All nuclear power plants incorporate root-cause analysis as an instrument to help identify and isolate key factors judged to be of significance following an incident or accident. Identifying the principal deficiencies can become very difficult when the event involves not only human and machine interaction, but possibly the underlying safety and quality culture of the organization. The current state of root-cause analysis is to conclude the investigation after identifying human and/or hardware failures. In this work, root-cause analysis is taken one step further by examining plant work processes and organizational factors. This extension is considered significant to the success of the analysis, especially when management deficiency is believed to contribute to the incident. The results of roof-cause analysis can be most effectively implemented if the organization, as a whole, wishes to improve the overall operation of the plant by preventing similar incidents from occurring again. The study adds to the existing root-cause analysis the ability to localize the causes of undesirable events and to focus on those problems hidden deeply within the work processes that are routinely followed in the operation and maintenance of the facility. References: 42
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