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["Code","Verbal Description","Definition"]
["A1","Design/Engineering Problem ","An event or condition that can be traced to a defect in design or other factors related to configuration, engineering, layout, tolerances, calculations, etc.  Note: even though Engineering is explicitly only in the branch title, its use throughout this branch is implicit.  Also, it is Engineering as a function or process, not as a job title. "]
["A1B1","DESIGN INPUT LTA ","Input to a design that was lacking adequate information that was necessary for the design. "]
["A1B1C01","- Design input cannot be met","The criteria and other requirements were so stringent that they could not be met. There were conflicting criteria. Not all of the necessary references were included"]
["A1B1C02","- Design input obsolete","The criteria were out-of-date. An old version of a requirement or specification was used. Process requirements/conditions changed and the changes were omitted from the input. "]
["A1B1C03","- Design input not correct","The wrong standards or requirements were used. The requirements were transcribed in error"]
["A1B1C04","- Necessary design input not available","The necessary requirements, codes, standards, etc. were not available to the designer"]
["A1B2","DESIGN OUTPUT LTA","Inadequate design output that did not meet the customer’s expectations or design requirements"]
["A1B2C01","- Design output scope LTA","The design did not consider all the possible scenarios. All the operating conditions, [normal and emergency] were not included in the design"]
["A1B2C02","- Design output not clear","The drawings were difficult to read. The specifications were difficult to understand. The specification could be interpreted in more than one way. "]
["A1B2C03","- Design output not correct","The drawings and other specifications were incorrect. The final design output did not include all changes. "]
["A1B2C04","- Inconsistent design output","There were differences between different output documents. The drawings and other design documents did not agree."]
["A1B2C05","- Design input not addressed in Design output","The specifications did not include all the requirements. Some criteria were left out of the design output. "]
["A1B2C06","– Drawing, specification or data error","The latest drawing revision was not referenced. The latest vendor information was not included in the design documentation. The correct data was not noted on the design documentation request. "]
["A1B2C07","- Error in equipment or material selection","The correct vendor identification number was not used for procurement of equipment. The correct grade of stainless steel was not specified for the material. Error in equipment selection to obtain a desired affect."]
["A1B2C08","- Errors not detectable","Personnel were unable to detect errors [by way of alarms or instrument readings] during or after the occurrence. A serious error went unnoticed because there was no way to monitor system status."]
["A1B2C09","– Errors not recoverable","The system was designed such that personnel were unable to recover from error discovered before a failure occurred. "]
["A1B3","DESIGN/DOCUMENTATION LTA","Design or documentation that did not include all of the required information and did not comply with document control and record requirements"]
["A1B3C01","– Design / documentation not complete","The designs and other documentation for equipment were incomplete. Items were missing from the documentation. A complete baseline did not exist. "]
["A1B3C02","– Design / documentation not up-to-date","Drawings and documents were not updated when changes were made. Documents/drawings did not reflect the current status. "]
["A1B3C03","– Design / documentation not controlled","The design documentation was not controlled per site requirements for document control and records."]
["A1B4","DESIGN/INSTALLATION VERIFICATION LTA","Design reviews, testing, independent inspections, and acceptance were not in compliance with customer expectations and/or site requirements"]
["A1B4C01","- Independent review of design / documentation LTA","A required review was not performed on the design, or a review was not performed by an independent reviewer. The design had problems passing the functional testing. "]
["A1B4C02","- Testing of design / installation LTA","Testing was not included as part of the design acceptance process. The testing did not verify the operability of the design. Design parameters did not successfully pass all testing criteria. "]
["A1B4C03","- Independent inspection of design / installation LTA","Independent Inspection attributes were not included in the design installation. Required Hold/Witness points were not verified by Quality Assurance (QA). Hold/Witness points did not pass the acceptance criteria. Commercial Grade Material was not adequately dedicated and documented. "]
["A1B4C04","- Acceptance of design / installation LTA","The customer had problems with acceptance of the design, testing, and/or verification. "]
["A1B5","OPERABILITY OF DESIGN/ENVIRONMENT LTA ","Personnel or environmental factors were not considered as part of the design"]
["A1B5C01","- Ergonomics LTA","Inadequate ergonomic design contributed to the occurrence. - The operator was physically incapable of performing the required task.  The operator had to go too far to respond to the alarm.  Personnel mobility or vision was restricted.  An individual had difficulty reaching the equipment or assumed an awkward position to complete a task.  The event was caused because illumination levels were not sufficient for task performance. "]
["A1B5C02","- Physical environment LTA","Inadequate equipment controls or control systems [e.g., push-buttons, rotary controls, J-handles, key-operated controls, thumb-wheels, multiple switches, joysticks] contributed to the occurrence. The control failed to provide an adequate range of control for the function it performs. The control was inadequately protected from accidental activation. Similar controls were indistinguishable from one another. Controls were in too close proximity of each other. Operating conditions [e.g. room temperature, work location, physical location, restricted vision, personal protective equipment, excessive noise, arrangement or placement of equipment] affected performance of the task. Lighting was inadequate. Noise was a factor. "]
["A1B5C03","- Natural environment LTA","Exposure to heat, cold, wind, and rain was not included in the design. Earthquake tested devices were not included in the design. System was not designed to withstand flooding, freezing, or high wind conditions. Lightning suppressing devices were not included in the design. The event was caused by excessive exposure of personnel to a hot or cold environment. "]
["A2","Equipment/Material Problem","Is defined as an event or condition resulting from the failure, malfunction, or deterioration of equipment or parts, including instruments or material. "]
["A2B1","CALIBRATION FOR INSTRUMENTS LTA","Calibrations did not include all the essential elements. Equipment as-found condition was less than adequate. "]
["A2B1C01","- Calibration LTA","The equipment involved in the incident was not included in a routine calibration program. Calibrations were performed too infrequently. The calibration did not include all the essential elements. "]
["A2B1C02","- Equipment found outside acceptance criteria","An event occurred as a result of equipment that was found outside of the specified acceptance criteria. The instrument calibration drift was outside of the acceptable range. Process instrumentation was outside of acceptable range criteria due to a standard that was out of calibration. "]
["A2B1C03","- Coordinated tuning or adjustments of instrumentation LTA","An event occurred as a result of multiple pieces of controls for equipment or instrumentation, where adjustment of one requires the coordinated adjustment(s) of others did not occur, or was performed incorrectly."]
["A2B2","PERIODIC/CORRECTIVE MAINTENANCE LTA","Periodic maintenance was not established for the equipment, instrument or component. The periodic maintenance was inadequate. Corrective maintenance was inadequate to correct the problem. Equipment history did not exist for the instrument or component. The equipment history was incomplete. "]
["A2B2C01","- Preventive maintenance for equipment LTA","An equipment malfunction was caused by a failure to perform scheduled preventive maintenance. Preventive maintenance was not established for the equipment or component that failed. Preventive maintenance was scheduled too infrequently. The preventive maintenance was incomplete. Preventive maintenance was performed on some of the components but not on others. (Note: Preventive maintenance is a maintenance program which is cyclical, it is done based on a repetitive basis based on some characteristic (numbers of operations, time, etc.))"]
["A2B2C02","- Predictive maintenance LTA","Predictive maintenance was not established for the equipment. The established frequency was inadequate to prevent or detect equipment degradation. The established method used to prevent or detect equipment degradation was inadequate. (Note: Predictive maintenance is a maintenance program which is based on the analysis of some characteristic of operations or equipment, when conditions (other than those of a cyclic nature) indicate it is time to perform the maintenance.)"]
