Preparing the Organization for Common Cause Analysis为常见原因分析准备组织.pptVIP

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Preparing the Organization for Common Cause Analysis为常见原因分析准备组织.ppt

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Preparing the Organization for Common Cause Analysis为常见原因分析准备组织

Presented by Michael D. Salazar Human and Organizational Performance Improvements ?2002 Common Cause Analysis (CCA) Is not Root Cause Analysis Does not prevent salient events Is an ongoing long term process Is aimed at correcting the cause(s) of dysfunctional behaviors Successful CCA requires 3 things Process Mapping Behavior Categorization Trending Process Mapping What are the critical steps of the task? Process Mapping What Barriers Prevent Error Propagation? Behavior Categorization(Why people don’t do what is expected.) Doesn’t understand “what” the behavior does. Doesn’t understand “how” to use the behavior. Doesn’t understand “when” to use the behavior. Cannot demonstrate “effective” use of the behavior. Does not understand “expectation” for use of the behavior. Does not understand “benefit” of using the behavior. (WIFM) “Consequences” of not using the behavior consequences of using the behavior. (cultural drivers) Other Considerations Process Missing critical step Sequencing problem Branching problem Over specification Under specification Design Limitations Behavior No behavior specified Wrong behavior specified Relying on behavior when risk is too great (SPS) Example: Undesired Equipment Actuation What they said in the interviews. What do These Events Tell Us? Different Events Different Departments Different People All using STAR Good Candidates for CCA Analyze the Steps Pull PT Drawer Actuate Handswitch Pull PC Board Lift Wires Irreversible Action Irreversible Action Irreversible Action Irreversible Action Don’t Miss Other Considerations Bottom Fuses or Bottom PT Drawer? No Indication of Pump Status? Confusing PPS Layout? Two Wires on One Terminal? Sequence Error, Go to XX PT Drawer, Pull Bottom Fuses Missing Critical Step, Check Pump Status Under specification, Include PPS Layout Design Limitation, Better Place to Lift Lead? Fix All the Causes Assign Actions to fix the “Other Considerations. ” Create Defense in Depth Assign Actions to Fix “Common Cau