IDENTIFYING ORGANIZATIONAL DEFICIENCIES THROUGH ROOT-CAUSE ANALYSIS

All nuclear power plants incorporate root-cause analysis as an instrum ent to help identify and isolate key factors judged to be of significa nce following an incident or accident. Identifying the principal defic iencies can become very difficult when the event involves not only hum an and machine interaction, but possibly the underlying safety and qua lity culture of the organization. The current state of root-cause anal ysis is to conclude the investigation after identifying human and/or h ardware failures. In this work, root-cause analysis is taken one step further by examining plant work processes and organizational factors. This extension is considered significant to the success of the analysi s, especially when management deficiency is believed to contribute to the incident. The results of roof-cause analysis can be most effective ly implemented if the organization, as a whole, wishes to improve the overall operation of the plant by preventing similar incidents from oc curring again. The study adds to the existing root-cause analysis the ability to localize the causes of undesirable events and to focus on t hose problems hidden deeply within the work processes that are routine ly followed in the operation and maintenance of the facility.