["A2B2C03","- Corrective maintenance LTA","Corrective maintenance was performed but failed to correct the originating problem. The equipment or component was reassembled improperly during corrective maintenance. Other problems were noted during maintenance activities that were not corrected. The actual job of performing a maintenance activity was complete, but was not performed correctly. "]
["A2B2C04","– Equipment history LTA","Equipment history / records did not exist for the equipment that malfunctioned. The history for the equipment that malfunctioned was incomplete / inadequate. The history did not contain all the information necessary to assure equipment reliability. Knowledge of equipment history would have prevented the incident or lessened its severity. "]
["A2B3","INSPECTION/TESTING LTA","Scheduled inspection/testing did not exist for the instrument or equipment. The inspection/testing was inadequate or not performed as required. The inspection/testing did not include all the essential elements. Note: A1B4 should be used for Design Testing. "]
["A2B3C01","– Start-up testing LTA","Functional testing did not exist for the equipment or system prior to placing them in service. Start-up testing was inadequate for the equipment or system being placed into service. "]
["A2B3C02","– Inspection / testing LTA","Required testing / inspection was not established or performed for the equipment involved in the incident. The required testing / inspection was performed at an incorrect frequency. The acceptance criteria for the required testing / inspection were inadequately defined. All essential components were not included in the required testing / inspection. "]
["A2B3C03","– Post-maintenance / post-modification testing LTA","The post-maintenance or post-modification testing specified was not performed or was performed incorrectly. The post-maintenance or post-modification testing was completed, but the testing requirements were less than adequate. The post-maintenance or post-modification testing was not performed in accordance with the schedule for testing. "]
["A2B4","MATERIAL CONTROL LTA","The problem was due to the inadequate handling, storage, packaging or shipping of materials or equipment. The shelf life for material was exceeded. An unauthorized material or equipment substitution was made. Spare parts were inadequately stored. There was an error made in the labeling or marking. "]
["A2B4C01","– Material handling LTA","Material / equipment was damaged during handling. Material / equipment was “mixed up” during handling.  Note: This code is for handling occurring onsite. Problems with handling occurring offsite would be coded under Procurement control LTA [A2B5], Management Methods LTA [A4B1], Means not provided for assuring adequate equipment quality, reliability, or operability [A4B2C08], or Written communication content LTA [A5B2]. "]
["A2B4C02","– Material storage LTA","The material, equipment or part was stored improperly. The material, equipment, or part was damaged in storage. The material, equipment, or part had weather damage. The material, equipment, or part was stored in an environment [heat, cold, acid fumes, etc.] that damaged it. Inadequate preventive maintenance [cleaning, lubrication, etc.] was performed on spare parts. "]
["A2B4C03","– Material packaging LTA","Material or equipment was packaged improperly. The material or equipment was damaged because of improper packaging. Material or equipment was exposed to adverse conditions because the packaging had been damaged. "]
["A2B4C04","– Material shipping LTA","The material / equipment was transported improperly. The material / equipment was damaged during shipping. "]
["A2B4C05","– Shelf life exceeded","Material, equipment, or parts that had exceeded the shelf life were installed. Materials continued in use after the shelf life was exceeded. "]
["A2B4C06","– Unauthorized material substitution"," Incorrect materials or parts were substituted. Material or parts were substituted without authorization. The requirements specified no substitution.  Note: This code is for material substitution occurring onsite. Problem with material substitution occurring offsite would be coded under Procurement control LTA [A2B5], Management Methods LTA [A4B1], Means not provided for assuring adequate equipment quality, reliability, or operability [A4B2C08], or Written communication content LTA [A5B2]. "]
["A2B4C07","– Marking / labeling LTA","There was an error made in the labeling or marking. Equipment identification, labeling, or marking was less than adequate. "]
["A2B5","PROCUREMENT CONTROL LTA","The error was due to inadequate control of changes to procurement specifications or purchase orders. A fabricated item failed to meet requirements or an incorrect item was received. Product acceptance requirements failed to match design requirements or were otherwise unacceptable. Note: This is only for equipment and materials, procured services are addressed in A4B2C10. "]
["A2B5C01","– Control of changes to procurement specification / purchase order LTA","Changes were made to purchase orders or procurement specifications without the proper review and approvals. The changes resulted in purchase of the wrong material, equipment, or parts. "]
["A2B5C02","– Fabricated item did not meet requirements","The item of concern was not fabricated according to the requirements specified in the procurement specifications/purchase requisition. "]
["A2B5C03","– Incorrect item received","An item received was not the one ordered. The inconsistency was not recognized. The item was accepted rather than returned."]
["A2B5C04","– Product acceptance requirements LTA","The product acceptance requirements were incomplete. The product acceptance requirements did not address all the safety concerns for the item. The requirements did not address all the concerns for efficiency. The product acceptance requirements did not address all the safety concerns for the items. "]
["A2B6","DEFECTIVE, FAILED OR CONTAMINATED","An event was caused by a failed or defective part. The material used was defective or flawed. The weld, braze or soldered joint was defective. The component reached the end of its expected service life. There was electrical or instrument noise interference or interaction. Foreign material or contaminant caused the equipment or component to fail. "]
["A2B6C01","– Damaged, defective, or failed part","A part or instrument lacked something essential to perform its intended function. A part (or component of a part) was damaged in the course of nearby activities, resulting in the part’s inability to carry out its intended function. The degraded performance of a part or a component contributed to its failure. Note: this does not explain why the object failed or was defective. Therefore, this node should be multi-coded. "]
["A2B6C02","– Defective or failed material","A component failed because the material used was not adequate for the application. The material used was found to be defective, flawed, or damaged. Note: this does not explain why the object failed or was defective. Therefore, this node should be multiple coded. "]
["A2B6C03","– Defective weld, braze, soldering joint, crimp, hinge, or other connection","A specific weld/crimp/joint/connection defect or failure. Note: this does not explain why the object failed or was defective. Therefore, this node should be multiple coded. "]
["A2B6C04","– End of life failure","The failure resulted from equipment or material having reached the end of its expected / normal service life. The failure was a result of the normal aging process for this component. "]
["A2B6C05","– Electrical or instrument noise","An unwanted signal or disturbance that interfered with the operation of equipment"]
["A2B6C06","– Contaminant","Failure or degradation of a system or component due to foreign material (i.e., dirt, crud, impurities, trash in river intake, etc.) or radiation damage due to excessive radiation exposure. Note: can be related to any material in an unwanted location. "]
["A2B6C07","- Software failure","A situation where the controlling software failed, the system froze (or hung up) or other computer-related software issues exist.  It is an \"occurrence\" rather than a true cause, and corrective actions should involve the vendors of the software."]
["A2B7","EQUIPMENT INTERACTIONS LTA","An event was caused by less than adequate interaction between two or more pieces of equipment within a larger system. These interactions are required or are essential for the proper operation of the system and usually do not require human intervention.  "]
["A2B7C01","-Communications Path LTA ","The communication path required for the normal interaction of two pieces of equipment is not allowing or is restricting orinterrupting effective machine interaction for normal, efficient operation. "]
["A2B7C02","-Data Quality LTA ","The content or quality of required/essential data between two or more pieces of equipment within a system has degraded to a point that the efficiency and accuracy of the system’s performance is less than adequate. Data integrity has been reduced to a less than adequate level for normal operation"]
["A2B7C03","-Supporting Power System LTA ","The power (AC or DC) required for the normal operation of the equipment or system is less than adequate. The power source(s) are under the control of the affected entity. Note:  For power sources that are not under the control of the affected entity see A7B1C02. "]
["A2B7C04","-Undesirable Operation of Coordinated Systems","An undesirable operation occurs as a result of less than adequate performance of a subsystem, due to lack of coordination, not because of equipment failure. This is usually in the absence of human intervention. "]
["A3","Individual Human Performance LTA","An event or condition resulting from the failure, malfunction, or deterioration of the human performance associated with the process. Note: Strictly speaking, A3B1, A3B2, & A3B3 nodes are only applicable when “problem-solving,” although this does not have to be conscious. These are not the intended coding when not engaged in solving a problem, e.g., falling asleep because of prescription medication [which might be A3B4C01 or A5B4C06]. Further, these codes are for individual actions or lack thereof. If an event has multiple occurrences of the same A3 C node[s], it is time to look for other rationale behind the behavior. Yes, there are single examples of group performance that is LTA. However, when it is multiple examples, there is usually another explanation. For example, the control room operators at Three Mile Island mutually incorrectly diagnosed several of the accident indications and also mutually avoided application of several potential recovery paths. These errors were eventually traced to how their training had treated these potentialities. "]
["A3B1","SKILL BASED ERROR","Inattention or over-attention to performance of work affected the event. "]
["A3B1C01","- Check of work LTA ","An individual made an error that would have been detectable and correctable if a check of the completed, or partially completed, work was performed. "]
["A3B1C02","- Step was omitted due to distraction ","Attention was diverted to another issue during performance of the task and the individual committed an error in performance due to the distraction. "]
