Problem Manifestation.pdf

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Problem ManifestationThe Firebird Forum, Volume 15, Number 2, February, 2012, Special Issue

Problem Manifestation(How they are found does matter.)

The Firebird Forum, Volume 15, Number 2, February, 2012, Special Issue

William R. Corcoran, Ph.D., P.E.NSRC Corporation

(860) [email protected]

Page 1 of 19, 2012 W. R. Corcoran, NSRC Corporation
mailto:[email protected]:[email protected]:[email protected]


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Problem Manifestation

(How they are found does matter.)

ByWilliam R. Corcoran, Ph.D., P.E.

PresidentNSRC Corporation

Windsor, CT860-285-8778

[email protected]

Abstract: The effort to solve problems often unintentionally detracts from efforts todetermine the methods by which the harmful factors and their symptoms couldhave been found by earlier, better, safer, and cheaper ways. Many of the classicdisasters of the recent past could have been averted by earlier detection of the

previously latent harmful conditions, behaviors, actions, or inactions as well asother active harmful conditions, behaviors, actions, or inactions that had not beeninvolved in earlier seriously consequential events. These issues are explored andsome countermeasures are proposed.

Introduction:

This topic should be revisited whenever an organization wants to reduce the

recurrence of being blindsided by problems. This is because at least one of thefactors of every unintended adverse consequential event is that the harmful factorsthat resulted in the consequences had not been detected and addressed earlier. Thisis self-evident and axiomatic. No exceptions have ever been identified.

For example, one of the harmful factors of the Davis-Besse 2002 near miss loss-of-coolant accident was the continued failure to clean the reactor vessel head beforeinspecting it, but another harmful factor was the failure to find that the reactorvessel head was not being properly cleaned. The second type of harmful factor iswhat we are focusing on now.

One of the guaranteed fruitful lines of inquiry in any causal analysis investigationis previously dysfunctional problem identification and resolution. Any root causeanalysis investigation that neglects this line of inquiry is bypassing a majoropportunity for improvement. An organization need not and should not wait for

mailto:[email protected]:[email protected]:[email protected]


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1. What were the earlier, better, safer, cheaper, more regulationcompliant, more socially responsible, more businesslike ways the

problem or its harmful factors could have been found before theproblem was manifested?

2. What is it about the way business is done that kept the organizationfrom finding the harmful factors in earlier, better, safer, cheaper, moreregulation compliant, more socially responsible, more businesslikeways before the problem was manifested?

How Problems are Manifested

The severe consequences, problems in their own right, are manifested by theevents that have those consequences. Their harmful factors, also problems in theirown right, are manifested by the investigations of the consequences.

But what are the other ways that harmful factors are can be manifested? Someapproaches will be discussed in what follows.

Precursors

When consequential events have had precursors2 the casual factors of the eventscould have been found by investigation of the precursor events. This method is notideal, but it is certainly earlier, better, safer, and cheaper than finding the harmful

factors by means of the current (avoidable) event.

Both ChallengerandColumbia had many precursors, none of which were highlyconsequential. Some of these precursors might, in some eyes at least, rise to thelevel of near misses. Thus, one should include the investigation of near misses asanother way that problems are manifested.

The Three Mile Island accident had a relatively non-consequential precursor atDavis-Besse in 1977. If the thinking of this article had been applied to it thenuclear power community may well have been spared the trauma of the 1979 coredamage event.

All previous similar events were precursors to the later events to which they weresimilar. Thus in-house operating experience (OE) includes precursors. Thus the useof OE becomes one of the earlier, better, safer, cheaper, more regulation compliant,

2http://darwin.nap.edu/books/0309092167/html/79.html

http://darwin.nap.edu/books/0309092167/html/79.htmlhttp://darwin.nap.edu/books/0309092167/html/79.html


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more socially responsible, more businesslike ways the harmful factors of theproblem could have been found before the problem was manifested.

In some organizations calling an event a precursor can be career-limiting. In some

organizations a person calling an event a near miss is considered not to be a teamplayer. These are culture issues to be addressed separately.

The Occurrence Pyramid

The Occurrence Pyramid can be viewed as a cost hierarchy of problem findingopportunities. Between the Near Miss layer and the Consequential layer there is astep change in costs and other consequences. See Figure 1 below.

Problems can be found by the investigation of compromises and infractions as wellas by investigation of near misses and consequentials. Anecdotal experience, atleast, indicates that the harmful factors of the compromises and infractions includethe harmful factors of the near misses and consequentials.

