Root cause analysis at the Savannah River Plant

Events (or near misses) provide important information about ways to improve plant performance. Any particular event may have several /open quotes/root causes/close quotes/ that need correcting to prevent recurrence of the event and, thereby, improve the safety of the plant. Also, by reviewing a large number of events, one can identify cause trends or /open quotes/generic concerns./close quotes/ A method has been developed at Savannah River Plant (SRP) to systematically evaluate events, identify their root causes, record the root causes, and analyze the root cause trends. By providing a systematic method to identify correctable root causes, the system helps the event investigator ask the right questions during the investigation. It also provides an independent safety analysis group and management with statistics indicating existing and developing trouble spots. 3 refs., 4 figs