how the work to be performed was organized. This would include work scope, planning, assignment and scheduling of a task to be performed. The investigator should review copies of applicable job orders, work packages, etc., to assess applicability of this cause category. While B3 addresses the organization and planning of work, failures in this node usually imply related failures in Supervisory Methods addressed in B4. A4B3C01 Insufficient time for worker to prepare task Scheduling of the task did not adequately address the time frame required for accepted worker preparation practices to occur.
A4B3C02Insufficient time allotted for taskScheduled duration of the task did not adequately address known conditions or account for reasonable emergent issues.
A4B3C03Duties not well-distributed among personnelThe work loading of individuals within a group or team did not adequately address training, experience, task frequency and duration, or other situational factors such that responsibility was inappropriately distributed.
A4B3C04Too few workers assigned to taskJob planning did not allot a realistic number of man-hours based on the scope of work described.
A4B3C05Insufficient number of trained or experienced workers assigned to taskThough the overall number of personnel assigned matched the planned man-hour allotment, organization methods failed to identify that the personnel assigned did not have adequate experience or training to perform the work.
A4B3C06Planning not coordinated with inputs from walkdowns/task analysisThe job plan did not incorporate information gathered during field visits or task analysis concerning the steps and conditions required for successful completion of the task.
A4B3C07Job scoping did not identify potential task interruptions and/or environmental stressThe work scoping process was not effective in detecting reasonable obstructions to work flow (e.g., shift changes) or the impact of environmental conditions.
A4B3C08Job scoping did not identify special circumstances and/or conditionsThe work scoping process was not effective in detecting work process elements having a dependency upon other circumstances or conditions.
A4B3C09Work planning not coordinated with all departments involved in taskInterdepartmental communication and teamwork were not supported by the planned work flow.
A4B3C10Problem performing repetitive tasks and/or subtasksThe work flow plan repeated tasks or sub tasks to the detriment of successful completion of the evolution.
A4B3C11Inadequate work package preparationThough scoping and planning were adequately performed, the work package did not reflect the information gathered from these activities.
A4B4Supervisory methods LTAThis category identifies causes that can be traced back to the immediate supervision and evaluated techniques that were used to monitor, direct and control work assignments. These problems are suspected in situations where better planning, preparation, selection of workers, better teamwork or supervision of work in progress could possible have prevented the incident. Information can be obtained during interviews with the supervisor and the personnel performing the work to determine if supervision was performed and if adequate feedback on job performance was received as the job progressed.
A4B4C01Tasks and individual accountability not made clear to workerTasks (and the individual accountability for the task) that were outside written guidance or training were not made clear to the worker.
A4B4C02Progress/status of task not adequately trackedSupervision did not take the appropriate actions to monitor the task progress or status.
A4B4C03Appropriate level of in-task supervision not determined prior to taskSupervision did not adequately assess the task for points of supervisory interaction prior to assignment to workers.
A4B4C04Direct supervisory involvement in task interfered with overview role Supervision became so involved with the actual task steps that overall command and control were adversely affected.
A4B4C05Emphasis on schedule exceeded emphasis on methods/doing a good jobAccepted standards for methods were not met due to supervision's focus on completing the activity within a certain time frame.
A4B4C06Job performance and self-checking standards not properly communicatedSupervision failed to adequately communicate how standards for job performance and self-checking could be applied to the actual job at hand.
A4B4C07Too many concurrent tasks assigned to workerSupervision failed to detect that concurrent job assignments for an individual exceeded the individual's abilities.
A4B4C08Frequent job or task shufflingSupervision transferred a worker from one task to another without adequate time to shift attention away from previous task.
A4B4C09Assignment did not consider worker's need to use higher order skills Supervision did not consider the worker's talents or innovative strengths that could be used to perform more challenging work.
A4B4C10Assignment did not consider worker previous taskSupervision did not adequately assess the previous task's impact upon the worker's ability to implement the current task.
A4B4C11Assignment did not consider worker's ingrained work patternsSupervision failed to assess the incompatibility between worker's ingrained work patterns and necessary work patterns for successful completion of the current task.