["A3B1C03","- Incorrect performance due to mental lapse ","The individual knew appropriate action(s) to take, but failed to initiate the correct action(s) based on inattention/over-attention. "]
["A3B1C04","- Infrequently performed steps were performed incorrectly","An individual was not completely familiar with the tasks required based on not frequently performing the tasks and not operating at a fluency level. "]
["A3B1C05","- Delay in time caused LTA actions ","An individual performed the wrong actions based on an extended length of time expiring between the time the task was defined and the time the task was completed. "]
["A3B1C06","- Wrong action selected based on similarity with other actions ","An individual selected a wrong action out of a series of actions that appeared to be the same, but are not. "]
["A3B1C07","- Omission/repeating of steps due to assumptions for completion ","Individual, based on assumptions, concluded that activity steps were not completed or completed. Based on the perceptions, an error occurred because the incorrect decision or assumption was made. "]
["A3B2","RULE BASED ERROR","A misapplication of a good rule for behavior or application of a bad rule applied for behavior during the work process impacted the event. Note: application of this node is not limited to misapplication of procedures. Rules are often mental rather than written. "]
["A3B2C01","- Strong rule incorrectly chosen over other rules ","Individual chose behavior rules based on the number of times the rule(s) had been used successfully in the past. The more times the rule(s) have been used successfully, the stronger the desire to apply the rule(s) become. "]
["A3B2C02","- Signs to stop were ignored and step performed incorrectly ","Most activities generate indication of status [both positive and negative]. The human tendency is to focus on the indications of success rather than all the indicators. The negative indicators are the “signs to stop.” “Signs” are not necessarily physical. "]
["A3B2C03","- Too much activity was occurring and error made in problem solving ","This error was initiated when the individuals committing the error experience information overload. The right set of decisions was not made based on too many details to process mentally. "]
["A3B2C04","- Previous success in use of rule reinforced continued use of rule ","If a rule for behavior has been used successfully in the past, there is an overwhelming tendency to apply the rule again, even though circumstances no longer warrant the use of the rule. "]
["A3B2C05","- Situation incorrectly identified or represented resulting in wrong rule used ","Individual interpreted facts based on training and experience that helped form stored mental knowledge from which the individual interpreted the facts. When the individual used the stored knowledge, the right set of training and experience was sometimes not selected based on the existing facts. A broader search of the stored knowledge would have been necessary to explain the existing facts. "]
["A3B3","KNOWLEDGE BASED ERROR","The problem was solved without using stored rules for behavior. The involved personnel were in a problem solving/troubleshooting mode. Note: Some people find it easier to think of this node as “Lack of Knowledge Based Error” since the essential gap is experiential. "]
["A3B3C01","- Attention was given to wrong issues ","Selective mental processing of information was targeted at the wrong issues and was not focused on the right issues. Often the individual focus was centered around what was psychologically important instead of targeted on what was logically important. "]
["A3B3C02","- LTA conclusion based on sequencing of facts ","An individual, when establishing a timeline or recalling step-by-step compilation of facts as they occurred in an event, sometimes reordered the sequence which affected the conclusion based on the facts. "]
["A3B3C03","- Individual justified action by focusing on biased evidence ","An individual was overconfident in evaluating the correctness of his/her knowledge. The chosen course of action was selected based on evidence that favored it and contradictory evidence was overlooked. "]
["A3B3C04","- LTA review based on assumption that process will not change ","Individual believed that no variability existed in the process and overlooked the fact that a change has occurred leading to differing results than normally realized. "]
["A3B3C05","- Incorrect assumption that a correlation existed between two or more facts ","Wrong assumptions were made based on the belief that two or more facts are related to each other and incorrect actions were taken based on the assumption.   Note: This also covers the case where there is an incorrect assumption that two or more facts do not correlate when they do. "]
["A3B3C06","- Individual underestimated the problem by using past events as basis ","Individuals tend to oversimplify events. Based on stored knowledge of past events, the individual underestimated problems with the existing event and plans for fewer contingencies than will actually be needed. "]
["A3B4","WORK PRACTICES LTA ","The capacity to perform work was impaired.  The act to incorrectly perform work was deliberate. "]
["A3B4C01","- Individual’s capability to perform work LTA "," Sensory/Perceptual Capabilities LTA - The problem was due to less than adequate vision [e.g., poor visual acuity, color blindness, tunnel vision]. The problem was caused by some defect in hearing [e.g., hearing loss, tone deafness]. There was a problem due to some sensory defect [e.g., poor sense of touch or smell].  • Motor/Physical Capabilities LTA - The causal factor was attributable to trouble with inadequate coordination or inadequate strength. The problem was due to inadequate size or stature of the individual involved. Other physical limitations [e.g., shaking, poor reaction time] contributed to the problem.  • Attitude/Psychological Profile LTA - The problem was due to a poor attitude on the part of an individual. The individual involved showed signs of emotional illness. "]
["A3B4C02","- Deliberate violation ","The action on the part of the individual was a deliberate action to commit human error.   Note: Be very careful in the application of this code. It may take professional diagnosis to determine if the action was intentional or the result of something beyond the control of the individual [A3B3C01]. There is usually some form of personal gain associated with this code. Also, this code relates only to a single individual; group behavior is entirely different. If this code is cited in more than ~5% of the incidents for a given facility, there is most likely some other underlying cause. "]
["A4","Management Problem ","An event or condition that could be directly traced to managerial actions, or methodology (or lack thereof). A “management” problem attributed to management methods (directions, monitoring, assessment, accountability, and corrective action), inadequate resource allocation, work organization and planning, supervisory methods and/or change management practices.   Note: Apparent Cause Corrective Actions for this branch in particular easily slip into correcting the program as opposed to the implementation. Fixing the program is the realm of Root Cause[s]. The analyst is cautioned to gauge Corrective Actions appropriately.  Also, even though the terms \"Management\" and \"Organization\" are used in the title, use of either one separately implies the other, and neither is intended as a job title, solely as a function or process."]
["A4B1","MANAGEMENT METHODS LTA","The processes used to control or direct work-related plant activities, including how manpower and material was allocated for a particular objective. Note: This cause section addresses management-controlled practices and policies and requires that the investigator gain familiarity with the standards or expectations that exist for performing work. [See note for A4B4.] "]
["A4B1C01","- Management policy guidance / expectations not well-defined, understood or enforced","Personnel exhibited a lack of understanding of existing policy and/or expectations, or policy/expectations were not well-defined or policy/expectation is not enforced. "]
["A4B1C02","- Job performance standards not adequately defined","Measurement of effectiveness could not be performed for a specific job function due to lack of defined standards. "]
["A4B1C03","– Management direction created insufficient awareness of the impact of actions on safety / reliability","Management failed to provide direction regarding safeguards against non-conservative actions by personnel concerning quality, safety or reliability. "]
["A4B1C04","- Management follow-up or monitoring of activities did not identify problems","Management's methods for monitoring the success of initiatives were ineffective in identifying shortcomings in the implementation. "]
["A4B1C05","- Management assessment did not determine causes of previous event or known problem","Analysis methods failed to uncover the causal factors of consequential or non-consequential events. "]
["A4B1C06","- Previous industry or in-house experience was not effectively used to prevent recurrence","Industry or in-house experience relating to a current problem that existed prior to the event, but was not assimilated by the organization.   Note: This code is not necessarily limited to the site’s formal lessons learned program. It can apply to any event of which the facility had been made aware. "]
["A4B1C07","- Responsibility of personnel not well defined or personnel not held accountable","Responsibility for process elements (procedures, engineering, training, etc.) was not placed with individuals or accountability for failures of those process elements was not placed with individuals. "]
["A4B1C08","- Corrective action responses to a known or repetitive problem was untimely","Corrective action for known or recurring problem was not performed at or within the proper time. "]
["A4B1C09","- Corrective action for previously identified problem or event was not adequate to prevent recurrence","Management failed to take meaningful corrective action for consequential or non-consequential events. "]
["A4B2","RESOURCE MANAGEMENT LTA ","Evaluation of the processes whereby manpower and material were allocated to successfully perform assigned tasks. Note: A4B2 serves as an expansion to A4B1, Management Methods, since both A4B1 and A4B2 are important inter-related factors. A4B2 provides more in-depth causal nodes for evaluating manpower and material issues impacting performance of work-related activities. "]
["A4B2C01","- Too many administrative duties assigned to immediate supervisors","The administrative load on immediate supervisors adversely affected their ability to supervise ongoing activities.   Note: This is a problem with the management of the supervisor not his/her supervisory methods [A4B4]. This is non-task activities [not actively supervising employees]. Task overload is A4B2C02. "]
