1. A1 Design / Engineering Problem
1.1. B1 DESIGN INPUT LTA
1.1.1. C01 Design input cannot be met
1.1.2. C02 Design input obsolete
1.1.3. C03 Design input not correct
1.1.4. C04 Necessary design input not available
1.2. B2 DESIGN OUTPUT LTA
1.2.1. C01 Design output scope LTA
1.2.2. C02 Design output not clear
1.2.3. C03 Design output not correct
1.2.4. C04 Inconsistent design output
1.2.5. C05 Design input not addressed in design output
1.2.6. C06 Drawing, specification, or data error
1.2.7. C07 Error in equipment or material selection
1.2.8. C08 Errors not detectable
1.2.9. C09 Errors not recoverable
1.3. B3 DESIGN / DOCUMENTATION LTA
1.3.1. C01 Design / documentation not complete
1.3.2. C02 Design / documentation not up-to-date
1.3.3. C03 Design / documentation not controlled
1.4. B4 DESIGN / INSTALLATION VERIFICATION LTA
1.4.1. C01 Independent review of design / documentation LTA
1.4.2. C02 Testing of design / installation LTA
1.4.3. C03 Independent inspection of design / installationLTA
1.4.4. C04 Acceptance of design / installation LTA
1.5. B5 OPERABILITY OF DESIGN / ENVIRONMENT LTA
1.5.1. C01 Ergonomics LTA
1.5.2. C02 Physical environment LTA
1.5.3. C03 Natural environment LTA
2. A2 Equipment / Material Problem
2.1. B1 CALIBRATION FOR INSTRUMENTS LTA
2.1.1. C01 Calibration LTA
2.1.2. C02 Equipment found outside acceptance criteria
2.2. B2 PERIODIC / CORRECTIVE MAINTENANCE LTA
2.2.1. C01 Preventive maintenance for equipment LTA
2.2.2. C02 Predictive maintenance LTA
2.2.3. C03 Corrective maintenance LTA
2.2.4. C04 Equipment history LTA
2.3. B3 INSPECTION / TESTING LTA
2.3.1. C01 Start-up testing LTA
2.3.2. C02 Inspection / testing LTA
2.3.3. C03 Post-maintenance / Post modification testing LTA
2.4. B4 MATERIAL CONTROL LTA
2.4.1. C01 Material handling LTA
2.4.2. C02 Material storage LTA
2.4.3. C03 Material packaging LTA
2.4.4. C04 Material shipping LTA
2.4.5. C05 Shelf lifeexceeded
2.4.6. C06 Unauthorized material substitution
2.4.7. C07 Marking / labeling LTA
2.5. B5 PROCUREMENT CONTROLLTA
2.5.1. C01 Control of changes to procurement specifications / purchase order LTA
2.5.2. C02 Fabricated item did not meet requirements
2.5.3. C03 Incorrect item received
2.5.4. C04 Product acceptance requirements LTA
2.6. B6 DEFECTIVE, FAILED OR CONTAMINATED
2.6.1. C01 Defective or failed part
2.6.2. C02 Defective or failed material
2.6.3. C03 Defective weld, braze or soldering joint
2.6.4. C04 End of life failure
2.6.5. C05 Electrical or instrument noise
2.6.6. C06 Contaminant
3. A3 Human Performance LTA
3.1. B1 SKILL BASEDERROR
3.1.1. C01 Check of work was LTA
3.1.2. C02 Step was omitted due to distraction
3.1.3. C03 Incorrect performance due to mental lapse
3.1.4. C04 Infrequently performed steps were performed incorrectly
3.1.5. C05 Delay in time caused LTA actions
3.1.6. C06 Wrong action selected based on similarity with other actions
3.1.7. C07 Omission / repeating of steps due to assumptions for completion
3.2. B2 RULE BASEDERROR
3.2.1. C01 Strong rule incorrectly chosen over other rules
3.2.2. C02 Signs to stopwere ignored and step performed incorrectly
3.2.3. C03 Too much activitywas occurring and error made in problem solving
3.2.4. C04 Previous success in use of rule reinforced continued use of rule
3.2.5. C05 Situation incorrectly identified or represented resulting in wrong rule used
3.3. B3 KNOWLEDGE BASED ERROR
3.3.1. C01 Attention was given to wrong issues
3.3.2. C02 LTA Conclusion based on sequencing of facts
3.3.3. C03 Individual justified action by focusing on biased evidence
3.3.4. C04 LTA review based on assumption that process will not change
3.3.5. C05 Incorrect assumption that a correlation existed between two or more facts
3.3.6. C06 Individual underestimated the problem by using past events as basis
3.4. B4 WORK PRACTICES LTA
3.4.1. C01 Individual's capability to perform work LTA [Examples include: Sensory / perceptual capabilities LTA, Motor / physical capabilities LTA, and Attitude / psychological profile LTA.]