A4B4C12Contact with personnel too infrequent to detect work habit/attitude changesSupervision not aware of deviation from desired work habits/attitudes due to lack of interaction with personnel.
A4B4C13Provided feedback on negative performance but not on positive performanceWorker's performance adversely affected by supervision's focus on negative performance feedback.
A4B5Change Management LTAThis category considers the process by which changes are controlled and implemented by management as organizational needs change to accommodate new business needs. When change occurs in organizations, problems can occur from the fact that consideration was not given to the impact of the change on other components of the system and its related processes. When combined with other organizational or system changes occurring at or near the same time, potential for error increases if change management techniques and methods are not factored in as part of the new change being implemented.
A4B5C01Problem identification did not identify need for changeExisting problem identification methods did not recognize the difference between actual practices and expectations.
A4B5C02Change not implemented in timely mannerA change in expectations was not realized in practices within an acceptable time period.
A4B5C03Inadequate vendor support of changeManagement failed to adequately assess the ability of vendors to supply products or services in support of changing expectations for a particular objective.
A4B5C04Risks/consequences associated with change not adequately reviewed/assessedElements of the process change were not recognized as having adverse impact or increased risk of adverse impact prior to implementing the change.
A4B5C05System interactions not consideredChanges to processes or physical systems caused interactions with other processes or physical systems that had were not identified prior to implementation.
A4B5C06Personnel/department interactions not consideredChanges to processes created new requirements for interaction between personnel or departments that were not considered in the implementation phase of the change.
A4B5C07Effects of change on schedules not adequately addressed Changes to processes that resulted in scheduled changes had effects on personnel or equipment that were not addressed in the change implementation.
A4B5C08Change related training not performed or not adequate Changes to processes resulted in a need for new training or revisions to existing training activities that were not performed or were not adequate to meet the needs of the new process.
A4B5C09Change related documents not developed or revised Changes to processes resulted in a need for new forms of written communication which were not created or changes to existing documents which were not revised.
A4B5C10Change related equipment not provided or not revisedChanges to processes resulting in a need for new or revised software/hardware which was not provided or revised.
A4B5C11Changes not adequately communicatedChanges to processes were not communicated to affected personnel effectively.
A4B5C12Changes not identifiable during taskChanges to processes were not distinguishable from the previous process such that personnel performance of the change was adversely affected.
A4B5C13Accuracy/effectiveness of change not verified or not validatedVerification/validation practices for process changes failed to identify inaccurate or ineffective methods.
A5Communications LTAInadequate presentation or exchange of information. "Communications" is defined as the act of exchanging information. Each individual involved in the occurrence should be questioned regarding messages he/she feels should have been received or transmitted. Determine what means of communication was used [i.e., the technique]. Persons on all sides of a communication link should be questioned regarding known or suspected problems.
A5B1Written communications method of presentation LTAProblems with visual attributes of accurate information.
A5B1C01Format deficienciesDid the layout of the written communication make it difficult to follow? Did the format differ from that which the user was accustomed to using? Were the steps of the procedure logically grouped?
A5B1C02Improper referencing or branchingDid the written communication refer to an excessive number of additional procedures? Did the written communication contain numerous steps of the type "Calculate limits per procedure XYZ"? Was the written communication difficult to follow because of excessive branching to other procedure? Did the written communication contain numerous steps of the type "If X, then go to procedure ABC. If Y, then go to procedure EFG." Did references to the different processes and areas contribute to the event?
A5B1C03Checklist LTAWas an error made because each separate action in a step did not have a checkoff space provided? Was the checklist confusing? Did each instruction clearly indicate what was required? Was enough room provided for the response? Did it require unique responses for each step?
A5B1C04Deficiencies in user aids (charts, etc.)Was an error made because graphics or drawings were of poor quality? Were the graphics or drawings unclear, confusing, or misleading? Were graphics, including datasheets, legible?
A5B1C05Recent changes not made apparent to userWas the written communication user required to carry out an action different from those he was accustomed to doing? Did the written communication identify that the step for this action had been revised? Did the written communication user perform the action as the previous revision specified rather than the current revision?