Figure 1 Each level of the Occurrence Pyramid gives options for problem

finding.



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Since it is clear that at least one of the necessary harmful factors of everyconsequential event is that the other harmful factors were not found earlier, at leastone of the corrective actions for every consequential event should involve

correcting the problem identification processes that did not identify those harmfulfactors in a more desirable way. One way of looking at this is called ProblemDistance.

Problem Distance

In the high hazard industries work is done by processes. Processes have steps.Whenever a problem is manifested in one process step it is always found that it had

been created in some earlier process step and missed in some number ofintermediate process steps. See Figure 2.

Problem Distance (in steps) is the number of steps from the step in which theproblem is created to the step in which it is manifested.

Every process step is an opportunity to introduce a problem. Every process step isalso an opportunity to find problems that were introduced at that step or at earliersteps.

Obviously, the problems that were not identified included those that were not

sufficiently transparent. (Transparency is doing business in such a way thatproblems are easy to see3.)

In general, the more transparent a process, the smaller the average problemdistance. This is one of the motivations for having transparency as a processspecification.

Transparency can be a deliberate design objective in processes. Every processfeature that makes it easier to find problems and/or harder to miss them is atransparency feature.

Of course when a problem is found at one step it is time to ask, What were theearlier, better, safer, cheaper, more regulation compliant, more sociallyresponsible, more businesslike ways the problem or its harmful factors could have

been found at this step and at earlier steps?

3See The Firebird Forum Vol. 14 No.2 on Transparency



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Just fixing the found problem is not a prudent approach, yet this is often done. Aproblem is a terrible thing to waste.

Figure 2 One might like problem distance to be zero.

Clearly it is cheaper to change a drawing than it is to rip out re-bar. Clearly it ischeaper to discover that a work order lacks acceptance criteria than it is to dealwith the consequences of incomplete work, as in the case of Davis-Besse. TheDavis-Besse issue, like many others, would have been headed off by an ordinarilyeffective pre-job brief

4, in which, for example, a person present would have asked,

How will we know we are done cleaning the reactor vessel head? or What are

the critical steps of this task?

Thus one is well-advised to fix the process step at which the problem was createdas well as all of the intervening process steps that could have detected the problem

44See The Firebird Forum Vol. 15 No.1 on Pre-job Briefs



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but did not do so. Especially relevant are review steps that add no value unless theydetect incoming problems.

Note that every problem caused, in part, by a defective procedure or work

instruction could have been prevented by detecting the defective procedure or workinstruction at any one of several process steps before the task execution.

Learning organizations strive to reduce the problem distance to zero by finding theproblems where they are created. They then fix the problem and the factors thatresulted in its creation.

Levels of Defense of Quality (and Safety)

In most, if not all, high hazard industries there are multiple levels of defense ofquality and safety. See Figure 3.

Figure 3 When all four levels fail consequentials occur.

In order to have a consequential event there must have been failures in all fourlevels of defense of quality. Clearly it is better to find the problems when they arelatent harmful conditions, behaviors, or inactions than when they have activatedand become involved in consequences.



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These latent harmful conditions, behaviors, or inactions and/or their deeperunderlying harmful factors and/or problems within their extent can be found at anylevel of defense. When they are not found until a consequential event occurs itmight make sense to ask, What is it about the way business is done at each of the

four levels that allows the latent harmful conditions, behaviors, or inactions to existuntil they become involved in consequential events?

Notice that it takes missed opportunities at all four levels to have a consequentialevent. Thus corrective actions to the problem identification process in each of thefour levels are needed.

Oversight, a Special Case

The following applies to external oversight as well as internal oversight.Dysfunctionally, there is often a taboo against criticizing oversight. This ofteninsulates oversight organizations from both feedback and accountability andreinforces their tendency toward denial of accountability for the revealed problems.

Thus, if oversight organizations are to improve, they must criticize themselves.They must ask themselves the question, What is it about the way we do businessthat allows the latent harmful factors to exist until they become involved inconsequential events?

In high performance organizations the oversight units do their own missedopportunity analyses on their own shortfalls that contributed to consequentialevents and near misses. In exceptional oversight organizations, when oversightfinds a problem, it does a missed opportunity analysis to determine what it is aboutthe way oversight does business that prevented it from finding the problem earlier.It does not just congratulate itself on finding the problem.

When There is a Major Problem

Major problems present special opportunities for reviewing how problems aremanifested. One need not be reminded that one of the reasons that major problemsarise is that their constituent underlying harmful factor problems were not foundand/or effectively addressed earlier.

