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Download A system for the feedback of experience from events in by International Atomic Energy Agency PDF

By International Atomic Energy Agency

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The response as well as the causes). The aim should be to provide both the technical details of the event and the lessons concerning human performance in ways that can be understood and applied easily to other situations. g. in the planning and scheduling of work, training, supervision, work practices, written instructions and the work environment). When there are latent weaknesses in any of these systems, conditions may exist that are likely to lead to errors. Information about previous malfunctions should also be provided.

In some cases the involvement of additional expertise in the cause analysis should be considered. Very often the notions of immediate (direct, observed) causes, root causes and contributing factors are used in the cause analysis. Cause identification should be carried out for the formulation of corrective actions. The depth of the causal analysis should be adequate for ensuring the determination of appropriate corrective actions. Numerous methods of root cause analysis, many having a similar basis, have been developed or are under development for addressing the connection between root causes and corrective actions (see the annexes).

An event and causal factors chart) should be started immediately and should be continuously updated as new data are obtained. 9. Investigators should prepare a written report and should present it to the management group that commissioned the investigation. In some cases there will be a request for corrective actions to be taken that are commensurate with the identified root causes. The investigation should include: — Preparing progress reports and other interim reports documenting significant activities, findings and concerns; — Ensuring safety, as appropriate, at the scene of the incident; — Ensuring that the investigative activities do not result in adverse impacts on the rest of the plant; — Ensuring that the plant management is advised of the status of the investigation and of progress and future plans in relation to it; 41 — Initiating requests for information, interviews with witnesses, laboratory tests and technical or administrative support; — Maintaining control over information and material collected as part of the investigation of an event.

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