["A4B2C02","- Insufficient supervisory resources to provide necessary supervision","Supervision resource is less than that required by task analysis considering the balance of procedures, supervision and training.   Note: This is a problem with the management of the supervisor not the supervisory methods [A4B4]. This is too many jobs to be actively supervised at once. Non-task [not actively supervising employees] overload is A4B2C01. "]
["A4B2C03","- Insufficient manpower to support identified goal / objective","Personnel were not available as required by task analysis of goal/objective. "]
["A4B2C04","- Resources not provided to assure adequate training was provided / maintained","Training resources were not available as required by task analysis. "]
["A4B2C05","- Needed resource changes not approved / funded","Corrective actions for existing deficiencies that were previously identified were not approved or funded. "]
["A4B2C06","- Means not provided to assure procedures / documents / records were of adequate quality and up-to-date","A process for changing procedures or other work documents to assure quality and timeliness was nonexistent or inadequate. "]
["A4B2C07","- Means not provided for assuring adequate availability of appropriate materials / tools","A process for supplying personnel with appropriate materials or tools did not exist. "]
["A4B2C08","- Means not provided for assuring adequate equipment quality, reliability, or operability","A process for assuring personnel’s equipment was satisfactory did not exist. "]
["A4B2C09","- Personnel selection did not assure match of worker motivations / job descriptions","Personnel selection processes failed to determine a mismatch between motivation and job description prior to task.   Note: Mismatch with motivations is under this code. Mismatch with skills is under A4B4C09. "]
["A4B2C10","– Means / method not provided for assuring adequate quality of contract services","A process for assuring quality contract services was being provided was nonexistent or inadequate. "]
["A4B3","WORK ORGANIZATION & PLANNING LTA","Problems in how the work to be performed was organized. This would include work scope, planning, assignment and scheduling of a task to be performed. Note: While A4B3 addresses the organization and planning of work, failures in this node usually imply related failures in Supervisory Methods addressed in A4B4. "]
["A4B3C01","- Insufficient time for worker to prepare task","Scheduling of the task did not adequately address the time frame required for accepted worker preparation practices to occur. "]
["A4B3C02","- Insufficient time allotted for task","Scheduled duration of the task did not adequately address known conditions or account for reasonable emergent issues. "]
["A4B3C03","- Duties not well-distributed among personnel","The work loading of individuals within a group or team did not adequately address training, experience, task frequency and duration, or other situational factors such that responsibility was inappropriately distributed. "]
["A4B3C04","- Too few workers assigned to task","Job planning did not allot a realistic number of man-hours or the number of people necessary to complete the task based on the scope of work described. "]
["A4B3C05","- Insufficient number of trained or experienced workers assigned to task","Though the overall number of personnel assigned matched the planned man-hour allotment, organization methods failed to identify that the personnel assigned did not have adequate experience or training to perform the work. "]
["A4B3C06","- Planning not coordinated with inputs from walkdowns / task analysis","The job plan did not incorporate information gathered during field visits or task analysis concerning the steps and conditions required for successful completion of the task. "]
["A4B3C07","- Job scoping did not identify potential task interruptions and/or environmental stress","The work scoping process was not effective in detecting reasonable obstructions to work flow (e.g., shift changes) or the impact of environmental conditions.   Note: This code applies to disruptions of circadian rhythms [biological functions based on 24-hour schedule] caused by scheduling of work. "]
["A4B3C08","- Job scoping did not identify special circumstances and/or conditions","The work scoping process was not effective in detecting work process elements having a dependency upon other circumstances or conditions. "]
["A4B3C09","- Work planning not coordinated with all departments involved in task","Interdepartmental communication and teamwork did not support the work flow being planned.   Note: The key word is “coordinated.” By not getting input from affected departments, the work plan is likely not to succeed. "]
["A4B3C10","– Problem performing repetitive tasks and/or subtasks","The work flow plan repeated tasks or subtasks to the detriment of successful completion of the evolution. "]
["A4B3C11","- Inadequate work package preparation","Though scoping and planning were adequately performed, the work package did not reflect the information gathered from these activities. The work package did not accurately reflect the work that was to be completed. "]
["A4B4","SUPERVISORY METHODS LTA","Causes that can be traced back to the immediate supervision and evaluated techniques that were used to monitor, direct and control work assignments. Note: this is supervision as a function not as a title. A manager can be the supervisor of another manager or a non-supervisor [by title] can be functioning as a supervisor. Problems with other than immediate supervision are coded under A4B1, A4B2 or A4B5 [which does not say that immediate supervision problems cannot be multiple coded under those B nodes]. "]
["A4B4C01","- Tasks and individual accountability not made clear to worker","Tasks (and the individual accountability for the task) that were outside written guidance or training were not made clear to the worker. "]
["A4B4C02","– Progress / status of task not adequately tracked","Supervision did not take the appropriate actions to monitor the task progress or status. "]
["A4B4C03","- Appropriate level of in-task supervision not determined prior to task","Supervision did not adequately assess the task for points of supervisory interaction prior to assignment to workers. "]
["A4B4C04","- Direct supervisory involvement in task interfered with overview role","Supervision became so involved with the actual task steps that overall command and control were adversely affected. "]
["A4B4C05","- Emphasis on schedule exceeded emphasis on methods / doing a good job","Accepted standards for methods were not met due to supervision's focus on completing the activity within a certain time frame. "]
["A4B4C06","- Job performance and self-checking standards not properly communicated","Supervision failed to adequately communicate how standards for job performance and self-checking could be applied to the actual job at hand. "]
["A4B4C07","- Too many concurrent tasks assigned to worker","Supervision failed to detect that concurrent job assignments for an individual exceeded the individual's abilities. "]
["A4B4C08","- Frequent job or task “shuffling”","Supervision transferred a worker from one task to another without adequate time to shift attention away from previous task. "]
["A4B4C09","- Assignment did not consider worker's need to use higher-order skills","Supervision did not consider the worker's talents or innovative strengths that could be used to perform more challenging work. "]
["A4B4C10","- Assignment did not consider effects of worker's previous task","upervision did not adequately assess the previous task's impact upon the worker's ability to implement the current task. "]
["A4B4C11","- Assignment did not consider worker's ingrained work patterns","Supervision failed to assess the incompatibility between worker's ingrained work patterns and necessary work patterns for successful completion of the current task. "]
["A4B4C12","- Contact with personnel too infrequent to detect work habit / attitude changes","Supervision not aware of deviation from desired work habits/attitudes due to lack of interaction with personnel. "]
["A4B4C13","- Provided feedback on negative performance but not on positive performance","Worker's performance adversely affected by supervision's focus on negative performance feedback. "]
["A4B5","CHANGE MANAGEMENT LTA ","Problems caused by the process by which changes were controlled and implemented by management as organizational needs change to accommodate new business needs. This group of codes is usually associated with non-routine change and may not always be appropriate for systems that have frequent updates or changes by design, such as routine software patches. The intent is that changes to procedures, systems, components, etc. should be controlled to ensure they are performed correctly, and unintended consequences are avoided (whenever possible)"]
["A4B5C01","– Problem identification methods did not identify need for change","Existing problem identification methods did not recognize the difference between actual practices and expectations. "]
["A4B5C02","- Change not implemented in a timely manner","A change in expectations was not realized in practices within an acceptable time period. "]
["A4B5C03","- Inadequate vendor support of change","Management failed to adequately assess the ability of vendors to supply products or services in support of changing expectations for a particular objective. \n Note: This code is intended to address the relationships between the organization and its vendors, as well as how well the organization determined the vendor to be appropriate.  Once the vendor is in place, how well the vendor performs is addressed in the A7B3-series of codes.\n"]
["A4B5C04","- Risks / consequences associated with change not adequately reviewed / assessed","Elements of the process, physical, or cyber (including software) system change were not recognized as having adverse impact or increased risk of adverse impact prior to implementing the change. "]
["A4B5C05","- System interactions not considered or identified","Changes to processes or physical systems caused interactions with other processes or physical systems that had were not identified prior to implementation. "]
["A4B5C06","– Personnel / department interactions not considered","Changes to processes created new requirements for interaction between personnel or departments that were not considered in the implementation phase of the change. "]
["A4B5C07","- Effect of change on schedules not adequately addressed","Changes to processes that resulted in scheduled changes had effects on personnel or equipment that were not addressed in the change implementation. "]
["A4B5C08","- Change-related training / retraining not performed or not adequate","Changes to processes resulted in a need for new training or revisions to existing training activities that were not performed or were not adequate to meet the needs of the new process.   Note: Use of this code implies application of the process by which the function of Training is notified that a change needs to be made. If training has been notified and the change has not been incorporated, then it is A6B3C03. "]
["A4B5C09","- Change-related documents not developed or revised","Changes to processes resulted in a need for new forms of written communication which were not created or changes to existing documents which were not revised.   Note: See A1B3 for Engineering or Design documents. "]