It takes a lot to have a major problem. Perhaps that explains their infrequency.



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The model given below in Figure 4 fits most, if not all, known major problems.The possible exceptions are, perhaps, natural disasters that were correctly notdesigned for. The Fukushima meltdowns may be a possible example.

As the figure illustrates, every major problem begins with a technical issue. Failureto manage the technical issue effectively eventually results in the major problem.

For example, at Davis-Besse the technical issue involved Alloy 600 and itsmechanical and chemical environments. That technical issue has been effectivelymanaged in all other similar nuclear facilities.

At Three Mile Island the issue was the vulnerability of instrument air to waterintrusion.

The presence of a technical issue is not unusual. Thus avoiding technical issues asa strategy for avoiding major problems should not be expected to be uniformlysuccessful.

Finding and correcting other weaknesses of the types indicated in the figure hasmore promise. Tolerating those weaknesses sets the stage for a major problem.

Every box in the model (other than, perhaps, the Technical Issue box) representsone or more missed opportunities to have headed the problem off earlier. The

missed opportunities that are not addressed represent temporarily latent issues thatwill contribute to the next major problem.



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Figure 4 Most major problems to date fit the model.

In Figure 5 on the next page the major problem recipe picture is displayed in theform of a factors-consequences matrix. It shows, perhaps more clearly, how toavoid major problems.

In the left hand column the harmful factors resulting in a major problem are listedabove the consequence. The rest of the columns show the actual case and sixhypothetical cases. Each hypothetical case indicates the effect of negating one ofthe harmful factors.


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Figure 5 Factors-consequences Matrix for Major Problem



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Whats Better?

Latent problems are the ones found before they cause any harm. Other problems

are manifested after some harm, perhaps minimal, occurs. When they are foundafter the event they are previously latent.

It is better to find the latent problems before an event than it is to find thepreviously latent problems during the investigation.

The most cost-effective mode of manifestation is when the problem is found on thefirst pass by a person who is accountable for it. Other modes are less cost-effective.

The seven basic modes of problem manifestation are:

1. The problem is found by a person accountable for it.2. The problem is found by an accountable persons management.3. The problem is found by an independent assessor.4. The problem is found by an external assessor.5. The problem is manifested by an adverse event that it was a harmful factor

of.6. The problem is manifested by an adverse event that it was not a harmful

factor of.

7. The problem is manifested by the report of a concerned stakeholder whogoes public with it or reports it outside the normal process.Downstream Identified Adverse Conditions (DIAC)

A Downstream Identified Adverse Condition (DIAC) is an adverse condition thatwas identified downstream in the process flow from where it first existed andtherefore could have been identified. It is challenging to imagine an identifiedadverse condition that is not a DIAC.

In a functional organization every identified adverse condition is treated as a DIACin that the organization always asks,

1. What were the earlier, better, safer, cheaper, more regulationcompliant, more socially responsible, more businesslike ways the

problem or its harmful factors could have been found before theproblem was manifested?



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2. What is it about the way business is done that kept the organizationfrom finding the harmful factors in earlier, better, safer, cheaper, moreregulation compliant, more socially responsible, more businesslikeways before the problem was manifested?

The functional organization relentlessly probes the processes to identify all of theupstream missed opportunities and establishes measures to reduce the likelihoodthat they will be missed in the future.

200% Accountability

In most processes in high hazard industries there are chains of interfaces. At eachinterface there is a provider who is providing a product or a service to a userwho accepts it and makes use of it.

When looking at problem identification ask, Who is accountable for identifyingproblems at an interface?

Is the provider 100% accountable for the quality/safety of the item provided? Isthe user 100% accountable for the quality/safety of the item accepted?

The answer is yes. Both are fully accountable.

When a defective item crosses an interface there are three problems to be dealtwith: 1) the defective item, 2) the non-detection by the provider, and 3) the non-detection by the user. The prudent organization will determine each of the threesets of factors.

A tragic example involved a weapon used in a drill. It was supposed to have beenloaded with blanks. It was picked up by a drill organizer and furnished to a drill

participant. The error was manifested when another drill participant was killed.

Identifying the accountabilities is a way of identifying missed opportunities forearlier, better, cheaper.ways to find problems. See Figure 6.



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Figure 6 Every time a problem goes through an interface there are

three problems. The problem itself and two non-detection problems.

Not For Root Cause Analysts Only

There are many missed opportunity analysis tools, which, if used artfully, can givevaluable insights into how problems could have been detected earlier, safer,cheaper.

