In July 2017, the Organization 630 senior manager requested that an assessment of selected causal analyses be performed for the period from July 2014 to July 2017. As a result, this assessment reviewed causal analyses performed by or for Environment, Safety and Health (ES&H) Center department personnel during the specified period. The purpose was to determine the degree to which ES&H Center personnel learn from use of the causal analysis process.
The 04100 Center Director requested an analysis of 2016 occurrence reports (ORs) involving electrical energy be performed to facilitate learning through use of performance assurance methodologies. Preliminarily, 11 reportable events were identified for review; however, this population was updated to 12 during the review. Appendix 1 includes the analysis protocol and a listing of the ORs reviewed. The Team completed its review at the end of October 2016. At that time, causal analysis and associated corrective action information was available for eight events. Elements of this analysis included determining the following: common weaknesses that contributed to electrical events; the quality of causal analysis products with the goal of providing sustainable long-term corrective actions; and how learning from issues, causes, and corrective actions from prior similar events is incorporated into causal analyses for today’s events. As used in this report, the term “trends” was used as a catalyst to determine categories of events for deeper analysis. The content of ORs is important. The information in an OR for a past event can be useful in addressing today’s issues because it provides information on systemic issues that were found and past actions addressing those issues. The effectiveness of those actions as viewed from today’s vantage point is useful input to the determination of corrective actions for current problems. Additionally, as a means of communication to DOE and NNSA, ORs provide a measure of Sandia’s maturity in understanding problems and their solutions.
A key element of successful world-class technical organizations is the ability to learn from problems, large and small. Mature technical organizations have procedures that support this learning process, but it is not the procedures alone that cause the organization to succeed. Organizational success is the result of managers understanding the objectives of learning from problems and the discipline managers bring to bear to follow through on corrective actions. Following through includes checking if the actions fixed the problem and to implement alternate actions if the original actions did not achieve the objectives.