["A4B5C10","- Change-related equipment not provided or not revised","Changes to processes resulting in a need for new or revised software/hardware that was not provided or revised. "]
["A4B5C11","- Changes not adequately communicated","Changes to processes were not communicated to affected personnel effectively.   Note: This code is for administrative controls. Written communications [detailed instructions] and Training have their own codes [A5B1C05 and A6B3C03, respectively]. "]
["A4B5C12","- Change not identifiable during task","Changes to processes were not distinguishable from the previous process such that personnel did not modify how they performed the process. "]
["A4B5C13","– Accuracy / effectiveness of change not verified or not validated","Verification/validation practices for process changes failed to identify inaccurate or ineffective methods. "]
["A5","Communications LTA ","Inadequate presentation or exchange of information. Note: “Communications” is defined as the act of exchanging information. Persons on all sides of a communication link should be questioned regarding known or suspected problems. "]
["A5B1","WRITTEN COMMUNICATIONS METHOD OF PRESENTATION LTA","Problems with visual attributes of accurate information. "]
["A5B1C01","- Format deficiencies","The layout of the written communication made it difficult to follow.  The format differed from that which the user was accustomed to using.  The steps of the procedure were not logically grouped.  Step(s) in the written communication had more than one action or direction to perform.  Some step(s) in the written communication stated one action, which in practice actually required several steps to perform. "]
["A5B1C02","- Improper referencing or branching","The written communication referred to an excessive number of additional procedures. The written communication contained numerous steps of the type “Calculate limits per procedure XYZ”. The written communication was difficult to follow because of excessive branching to other procedures. The written communication contains numerous steps of the type “If X, then go to procedure ABC. If Y, then go to procedure EFG.” References to the different processes and areas contributed to the event. "]
["A5B1C03","- Checklist LTA","An error was made because each separate action in a step did not have a check-off space provided. The checklist was confusing. Each instruction did not clearly indicate what was required. Insufficient room was provided for the response. The checklist required unique responses for each step. "]
["A5B1C04","- Deficiencies in user aids (charts, etc.)","An error was made because graphics or drawings were of poor quality. The graphics or drawings were unclear, confusing, or misleading. Graphics, including datasheets, were not legible. "]
["A5B1C05","- Recent changes not made apparent to user","The written communication user was required to carry out an action different from those he was accustomed to doing. The written communication did not identify that the step for this action had been revised. The written communication user performed the action as the previous revision specified rather than the current revision. "]
["A5B1C06","- Instruction step / information in wrong sequence","The instructions/steps in the written communication were out of sequence. "]
["A5B1C07","– Unclear / complex wording or grammar","Wording, grammar or symbols fail too clearly and concisely specify the required action: instructions provided for team of users failed to specify roles of each user.  Considering the training and experience of the user, the written communication was too difficult to understand or follow.  There was insufficient information to identify the appropriate written communication. The written communication was not designed for the “less practiced” user. "]
["A5B2","WRITTEN COMMUNICATION CONTENT LTA","Any written document used to perform work such as procedures, work orders, memos, standing orders, manuals, surveillance, etc. Note: A1B3 should be used for Design/Engineering documentation. Investigation of written communications problems requires a copy of the applicable document[s] for review. "]
["A5B2C01","- Limit inaccuracies"," Limits were not expressed clearly and concisely. Limits or permissible operating ranges were expressed in a ± format instead of absolute numbers. "]
["A5B2C02","- Difficult to implement","Standards, Policies or Administrative Controls (SPAC) were not followed because no practical way of implementing them existed. Implementation would have hindered production. "]
["A5B2C03","– Data / computations wrong / incomplete","The error was made because of a mistake in recording or transferring data. Calculations were made incorrectly. The formula or equation was confusing or had multiple steps. "]
["A5B2C04","- Equipment identification LTA","The equipment identification was too generic. Equipment identification or labeling in the field did not agree with the identification in the procedure. "]
["A5B2C05","- Ambiguous instructions / requirements","The instructions in the written communication were unclear, uncertain, or interpretable in more than one way.  Different procedures related to the same task contained different requirements. There were conflicting or inconsistent requirements stated in different steps of the same procedure. Requirements were stated in different units. "]
["A5B2C06","- Typographical error","A typographical error in the written communication caused the event. "]
["A5B2C07","- Facts wrong / requirements not correct","Specific information in the written communication was incorrect. The written communication contained outdated requirements.  The written communication did not reflect the current status of equipment.  Note: This is for information that is in the written communication. A5B2C08 is for information that is not in the document. "]
["A5B2C08","– Incomplete / situation not covered","Details of the written communication were incomplete.  Insufficient information was presented.  The written communication did not address situations likely to occur during the completion of the procedure.  Note: This is for information that is not in the written communication.  A5B2C07 is for information that is in the document. "]
["A5B2C09","- Wrong revision used","The wrong revision of the written communication was used. "]
["A5B3","WRITTEN COMMUNICATION NOT USED","Written communication was not used to do the job. Written communication did not exist for the job. The written communication system was required to be used and was not just for training. Note: former ORPS code for “Procedure not used or used incorrectly” should be coded under A3 for what led to the misuse. "]
["A5B3C01","- Lack of written communication","Some form of written communication did not exist for the job task being performed. "]
["A5B3C02","- Not available or inconvenient for use","The written communication was not readily available. A copy of the written communication was not available in the designated file or rack. A “master copy” of the written communication was not available for reproductions. Use of the written communication was inconvenient because of working conditions (e.g., radiation areas, tight quarters, plastic suits). "]
["A5B4","VERBAL COMMUNICATION LTA ","The problem was caused by the transmission or receiving of information by voice or signal [e.g., face-to-face, telephone, and radio]. Note: Each individual involved in the occurrence should be questioned regarding messages he/she feels should have been received or transmitted. "]
["A5B4C01","- Communication between work groups LTA","Lack of communication between work groups [production, technical, or support] contributed to the incident.  Note: Communication within a work group is most likely related to A4B3 or A4B4 issues. "]
["A5B4C02","- Shift communications LTA","Lack of communication between management and the shifts contributed to the incident.  Management had not effectively communicated policies to the employees.  Concerns of employees were not communicated to management.  This code extends to miscommunication between supervisors and managers.  There was incorrect, incomplete, or otherwise inadequate communication between workers during a shift.  A more effective method of communication could have been used.  Note: This situation usually involves the relief of one worker by another.  There was incorrect, incomplete, or otherwise inadequate communication between personnel during a shift change.  Note: Turnover between shifts is usually more formal than within-shift turnover.  Use of log-out and log-in procedures is very helpful.  Detailed instructions and other important status information should be exchanged. "]
["A5B4C03","- Correct terminology not used","Standard or accepted terminology was not used. The communication could be interpreted more than one way.  One piece of equipment had two or more commonly used names.  The terminology could have applied to more than one item.  Note: The same word or phrase can mean different things to different people.  Two people can both feel that communication is accurate when, in fact, it is not because of inconsistent nomenclature.  Regional or non-standard speech may also present a problem. "]
["A5B4C04","– Verification / repeat back not used","A communication error was caused by failure to repeat back a message to the sender for the purposes of verifying that the message was heard and understood correctly. "]
["A5B4C05","- Information sent but not understood","A message or instruction was misunderstood because of noise interference.  A message or instruction was misunderstood because it was too long.  The message should have been written instead of oral.  The message could have been shortened or broken up.  Note: Communication can be greatly disrupted by ambient sound levels, general noise, whines, buzzes and the like.  Human speech communication takes place in a narrow frequency band between 600 and 4800 Hz.  This is known as the speech interference zone.  Sounds can mask frequencies of speech in this zone, thereby making communication very difficult.   Note: A related code is Physical Environment LTA [A1B5C02], which addresses noise interference other than speech. "]
["A5B4C06","- Suspected problems not communicated to supervision","There was incorrect, incomplete or an otherwise lack of communication between personnel and their supervision. The problem was not communicated to supervision.  Different methods of communication could have been used to help personnel communicate with supervision. "]
["A5B4C07","- No communication method available","A method or system did not exist for communicating the necessary message or information. The communication system was out of service or otherwise unavailable at the time of the incident. "]
["A6","TrainingDeficiency ","An event or condition that could be traced to a lack of training or insufficient training to enable a person to perform a desired task adequately. Note: A training deficiency is usually exposed by a human error, so the use of this branch of the CAT is often coupled with A3B2 or A3B3. "]