A5B1C06Instruction step/information in wrong sequenceWere the instructions/steps in the written communication out of sequence?
A5B1C07Unclear/complex wording or grammarWording, grammar or symbols fail too clearly and concisely specify the required action: instructions provided for team of users fail to specify roles of each user.
A5B2Written communication content LTAAny written document used to perform procedures, work orders, memos, standing orders, vendor manuals, surveillance, etc. Investigation of written communications problems requires a copy of the applicable document[s] for review.
A5B2C01Technical InaccuraciesWere limits expressed clearly and concisely? Were limits or permissible operating ranges expressed in absolute numbers instead of a ( format?
A5B2C02Difficult to implementWere Standards Policies and Administrative Controls not followed because no practical way of implementing them existed? Would implementation have hindered production?
A5B2C03Data/computations wrong/incompleteWas the error made because of a mistake in recording or transferring data? Were calculations made incorrectly? Was the formula or equation confusing? Did it have multiple steps?
A5B2C04Equipment identification LTAWas the equipment identification too generic? Did equipment identification or labeling in the field agree with the identification in the procedure?
A5B2C05Ambiguous instructions/requirementsWere the instructions in the written communication unclear, uncertain, or interpretable in more than one way? Did different procedures related to the same task contain different requirements? Were their conflicting or inconsistent requirements stated in different steps of the same procedure? Were requirements stated in different units?
A5B2C06Typographical errorWas a typographical error in the written communication responsible for the event?
A5B2C07Facts wrong/requirements not correctWas specific information in the written communication incorrect? Did the written communication contain current requirements? Did the written communication reflect the current status of equipment?
A5B2C08Incomplete/situation not coveredWere details of the written communication incomplete? Was sufficient information presented? Did the written communication address all situations likely to occur during the completion of the document?
A5B2C09Wrong revision usedWas the wrong revision of the written communication used?
A5B3Written communication not usedWas written communication used to do the job? Did the written communication exist for the job? Was the written communication system required to be used or was it just for training?
A5B3C01Lack of written communicationDid some form of written communication exist for the job task being performed?
A5B3C02Not available or inconvenient for useWas the written communication readily available? Was there a copy of the written communication in the designated file or rack? Was there a "master copy" or the written communication available for reproductions? Was the written communication use inconvenient because of working conditions (e.g., radiation areas, tight quarters, and plastic suits)? Considering the training and experience of the user, was the written communication too difficult to understand or follow? Was there sufficient information to identify the appropriate written communication? Was the written communication designed for the "less practiced" user?
A5B4Verbal communication LTAThis general cause category focuses on the transmission or receiving of information by voice or signal. This segment addresses many modes of communication [e.g., face-to-face, telephone, radio, and video display terminal]. It does not address the more formal methods of communication involving written procedures, specifications, etc. Each individual involved in the occurrence should be questioned regarding messages he/she believes should have been received or transmitted.
A5B4C01Communication between work groups LTADid lack of communication between work groups [production, technical, or support] contribute to the incident? Did methods exist for communicating between work groups?
A5B4C02Shift communications LTADid lack of communication between management and the shifts contribute to the incident? Had management effectively communicated policies to the employees? Were concerns of employees communicated to management? Was there incorrect, incomplete, or otherwise inadequate communication between workers during a shift? Could a more effective method of communication have been used?
A5B4C03Correct terminology not usedWas standard or accepted terminology used? Could the communication be interpreted more than one way? Did one piece of equipment have two or more commonly used names? Could the terminology have applied to more than one item?
A5B4C04Verification/repeat back not usedWas a communication error caused by failure to repeat back a message to the sender for the purposes of verifying that the message was heard and understood correctly?
A5B4C05Information sent but not understoodWas there incorrect, incomplete or otherwise lack of communication between personnel and their supervision? Why was the problem not communicated to supervision? Could different methods of communication be used to help personnel communicate with supervision?
A5B4C06 Suspected problem not communicated to supervisionWas a message or instruction misunderstood because of noise interference?
A5B4C07No communication method availableDid a method or system exist for communicating the necessary message or information? Was the communication system out of service or otherwise unavailable at the time of the incident?
