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Assessment and Causal Analysis: Enforcement Lessons-Learned

HSS. Office of Health, Safety and Security. Assessment and Causal Analysis: Enforcement Lessons-Learned. ISM Workshop 2007 Tony Weadock Office of Enforcement. HSS. Office of Health, Safety and Security. Overview. Enforcement Program Performance Issue

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Assessment and Causal Analysis: Enforcement Lessons-Learned

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  1. HSS Office of Health, Safety and Security Assessment and Causal Analysis:Enforcement Lessons-Learned ISM Workshop 2007 Tony Weadock Office of Enforcement

  2. HSS Office of Health, Safety and Security Overview • Enforcement Program • Performance Issue • Assessment Program - strengths and weaknesses • Causal Analysis - strengths and weaknesses • Enforcement response and path forward

  3. HSS Office of Health, Safety and Security Enforcement Program • HQ office • Network of coordinators • Authority to issue civil penalties • Issue average of 10 nuclear safety actions/year

  4. HSS Office of Health, Safety and Security Program Changes • New Office and Staff • Expanded scope • 10 CFR 851 • 10 CFR 824

  5. HSS Office of Health, Safety and Security Enforcement Approach • Contractors best positioned to recognize and correct noncompliances • Incentives • Discretion • Mitigation (self-reporting and corrective actions) • Formal reporting to NTS or ITAC • Enforcement actions pursued for significant and egregious noncompliances

  6. HSS Office of Health, Safety and Security Enforcement Approach(cont.) • To date (nuclear safety): • Reviewed between 10 – 15K potential cases • 104 Enforcement Actions • $8.8 M imposed in civil penalties • $5.7 M waived • 6 Consent Orders • Nuclear safety approach is model for security and worker safety enforcement

  7. HSS Office of Health, Safety and Security Performance Issue How does Enforcement evaluate contractor performance? • Monitors events, NTS, assessments, etc. • Investigations • Program Reviews

  8. HSS Office of Health, Safety and Security Performance (cont.) • Significant percentage of serious nuclear safety violations are not self-identified • Majority of enforcement cases involve recurrent events or issues • Conclusion – need to improve the identification and correction of nuclear safety problems

  9. HSS Office of Health, Safety and Security Performance (cont.) • Resulting emphasis on review of causal analysis and assessment processes • Enforcement Director acts as visible advocate • Goal – assessment driven vs. event driven • Business case

  10. HSS Office of Health, Safety and Security Assessment ProgramGeneral • Management and independent assessment (830.122(i) and (j)) • See more issues with management assessment • Evaluate (from a high level) as part of the Program Review process • Investigations – event follow-up presents opportunity to evaluate assessment program

  11. HSS Office of Health, Safety and Security Assessment ProgramStrengths • Peer Reviews • Effectiveness Reviews • Focus on fewer, more significant assessments • Increased use of site tracking systems – better trending of issues • SMEs used to critique management assessments

  12. HSS Office of Health, Safety and Security Assessment ProgramWeaknesses • Perfunctory, checklist approach • Unqualified assessors – functional area and process • Too much information – can be misleading • Human resources • Inconsistent terminology • No formal tracking or disposition of issues • Lack of critical self-evaluation of program • Lack of perceived value by management

  13. HSS Office of Health, Safety and Security Causal AnalysisGeneral • 10 CFR 830.122(c)(3) – Quality Improvement • Graded approach • Multiple methods in use

  14. HSS Office of Health, Safety and Security Causal AnalysisStrengths • Formalization of instances when root cause analysis is required • Extent of condition (and cause) • Incorporation of Human Performance Improvement • Use of causal analysts in reviewing corrective actions • Effectiveness reviews

  15. HSS Office of Health, Safety and Security Causal AnalysisWeaknesses • Truncate before getting to underlying issues • Cause terminology more conducive to trending than developing corrective actions • Focusing on part of the problem • Extent of condition/cause not evaluated

  16. HSS Office of Health, Safety and Security Weaknesses (cont.) • Precursors not evaluated • Tendency to avoid cultural issues • Poor linkage between causes and corrective actions • Corrective actions not completed or timely

  17. HSS Office of Health, Safety and Security Enforcement Response • Increased emphasis • Escalation of penalties • EGS 05-01 (since incorporated into Enforcement Process Overview)

  18. HSS Office of Health, Safety and Security EGS 05-01 Enforcement evaluation includes looking for: • Extent of condition review • Precursor review • Evaluation of assessment effectiveness

  19. HSS Office of Health, Safety and Security Path Forward • Continue emphasis/escalation • Support peer review process • Continuing dialogue • HS-40 sponsors EFCOG Safety and Security Regulatory and Contractor Assurance Working Groups • Expediting enforcement process • Integrating VPP

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