["A6B1","NO TRAINING PROVIDED","A lack of appropriate training. The task had not been identified. The task had not been identified for training. The training requirements had not been identified. Training on the task had not been developed. Training had not been conducted. "]
["A6B1C01","- Decision not to train","The decision was made not to provide specific training on a task. Some employees were not required to receive training. Experience was considered a substitute for training.  Note: Items in this area will generally have multiple codes with an additional entry under “Management Problem”. A6B1 hinges on the Job Task Analysis (JTA). If the JTA was LTA, it is A6B1C01. If the JTA was not completed, it is A6B1C02. If a particular individual’s training was waived regardless of the JTA because of assumed experience it is A6B1C03. "]
["A6B1C02","- Training requirements not identified","Training on the task was not part of the employee’s training requirements. The necessary training had not been defined for the job description.  Note: A6B1 hinges on the Job Task Analysis (JTA). If the JTA was LTA, it is A6B1C01. If the JTA was not completed, it is A6B1C02. If a particular individual’s training was waived regardless of the JTA because of assumed experience it is A6B1C03. "]
["A6B1C03","- Work incorrectly considered “skill-of-the-craft”","The work was not a “skill” that could be developed through job experience. The operator did not have appropriate training for the task. Provisions to assure operators have received proper training prior to assignment to this task were not addressed.  Note: A6B1 hinges on the Job Task Analysis (JTA). If the JTA was LTA, it is A6B1C01. If the JTA was not completed, it is A6B1C02. If a particular individual’s training was waived regardless of the JTA because of assumed experience it is A6B1C03. "]
["A6B2","TRAINING METHODS LTA","The correct training setting was not used. There was not enough practice (or hands-on) time allotted. Testing did not adequately measure the employee’s ability to perform the task. The task was not identified for refresher training. The training had inadequate instructors and facilities. "]
["A6B2C01","- Practice or “hands-on” experience LTA","The on-the-job training did not provide opportunities to learn skills necessary to perform the job. There was insufficient on-the-job training. There was an inadequate amount of preparation before performing the activity. The employee had not previously performed the task under direct supervision. "]
["A6B2C02","- Testing LTA","Testing did not cover all the knowledge and skills necessary to do the job. Testing did not adequately reflect the trainee’s ability to perform the job. "]
["A6B2C03","- Refresher training LTA","Training updates were not performed. Continuing training was not performed to keep employees equipped to perform non-routine tasks. The frequency of continuing training was inadequate. The frequency of refresher training was not sufficient to maintain the required knowledge and skills. "]
["A6B2C04","- Inadequate presentation","The qualifications for the instructor were inadequate. The qualification did not include all that is necessary to perform training on this task. The instructor who performed the training was not qualified on this task. The training equipment was inadequate. Simulators were not used. The equipment used in training was not like that used on the job. "]
["A6B3","TRAINING MATERIAL LTA ","The program design and objective were incomplete. Job/task analyses were inadequate. The training content was inadequate. Training materials did not adequately address new work methods. Training did not adequately address normal and abnormal/emergency working conditions. Training did not adequately address performance standards for the job/task. "]
["A6B3C01","- Training objectives LTA","The task analysis incorrectly identified the knowledge and skills necessary to complete the task. The proper setting in which to train the operator was not identified. The objectives were not written to accurately represent the task analysis. The objective did not satisfy the needs identified in the task analysis. The objectives did not cover all of the requirements necessary to successfully complete the task. "]
["A6B3C02","- Inadequate content","The lesson content did not address all the training objectives. The lessons did not contain all the information necessary to perform the job.  The knowledge and skills required to perform the task or job were not identified. "]
["A6B3C03","- Training on new work methods LTA","Training was not provided when the work methods for this task were changed. Training on changes to the procedure for the task was not provided. Training on new equipment used to perform the task was not provided.  Note: Use of this code is when training has been notified that a change needs to be made and the change has not been incorporated. If it is application of the process by which the function of Training is notified that a change needs to be made, then it is A4B5C08. "]
["A6B3C04","- Performance standards LTA","The requirements for performance on a system were not stringent enough. Meeting the standards for training qualification on a task did not provide sufficient training to perform the task under normal, abnormal, and emergency conditions. "]
["A7","Other Problem","The problem was caused by factors beyond the control of the organization, legacy radiological or hazardous material."]
["A7B1","EXTERNAL PHENOMENA","An event or condition caused by factors that were not under the control of the reporting organization. "]
["A7B1C01","- Weather or ambient conditions LTA","Unusual weather or ambient conditions, including hurricanes, tornadoes, flooding, earthquake, and lightning.  Note: This is actually a “nature of occurrence” rather than a true apparent cause.  In other words, this is “what” happened rather than “why” it happened.  If the event did not take into account the effects of weather or ambient conditions on the facility try Design Input LTA [A1B1], Operability of Design/Environment LTA [A1B5], or Change Management LTA [A4B5]. "]
["A7B1C02","– Power failure or transient","Special cases of power loss that are attributable to outside supplied power.  Note: This is actually a “nature of occurrence” rather than a true apparent cause.  In other words, this is “what” happened rather than “why” it happened.  There are no examples or potential corrective actions for this node.  If the event did not take into account the effects of an external power failure or transient on the facility try Design Input LTA [A1B1], Operability of Design/Environment LTA [A1B5], Management Methods [A4B1], or Change Management LTA [A4B5]. "]
["A7B1C03","– External fire or explosion","An external fire, explosion, or implosion, to include any fire or explosion within the BPS which extends the event to other elements of the BPS.  Note: This is actually a “nature of occurrence” rather than a true apparent cause. In other words, this is “what” happened rather than “why” it happened. There are no examples or potential corrective actions for this node. If the event did not take into account the effects of an external fire or explosion on the facility try Design Input LTA [A1B1], Operability of Design/Environment LTA [A1B5], Management Methods [A4B1], or Change Management LTA [A4B5]. "]
["A7B1C04","– Other natural phenomena LTA","This node covers all natural phenomena not addressed by A7B1C01, for example, animal intrusion.  Note: This is actually a “nature of occurrence” rather than a true apparent cause.  In other words, this is “what” happened rather than “why” it happened.  It is included here to round out the logic of the Causal Analysis Tree.  There are no additional examples or potential corrective actions for this node.  If the event did not take into account the effects of other natural phenomena on the facility try Design Input LTA [A1B1], Operability of Design/Environment LTA [A1B5], Management Methods [A4B1], or Change Management LTA [A4B5]. "]
["A7B1C05","Copper Theft","This node is an \"occurrence\" rather than a true apparent cause.  In other words, this is \"what happened\" rather than \"why it happened.  It is included here to round out the logic of the Causal Analysis Tree.  There are no additional examples or potential corrective actions for this node."]
["A7B1C06","Vandalism","This node is an \"occurrence\" rather than a true apparent cause.  In other words, this is \"what happened\" rather than \"why it happened.  It is included here to round out the logic of the Causal Analysis Tree.  There are no additional examples or potential corrective actions for this node."]
["A7B2","RADIOLOGICAL/HAZARDOUS MATERIAL PROBLEM ","An event related to radiological or hazardous material contamination that could not be attributed to any of the other causes. "]
["A7B2C01","– Legacy contamination","Radiological or hazardous material contamination attributed to past practices.  Note: This is closer to a “nature of occurrence” rather than a true apparent cause.  In other words, this is more of “what” happened rather than “why” it happened.  It usually takes a review of work history or isotopic analysis to determine if the material is actually legacy. "]
["A7B2C02","– Source unknown","Radiological or hazardous material contamination where the source cannot be reasonably determined.  Note: This is actually a “nature of occurrence” rather than a true apparent cause.  In other words, this is “what” happened rather than “why” it happened.  This node is used when a review of work history or isotopic analysis fails to determine if the material is actually legacy and no corrective action other than control is planned"]
["A7B3","VENDOR or SUPPLIER PROBLEM","An event related to vendor or supplier issues, to include communications, follow-up, testing or other undefined interactions."]
["A7B3C01","- Follow-up LTA","Vendor has been made aware of a problem, or discovered the problem in some manner, yet the follow-up to address the problem is LTA. "]
["A7B3C02","- Vendor corrective actions LTA ","Corrective actions taken by a vendor did not resolve the problem; actions address symptoms, and not the underlying problem. Root cause analysis (RCA) not undertaken by vendor, or at least was not communicated to the organization subject to the problem being addressed"]
["A7B3C03","- Extent-of-Condition communications LTA ","Vendor has been made aware of a problem, or discovered the problem in some manner, yet the extent to which this problem exists is not determined (or at least communicated to those using the product). "]
["AN","No Causes found","No cause codes can be attributed to this Entity; designed to be used where the overall event being evaluated involved multiple entities, and some of the entities were found to not be a contributor to the event"]
["AX","Overall Configuration Issue","Situations where switch positions, mechanical component positions, or software settings are found to be incorrect, resulting in undesirable actual or potential results."]
["AXB1","INSTALLATION/DESIGN CONFIGURATION LTA","Switch positions, mechanical component positions, or software settings were incorrectly set, calculated, or input during installation."]