A6Training deficiencyAn event or condition that can be traced to a lack of training or insufficient training to enable a person to perform a desired task adequately. A training deficiency is usually exposed by a human error, so the use of this branch of the CAT should be coupled with the Human Performance branch.
A6B1No training providedHad the task been identified? Had the task been identified for training? Had the training requirements been identified? Had training on the task been developed? Had training been conducted?
A6B1C01Decision not to trainWas the decision made not to provide specific training on a task? Were some employees not required to receive training? Was experience considered a substitute for training?
A6B1C02Training requirements not identifiedWas training on the task part of the employee's training requirements? Had the necessary training been defined for the job description?
A6B1C03Work considered skill of the craftWas the work a 'skill' that could only be developed through extensive job experience? Did the operator have enough experience in the job to develop this "skill-of-the-craft"? Were provisions made to assure operators have developed this "skill-of-the-craft" prior to assignment to this task?
A6B2Training methods LTAWas the correct training setting used? Was there enough practice (or hands-on) time allotted?
A6B2C01Practice or hands on experience LTADid the on-the-job training provide opportunities to learn skills necessary to perform the job? Was there sufficient on-the-job training? Was there an inadequate amount of preparation before performing the activity? Had the employee previously performed the task under direct supervision?
A6B2C02Testing LTADid testing cover all the knowledge and skills necessary to do the job? Did testing adequately reflect the trainees ability to perform the job?
A6B2C03Refresher training LTAWere training updates performed? Was continuing training performed to keep employees equipped to perform non-routine tasks? Was the frequency of continuing training adequate? The frequency of refresher training was not sufficient to maintain the required knowledge and skills.
A6B2C04Inadequate presentationWere the qualifications for the instructor adequate? Did the qualification include all that is necessary to perform training on this task? Was the instructor who performed the training qualified on this task? Was the training equipment adequate? Were simulators used? Was the equipment used in training like that used on the job?
A6B3Training content LTAWere job/task analyses adequate? Were the program design and objective complete? Did the training have adequate instructors and facilities? Was the task identified for refresher training? Was refresher training performed? Does testing adequately measure the employee's ability to perform the task? Does training include normal and abnormal/emergency working conditions?
A6B3C01Training objectives LTADid the task analysis correctly identify the knowledge and skills necessary to complete the task? Was the proper setting identified in which to train the operator? Were the objectives written to accurately represent the task analysis? Did the objective satisfy the needs identified in the task analysis? Did the objectives cover all of the requirements necessary to successfully complete the task?
A6B3C02Inadequate contentDid the lesson content address all the training objectives? Did the lessons contain all the information necessary to perform the job? The knowledge and skills required to perform the task or job were not identified.
A6B3C03Training on new work methods LTAWas training provided when the work methods for this task were changed? Was training provided on changes to the procedure for the task? Was training provided on new equipment used to perform the task?
A6B3C04Performance standards LTAWere the requirements for performance on a system stringent enough? Did meeting the standards for training qualification on a task provide sufficient training to perform the task under normal, abnormal, and emergency conditions?
A7Other problemThis 'A' node is a compilation of two nodes of the ORPS tree. The use of these codes is restricted to ORPS causal analysis only.
A7B1External phenomenaAn event or condition caused by factors that are not under the control of the reporting organization or the suppliers of the failed equipment or service.
A7B1C01Weather or ambient conditionUnusual weather or ambient conditions, including hurricanes, tornadoes, flooding, earthquake, and lightning.
A7B1C02Power failure or transientSpecial cases of power loss that are attributable to outside supplied power.
A7B1C03External fire or explosionAn external fire, explosion, or implosion.
A7B1C04Other natural phenomenaThis node covers all natural phenomena not addressed by A7B1C1, for example, animal intrusion.
A7B2Radiological/hazardous material problemAn event related to radiological or hazardous material contamination that cannot be attributed to any of the other causes.
A7B2C01Legacy contaminationRadiological or hazardous material contamination attributed to past practices.
A7B2C02Source unknownRadiological or hazardous material contamination where the source cannot be reasonably determined.