3.4.2. C02 Deliberate violation
4. A5 Communications LTA
4.1. B1 WRITTEN COMMUNICATIONS METHOD OF PRESENTATION LTA
4.1.1. C01 Format deficiencies
4.1.2. C02 Improper referencing or branching
4.1.3. C03 Checklist LTA
4.1.4. C04 Deficiencies in user aids (charts, etc.)
4.1.5. C05 Recent changes not made apparent to user
4.1.6. C06 Instruction step / information in wrong sequence
4.1.7. C07 Unclear / complex wording or grammar
4.2. B2 WRITTEN COMMUNICATION CONTENT LTA
4.2.1. C01Limit inaccuracies
4.2.2. C02 Difficult to implement
4.2.3. C03 Data / computations wrong / incomplete
4.2.4. C04 Equipment identification LTA
4.2.5. C05 Ambiguous instructions / requirements
4.2.6. C06 Typographical error
4.2.7. C07 Facts wrong / requirements not correct
4.2.8. C08 Incomplete / situation not covered
4.2.9. C09 Wrong revision used
4.3. B3 WRITTEN COMMUNICATION NOT USED
4.3.1. C01 Lack of written communication
4.3.2. C02 Not available or inconvenient for use
4.4. B4 VERBAL COMMUNICATION LTA
4.4.1. C01 Communication between work groups LTA
4.4.2. C02 Shift communications LTA
4.4.3. C03 Correct terminology not used
4.4.4. C04 Verification / repeat back not used
4.4.5. C05 Information sent but not understood
4.4.6. C06 Suspected problems not communicated to supervision
4.4.7. C07 No communication method available
5. A6 Training Deficiency
5.1. B1 NO TRAINING PROVIDED
5.1.1. C01 Decision not to train
5.1.2. C02 Training requirements not identified
5.1.3. C03 Work incorrectly considered "skill of the craft"
5.2. B2 TRAINING METHODS LTA
5.2.1. C01 Practice or hands-on experience LTA
5.2.2. C02 Testing LTA
5.2.3. C03 Refresher training LTA
5.2.4. C04 Inadequate presentation
5.3. B3 TRAINING MATERIAL LTA
5.3.1. C01 Training objectives LTA
5.3.2. C02 Inadequate content
5.3.3. C03 Training on new work methods LTA
5.3.4. C04 Performance standards LTA
6. A7 Other Problem
6.1. B1 EXTERNAL PHENOMENA
6.1.1. C01 Weather or ambient conditions LTA
6.1.2. C02 Power failure or transient
6.1.3. C03 External fire or explosion
6.1.4. C04 Other natural phenomena LTA
6.2. B2 RADIOLOGICAL / HAZARDOUS MATERIAL PROBLEM
6.2.1. C01 Legacy contamination
6.2.2. C02 Source unknown
7. A4 Management Problem
7.1. B1 MANAGEMENTMETHODS LTA
7.1.1. C01 Management policy guidance/ expectations not well-defined, understood or enforced
7.1.2. C02 Job performance standards not adequately defined
7.1.3. C03 Management direction created insufficient awareness of impact of actions on safety / reliability
7.1.4. C04 Management follow-up or monitoring of activities did not identify problems
7.1.5. C05 Management assessment did not determine causes of previous event or known problem
7.1.6. C06 Previous industry or in-house experience was not effectively used to prevent recurrence
7.1.7. C07 Responsibility of personnel not well-defined or personnel not held accountable
7.1.8. C08 Corrective action responses to a known or repetitive problem was untimely
7.1.9. C09 Corrective action for previously identified problem or event was not adequate to prevent recurrence
7.2. B2 RESOURCE MANAGEMENT LTA
7.2.1. C01 Too many administrative duties assigned to immediate supervisor
7.2.2. C02 Insufficient supervisory resources to provide necessary supervision