["AXB2","MAINTENANCE/MODIFICATION CONFIGURATION LTA","Maintenance or modification results where switches, mechanical components, or software settings were placed or left in an incorrect status resulting in potential or actual undesirable results"]
["AZ","Information to determine cause LTA","Where the information provided is not sufficient to determine a cause, or where the event was intended (no cause exists) - for removing this event from the queue of events to be reviewed"]
["AZB1","UNABLE TO IDENTIFY SPECIFIC ROOT CAUSE","This code is used when the analyst is unable to identify specific Root Cause, even though multiple contributing causes have been identified. When multiple contributing causes are present and it cannot be discerned from the report which cause was the root cause, this code is used. The code should only be used when sufficient evidence is present to determine multiple contributing causes"]
["AZB1C01","- Multiple, parallel causal sequences exist ","Multiple effects or sequences exist which led to the event, and no common cause of these sequences can be identified.  As a result, no distinct root cause can be determined."]
["AZB1C02","- Context out-of-scope of analysis","In reviewing the event, it was determined that the specific root cause cannot be easily determined as there are historical issues/decisions indicated, and the context of those issues/decisions are missing or cannot be evaluated.\nNote: This is intended to recognize that decisions may have been made in the past, for business, engineering, or other technical/financial reasons, which are beyond the scope of the current regime of the organization. "]
["AZB1C03","- No cause uncovered after exhaustive testing","After complete and thorough testing and inspection of mechanical and/or computer systems, no specific cause could be identified"]
["AZB2","REPORT STOPS AT FAILURE/ERROR MODE","Often a report stops at the failure or error mode versus the objective of cause analysis which is the failure or error mechanism. The sub-codes for this area are used to further detail why the analysts believe the mode versus the mechanism is described"]
["AZB2C01","-Apparent cause analysis only ","An apparent cause is defined as a determination based on the evaluator’s judgment and experience. The emphasis of an apparent cause analysis is primarily to correct a particular event or problem without a special effort to identify the underlying system or process problems that may have contributed to the problem. A proper corrective action plan often cannot be determined based on apparent causes. By only looking at apparent causes, the underlying root cause may be overlooked allowing a reoccurrence of the deficiency leading to the event. Note if report states weather as more than an initiating cause, AZB2C03 might be appropriate"]
["AZB2C02","-No causal sequence established or identified ","This code is used when the root cause cannot be identified due to the report not having a causal sequence established or identified. This code can also be used when the time sequence is used incorrectly because the cause sequence is different"]
["AZB2C03","-Attributed to weather beyond initiating cause","This code is used when non-extreme weather events (such as lightening) are attributed for cause beyond the system design. This code is not appropriate for extreme weather that exceeds normal system design (tornados, hurricanes, etc). "]
["AZB3","OTHER PARTIES INVOLVED IN EVENT","The report points at, or cites, that the problem was caused by some identified or unidentified third party, not the entity making the report.  This third party is not under the control or direction of the reporting entity, thus the report is not able to result in solutions which meet the requirements of a “good solution” (not under the control of the entity). The sub-codes for this area are used to further detail characteristics of the third party"]
["AZB3C01","-Other entity cited as involved in event","The report cites that some other NERC-registered entity was a contributing party to this event, and that entity is responsible for taking corrective actions"]
["AZB3C02","-Vendor or contractor cited as involved in event","The report cites that some vendor or contractor was a contributing party to this event, and that party is responsible for taking corrective actions"]
["AZB4","CROSS-REFERENCE REQUIRED FOR OTHER SOURCES OF INFORMATION","The report points at, or cites, other sources of information where information may be reviewed, which is not contained within this report or supporting documentation.  This is a code that could be used if the report states further investigation is being undertaken, as an example, or that something occurred during this event (such as a mis-operation) for which other reports are required.. The sub-codes for this area are used to further detail other data or information sources to be reviewed when the data becomes available (some future time frame). "]
["AZB4C01","-Requires secondary review once appropriate reports are received","The report cites (or implies from its content) that some additional reporting will be taking place, at some future timeframe (not available for the report). For completeness, a secondary review will be needed once appropriate reports (such as a Misoperation report as part of PRC-004 process or entity-cited additional investigation report) is received"]
["AZB4C02","-Requires secondary review once additional outside investigative report is received","The report cites (or implies from its content) that some additional investigation is taken place, and a follow-up report from that investigation may shed light on this event.  This investigation is not completed, and thus its results are not included in this EA report. For completeness, a secondary review will be needed once this outside report is received"]
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[]
["A8","Operating Practices","Situations where system operating practices result in situations and corrective actions to be taken"]
["A8B1","FREQUENCY DEVIATIONS","Operating practices have resulted in frequencies which deviate from the expected or desired frequency"]
["A8B1C01","Prolonged high average frequency","The system has been operated at frequencies over a long period of time which are higher than the normal or desired frequency"]
["A8B1C02","Prolonged low average frequency","The system has been operated at frequencies over a long period of time which are lower than the normal or desired frequency"]

{"sheet":"Level A","index":2,"n_rows":12,"n_cols":4,"rows_kept":12,"cut":false,"hidden":false,"merged":[]}
["Code","Verbal Description","Code","Definition"]
["A1","Design/Engineering","A1","An event or condition that can be traced to a defect in design or other factors related to configuration, engineering, layout, tolerances, calculations, etc.  Note: even though Engineering is explicitly only in the branch title, its use throughout this branch is implicit.  Also, it is Engineering as a function or process, not as a job title. "]
["A2","Equipment/Material","A2","Is defined as an event or condition resulting from the failure, malfunction, or deterioration of equipment or parts, including instruments or material. "]
["A3","Individual Human Performance","A3","An event or condition resulting from the failure, malfunction, or deterioration of the human performance associated with the process. Note: Strictly speaking, A3B1, A3B2, & A3B3 nodes are only applicable when “problem-solving,” although this does not have to be conscious. These are not the intended coding when not engaged in solving a problem, e.g., falling asleep because of prescription medication [which might be A3B4C01 or A5B4C06]. Further, these codes are for individual actions or lack thereof. If an event has multiple occurrences of the same A3 C node[s], it is time to look for other rationale behind the behavior. Yes, there are single examples of group performance that is LTA. However, when it is multiple examples, there is usually another explanation. For example, the control room operators at Three Mile Island mutually incorrectly diagnosed several of the accident indications and also mutually avoided application of several potential recovery paths. These errors were eventually traced to how their training had treated these potentialities. "]
["A4","Management / Organization","A4","An event or condition that could be directly traced to managerial actions or methodology (or lack thereof). A management problem attributed to management methods (directions, monitoring, assessment, accountability, and corrective action), inadequate resource allocation, work organization and planning, supervisory methods, and change management practices. \nNote: Apparent Cause Corrective Actions for this branch in particular easily slip into correcting the program as opposed to the implementation. Fixing the program is the realm of root causes. The analyst is cautioned to gauge Corrective Actions appropriately. Also, even though the terms “Management” and “Organization” are used in the title, use of either one separately implies the other, and neither is intended as a job title, solely as a function or process.\n"]
["A5","Communications","A5","Inadequate presentation or exchange of information. Note: “Communications” is defined as the act of exchanging information. Persons on all sides of a communication link should be questioned regarding known or suspected problems. "]
["A6","Training","A6","An event or condition that could be traced to a lack of training or insufficient training to enable a person to perform a desired task adequately. Note: A training deficiency is usually exposed by a human error, so the use of this branch of the CAT is often coupled with A3B2 or A3B3. "]
["A7","Other","A7","The problem was caused by factors beyond the control of the organization, legacy radiological or hazardous material."]
["A8","(Open)","A8","Situations where system operating practices result in situations and corrective actions to be taken"]
["AN","No Causes found","AN","No cause codes can be attributed to this Entity; designed to be used where the overall event being evaluated involved multiple entities, and some of the entities were found to not be a contributor to the event"]
["AX","Overall Configuration","AX","Situations where switch positions, mechanical component positions, or software settings are found to be incorrect, resulting in undesirable actual or potential results."]