For example:

Factor Trees could include harmful conditions, behaviors, or inactions fornon-detection of the harmful factors in the trees.

The Comparative TimeLine (CTL) could include the reviews, inspections,surveillances, sign-offs, etc. that could have detected the latent harmfulconditions, behaviors, or inactions while they were still latent.



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The Barrier Analysis Matrix (BAM) could include the missing,ineffective, and failed barriers. Note that BAM can be expressed inchronological order the same as the Comparative TimeLine.

The Missed Opportunity Matrix (MOM) could include the individuals andorganizations that could have affected detection processes. Note that BAMcan be expressed in chronological order the same as the ComparativeTimeLine. For a Missed Opportunity Analysis, the Chronological MissedOpportunity Matrix (CMOM) would probably be a preferred way to showthe work.

The Previous Similar Occurrence Analysis could include the precursors ofthe current event, whose root cause analyses may have elements that belongin the Factor Tree, the CTL, the BAM, and/or the MOM/ CMOM.

The Lines of Inquiry for the overall investigation can include specificaspects of Problem Identification and Resolution.

The recommended corrective actions should consider:

Fixing the problems, of course. Fixing the processes that created the problems. Fixing the processes that should have detected the problems and their

harmful factors before the event.

One of the lines of inquiry for such an investigation could well include, What is itabout the way business is done that allowed the problem detection processes to be

the way they were?

Interim Conclusions

Since there is so much more to be said about problem manifestation, lets wrap upfor now with some indisputable conclusions.

1. The cost of dealing with a problem is a strong function of how long itsharmful factors have been allowed to exist. The longer the harmful factors

work the more harm they do.2. It can, therefore, be as important to deal with how a problem was found as it

is to deal with the problem itself.3. Consequential problems are reliable evidence of improvement opportunities

in problem identification and resolution.4. Problem identification and resolution deficiencies are always involved in the

causation of highly consequential events.



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5. Every high hazard enterprise should ask how the problem du jourwasmanifested and what were the earlier, safer, better, cheaper ways to find itand its harmful factors.

6. Missed opportunity analysis should be an expectation in every case of aproblem identified inappropriately.

7. An analysis of extent (i.e., extent of condition and extent of cause) shouldfollow every missed opportunity analysis.

8. Harmful factors that meet the organizations definition of root cause areoften the result of deeper important harmful factors that merit identificationand correction.

Some Folk Wisdom of Problem Manifestation

The following non-scientific folk wisdom can be useful in explaining some of theabove concepts to personnel who come from cultures in which the above conceptsseem strange:

The Real Standards:Expression 1: The real standard is what is tolerated.Expression 2: Its not what is expected; its what is inspected andcorrected.Expression 3: Problems that are not fixed become an accepted part ofthe landscape.

The Kitty Litter Principle:Version 1: To find the lumps you need to dig beneath the surface.Version 2: If you dig beneath the surface you will find the lumps.

The Cockroach Principle:Version 1: Cockroaches never travel alone.Version 2: If you see one on the kitchen floor there are thirty underthe refrigerator.

The Waste Principle:A problem is a terrible thing to waste.



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Some Expectations for Problem Identification

10CFR50, Appendix B, Criterion XVI: Corrective Actions:

Measures shall be established to assure that conditions adverse toquality, such as failures, malfunctions, deficiencies, deviations,defective material and equipment, and non-conformances are

promptly identified and corrected.

NRC Traits for a Strong Nuclear Safety Culture (NRC-2010-0282 FinalSafety Culture Policy Statement)

Problem Identification and Resolution: Issues potentially impactingsafety are promptly identified, fully evaluated, and promptlyaddressed and corrected commensurate with their significance

Questioning Attitude: Individuals avoid complacency andcontinuously challenge existing conditions and activities in order toidentify discrepancies that might result in error or inappropriateaction.

INPO Principles for a Strong Nuclear Safety Culture

A questioning attitude is cultivated: Individuals demonstrate aquestioning attitude by challenging assumptions, investigatinganomalies, and considering potential adverse consequences of plannedactions. All employees are watchful for conditions or activities thatcan have an undesirable effect on plant safety.

Training Opportunities:

Bill Corcoran will be leading one day Root Cause Analysis Training Sessions inconjunction with the American Nuclear Society 2012 Utility Working Conferenceat Hollywood, FL on August 9, 2012 (more athttp://www.new.ans.org/meetings/c_2 ).

http://www.new.ans.org/meetings/c_2http://www.new.ans.org/meetings/c_2


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Page 19 of 19 2012 W R Corcoran NSRC Corporation

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