7.2.3. C03 Insufficient manpower to support identified goal / objective
7.2.4. C04 Resources not provided to assure adequate training was provided / maintained
7.2.5. C05 Needed resource changes not approved / funded
7.2.6. C06 Means not provided to assure procedures / documents / records were of adequate quality and up-to-date
7.2.7. C07 Means not provided for assuring adequate availability of appropriate materials / tools
7.2.8. C08 Means not provided for assuring adequate equipment quality, reliability, or operability
7.2.9. C09 Personnel selection did not assure match of worker motivations / job descriptions
7.2.10. C10 Means / method not provided for assuring adequate quality of contract service
7.3. B3 WORK ORGANIZATION & PLANNING LTA
7.3.1. C01 Insufficient time for worker to prepare task
7.3.2. C02 Insufficient time allotted for task
7.3.3. C03 Duties not well-distributed among personnel
7.3.4. C04 Too few workers assigned to task
7.3.5. C05 Insufficient number of trained or experienced workers assigned to task
7.3.6. C06 Planning not coordinated with inputs from Walk downs/ task analysis
7.3.7. C07 Job scoping did not identify potential task interruptions and / or environmental stress
7.3.8. C08 Job scoping did not identify special circumstances and / or conditions
7.3.9. C09 Work planning not coordinated with all departments involved in task
7.3.10. C10 Problem performing repetitive tasks and / or subtasks
7.3.11. C11 Inadequate work package preparation
7.4. B4 SUPERVISORY METHODS LTA
7.4.1. C01 Tasks and individual accountability not made clear to worker
7.4.2. C02 Progress / status of task not adequately tracked
7.4.3. C03 Appropriate level of in-task supervision not determined prior to task
7.4.4. C04 Direct supervisory involvement in task interfered with overview role
7.4.5. C05 Emphasis on schedule exceeded emphasis on methods / doing a good job
7.4.6. C06 Job performance and self-checking standards not properly communicated
7.4.7. C07 Too many concurrent tasks assigned to worker
7.4.8. C08 Frequent job or task "shuffling"
7.4.9. C09 Assignment did not consider worker's need to use higher-order skills
7.4.10. C10 Assignment did not consider worker's previous task
7.4.11. C11 Assignment did not consider worker's ingrained work patterns
7.4.12. C12 Contact with personnel too infrequent to detect work habit/attitude changes
7.4.13. C13 Provided feedback on negative performance but not on positive performance
7.5. B5 CHANGE MANAGEMENT LTA
7.5.1. C01 Problem identification did not identify need for change
7.5.2. C02 Change not implemented in timely manner
7.5.3. C03 Inadequate vendor support of change
7.5.4. C04 Risks / consequences associated with change not adequately reviewed / assessed
7.5.5. C05 System interactions not considered
7.5.6. C06 Personnel / department interactions not considered
7.5.7. C07 Effects of change on schedules not adequately addressed
7.5.8. C08 Change-related training / retraining not performed or not adequate
7.5.9. C09 Change-related documents not developed or revised
7.5.10. C10 Change-related equipment not provided or not revised
7.5.11. C11 Changes not adequately communicated
7.5.12. C12 Change not identifiable during task
7.5.13. C13 Accuracy / effectiveness of change not verified or not validated