Best of The Root Cause Network™ Newsletter – Beat ‘Em or Lead ‘Em … A Tale of Two Plants

Note: We have decided to republish articles from the Root Cause Network™ Newsletter that we find particularly interesting and still applicable today. These are used with the permission of the original publisher. In some cases, we have updated some parts of the text to keep them “current,” but we have tried to present them in their original form as much as possible. If you enjoy these reprints, let us know. You should expect about two per month.

BEAT ‘EM OR LEAD ‘EM
A TALE OF TWO PLANTS

You’re the VP of a 1000 MW nuclear power plant. A senior reactor operator in the control room actuates the wrong valve.

The turbine trips.

The plant trips.

If the plant had just 30 more days of uninterrupted operation, your utility would have been eligible for a better rate structure based on the Public Service Commission’s (PUC) policy that rewards availability. Now you can kiss that hefty bonus check (that is tied to plant performance goals) goodbye.

To make matters worse, during the recovery, a technician takes a “shortcut” while performing a procedure and disables several redundant safety circuits. An inspector catches the mistake, and now the Nuclear Regulatory Commission (the plant’s nuclear safety regulator, the NRC) is sending a special inspection team to assess the plant’s culture. That could mean days, weeks, or even months of downtime due to regulatory startup delays.

What do you do???

PLANT 1 – RAPID ACTION

He who hesitates is lost!

Corporate expects heads to roll!

You don’t want to be the first, so you:

1. Give the operator a couple of days off without pay. Tell him to think about his mistake. He should have used STAR! If he isn’t more careful next time, he had better start looking for another job.
2. Fire the technician. Make him an example. There is NO excuse for taking a shortcut and not following procedures. Put out another memo telling everyone that following procedure is a “condition of employment.”
3. Expedite the root cause analysis. Get it done BEFORE the NRC shows up. There is no time for detailed analysis. Besides, everyone knows what’s wrong – the operator and technician just goofed up! (Human error is the cause.) Get the witch-hunt over fast to help morale.
4. Write a quick report. Rapid action will look good to the regulator. We have a culture that does not accept deviation from strict rules and firing the technician proves that. Tell them that we are emphasizing the human performance technology of STAR. Maybe they won’t bother us anymore.
5. Get the startup preparation done. We want to be ready to go back on-line as soon as we can to get the NRC off our backs, and a quick start-up will keep the PUC happy.

PLANT 2 – ALTERNATIVE ACTION

No one likes these types of situations, but you are prepared, so you:

1. Start a detailed root cause analysis. You have highly trained operations and maintenance personnel, system and safety engineers, and human factors professionals to find correctable root causes. And your folks don’t just fly by the seat of their pants. They are trained in a formal investigation process that has been proven to work throughout a variety of industries – TapRooT®! It helps them be efficient in their root cause analysis efforts. And they have experts to help them if they have problems getting to the root causes of any causal factors they identify.
2. Keep the NRC Regional Office updated on what your team is finding. You have nothing to hide. Your past efforts in sharing your root cause analyses have given them confidence that you will conduct a thorough investigation.
3. “Keep the hounds at bay.” Finding the real root causes of problems takes time to perform a trough investigation. Resist the urge (based on real or perceived pressure) to give in to knee-jerk reactions. You don’t automatically punish those involved. Yoiu believe your people consistently try to do their best. You have avoided the negative progression that starts with a senseless witch-hunt, progresses to fault-finding, and results in future lies and cover-ups.
4. Check to see that the pre-staged corrective maintenance has started. Plant down time – even unscheduled forced outages – is too valuable to waste. You use every chance to fix small problems to avoid the big ones.
5. Keep up to date on the root cause analysis team’s progress. Make sure you do everything in your power to remove any roadblocks that they face.
6. Get ready to reward those involved in the investigation and in developing and implementing effective corrective actions. This is a rare opportunity to showcase your team’s capabilities in the heat of battle. Reward them while the sweat is still on their brow.
7. Be critical of the investigation that is presented to you. Check that all possible root causes were looked into. Publicly ask: “What could I have done to prevent this incident?” Because of your past efforts, the team will be ready for good questions and will have answers.

DIFFERENCES

Which culture is more common in your industry?

Which plant would you rather manage?

Where would you rather work?

What makes Plant 1 and Plant 2 so different? It is really quite simple…

• Management Attitude: A belief in your people means that you know they are trying to do their best. There is no higher management purpose than to help them succeed by giving them the tools they need to get the job done right.
• Trust: Everyone trusts everyone on this team. This starts with good face-to-face communications. It includes a fair application of praise and punishment after a thorough root cause analysis.
• Systematic Approach and Preparation: Preparation is the key to success and the cause of serendipity. Preparation requires planning and training. A systematic approach allows outstanding performance to be taught and repeated. That’s why a prepared plant uses TapRooT®.

Which plant exhibited these characteristics?

HOW TO CHANGE

Can you change from Plant 1 to Plant 2? YES! But how???

The first step must be taken by senior managers. The right attitude must be adopted before trust can be developed, and a systematic approach can succeed.

Part of demonstrating your belief in your people is making sure they have the tools they need. This includes:

• Choosing an advanced, systematic root cause analysis tool (TapRooT®).
• Adopting a written accident/incident investigation policy that shows management’s commitment to thorough investigations and detailed root cause analysis.
• Creating a database to trend incident causes and track corrective actions to completion.
• Training people to use the root cause analysis tool and the databases that go with it.
• Making sure that people have time to do proper root cause analysis, help if things get difficult, and the budget to implement effective corrective actions.
• Providing a staff to assist with and review important incidents, to trend investigation results, and to track the implementation of corrective actions and report back to management on how the performance improvement system is performing.

Once the proper root cause analysis methods (that look for correctable root causes rather than placing blame) are implemented and experienced by folks in the field, trust in management will become a forgone conclusion.

YOU CAN CHANGE

Have faith that your plant can change. If you are senior management, take the first step: Trust your people.

Next, implement TapRooT® to get to the real, fixable causes of accidents, incidents, and near-misses. See Chapter 6 of the © 2008 TapRooT® Book to get great ideas that will make your TapRooT® implementation world-class.

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Copyright 2014 by System Improvements, Inc. Adapted from an article in the March 1992 Root Cause Network™ Newsletter (© 1992 by System Improvements – used by permission) that was based on a talk given by Mark Paradies at the 1990 Winter American Nuclear Society Meeting. It was inspired by Charles Dickens ‘ classic work: A Tale of Two Cities.