["AZ","Information to determine cause LTA","AZ","Where the information provided is not sufficient to determine a cause, or where the event was intended (no cause exists) - for removing this event from the queue of events to be reviewed"]

{"sheet":"Level AB","index":3,"n_rows":39,"n_cols":4,"rows_kept":39,"cut":false,"hidden":false,"merged":[]}
["Code","Verbal Description","Code","Definition"]
["A1B1","DESIGN INPUT LTA ",{"$f":"A2","v":"A1B1"},"Input to a design that was lacking adequate information that was necessary for the design. "]
["A1B2","DESIGN OUTPUT LTA",{"$f":"A3","v":"A1B2"},"Inadequate design output that did not meet the customer’s expectations or design requirements"]
["A1B3","DESIGN/DOCUMENTATION LTA","A1B3","Design or documentation that did not include all of the required information and did not comply with document control and record requirements"]
["A1B4","DESIGN/INSTALLATION VERIFICATION LTA","A1B4","Design reviews, testing, independent inspections, and acceptance were not in compliance with customer expectations and/or site requirements"]
["A1B5","OPERABILITY OF DESIGN/ENVIRONMENT LTA ","A1B5","Personnel or environmental factors were not considered as part of the design"]
["A2B1","CALIBRATION FOR INSTRUMENTS LTA","A2B1","Calibrations did not include all the essential elements. Equipment as-found condition was less than adequate. "]
["A2B2","PERIODIC/CORRECTIVE MAINTENANCE LTA","A2B2","Periodic maintenance was not established for the equipment, instrument or component. The periodic maintenance was inadequate. Corrective maintenance was inadequate to correct the problem. Equipment history did not exist for the instrument or component. The equipment history was incomplete. "]
["A2B3","INSPECTION/TESTING LTA","A2B3","Scheduled inspection/testing did not exist for the instrument or equipment. The inspection/testing was inadequate or not performed as required. The inspection/testing did not include all the essential elements. Note: A1B4 should be used for Design Testing. "]
["A2B4","MATERIAL CONTROL LTA","A2B4","The problem was due to the inadequate handling, storage, packaging or shipping of materials or equipment. The shelf life for material was exceeded. An unauthorized material or equipment substitution was made. Spare parts were inadequately stored. There was an error made in the labeling or marking. "]
["A2B5","PROCUREMENT CONTROL LTA","A2B5","The error was due to inadequate control of changes to procurement specifications or purchase orders. A fabricated item failed to meet requirements or an incorrect item was received. Product acceptance requirements failed to match design requirements or were otherwise unacceptable. Note: This is only for equipment and materials, procured services are addressed in A4B2C10. "]
["A2B6","DEFECTIVE, FAILED OR CONTAMINATED","A2B6","An event was caused by a failed or defective part. The material used was defective or flawed. The weld, braze or soldered joint was defective. The component reached the end of its expected service life. There was electrical or instrument noise interference or interaction. Foreign material or contaminant caused the equipment or component to fail. "]
["A2B7","EQUIPMENT INTERACTIONS LTA","A2B7","An event was caused by less than adequate interaction between two or more pieces of equipment within a larger system. These interactions are required or are essential for the proper operation of the system and usually do not require human intervention.  "]
["A3B1","SKILL BASED ERROR","A3B1","Inattention or over-attention to performance of work affected the event. "]
["A3B2","RULE BASED ERROR","A3B2","A misapplication of a good rule for behavior or application of a bad rule applied for behavior during the work process impacted the event. Note: application of this node is not limited to misapplication of procedures. Rules are often mental rather than written. "]
["A3B3","KNOWLEDGE BASED ERROR","A3B3","The problem was solved without using stored rules for behavior. The involved personnel were in a problem solving/troubleshooting mode. Note: Some people find it easier to think of this node as “Lack of Knowledge Based Error” since the essential gap is experiential. "]
["A3B4","WORK PRACTICES LTA ","A3B4","The capacity to perform work was impaired.  The act to incorrectly perform work was deliberate. "]
["A4B1","MANAGEMENT METHODS LTA","A4B1","The processes used to control or direct work-related plant activities, including how manpower and material was allocated for a particular objective. Note: This cause section addresses management-controlled practices and policies and requires that the investigator gain familiarity with the standards or expectations that exist for performing work. [See note for A4B4.] "]
["A4B2","RESOURCE MANAGEMENT LTA ","A4B2","Evaluation of the processes whereby manpower and material were allocated to successfully perform assigned tasks. Note: A4B2 serves as an expansion to A4B1, Management Methods, since both A4B1 and A4B2 are important inter-related factors. A4B2 provides more in-depth causal nodes for evaluating manpower and material issues impacting performance of work-related activities. "]
["A4B3","WORK ORGANIZATION & PLANNING LTA","A4B3","Problems in how the work to be performed was organized. This would include work scope, planning, assignment and scheduling of a task to be performed. Note: While A4B3 addresses the organization and planning of work, failures in this node usually imply related failures in Supervisory Methods addressed in A4B4. "]
["A4B4","SUPERVISORY METHODS LTA","A4B4","Causes that can be traced back to the immediate supervision and evaluated techniques that were used to monitor, direct and control work assignments. Note: this is supervision as a function not as a title. A manager can be the supervisor of another manager or a non-supervisor [by title] can be functioning as a supervisor. Problems with other than immediate supervision are coded under A4B1, A4B2 or A4B5 [which does not say that immediate supervision problems cannot be multiple coded under those B nodes]. "]
["A4B5","CHANGE MANAGEMENT LTA ","A4B5","Problems caused by the process by which changes were controlled and implemented by management as organizational needs change to accommodate new business needs. "]
["A5B1","WRITTEN COMMUNICATIONS METHOD OF PRESENTATION LTA","A5B1","Problems with visual attributes of accurate information. "]
["A5B2","WRITTEN COMMUNICATION CONTENT LTA","A5B2","Any written document used to perform work such as procedures, work orders, memos, standing orders, manuals, surveillance, etc. Note: A1B3 should be used for Design/Engineering documentation. Investigation of written communications problems requires a copy of the applicable document[s] for review. "]
["A5B3","WRITTEN COMMUNICATION NOT USED","A5B3","Written communication was not used to do the job. Written communication did not exist for the job. The written communication system was required to be used and was not just for training. Note: former ORPS code for “Procedure not used or used incorrectly” should be coded under A3 for what led to the misuse. "]
["A5B4","VERBAL COMMUNICATION LTA ","A5B4","The problem was caused by the transmission or receiving of information by voice or signal [e.g., face-to-face, telephone, and radio]. Note: Each individual involved in the occurrence should be questioned regarding messages he/she feels should have been received or transmitted. "]
["A6B1","NO TRAINING PROVIDED","A6B1","A lack of appropriate training. The task had not been identified. The task had not been identified for training. The training requirements had not been identified. Training on the task had not been developed. Training had not been conducted. "]
["A6B2","TRAINING METHODS LTA","A6B2","The correct training setting was not used. There was not enough practice (or hands-on) time allotted. Testing did not adequately measure the employee’s ability to perform the task. The task was not identified for refresher training. The training had inadequate instructors and facilities. "]
["A6B3","TRAINING MATERIAL LTA ","A6B3","The program design and objective were incomplete. Job/task analyses were inadequate. The training content was inadequate. Training materials did not adequately address new work methods. Training did not adequately address normal and abnormal/emergency working conditions. Training did not adequately address performance standards for the job/task. "]
["AXB1","INSTALLATION/DESIGN CONFIGURATION LTA",{"$f":"A30","v":"AXB1"},"Switch positions, mechanical component positions, or software settings were incorrectly set, calculated, or input during installation."]
["AXB2","MAINTENANCE/MODIFICATION CONFIGURATION LTA",{"$f":"A31","v":"AXB2"},"Maintenance or modification results where switches, mechanical components, or software settings were placed or left in an incorrect status resulting in potential or actual undesirable results"]
["A7B1","EXTERNAL PHENOMENA","A7B1","An event or condition caused by factors that were not under the control of the reporting organization. "]
["A7B2","RADIOLOGICAL/HAZARDOUS MATERIAL PROBLEM ","A7B2","An event related to radiological or hazardous material contamination that could not be attributed to any of the other causes. "]
["A7B3","VENDOR or SUPPLIER PROBLEM ","A7B3","An event related to vendor or supplier issues, to include communications, follow-up, testing or other undefined interactions. "]
["AZB1","UNABLE TO IDENTIFY SPECIFIC ROOT CAUSE","AZB1","This code is used when the analyst is unable to identify specific Root Cause, even though multiple contributing causes have been identified. When multiple contributing causes are present and it cannot be discerned from the report which cause was the root cause, this code is used. The code should only be used when sufficient evidence is present to determine multiple contributing causes"]
["AZB2","REPORT STOPS AT FAILURE/ERROR MODE","AZB2","Often a report stops at the failure or error mode versus the objective of cause analysis which is the failure or error mechanism. The sub-codes for this area are used to further detail why the analysts believe the mode versus the mechanism is described"]
["AZB3","OTHER PARTIES INVOLVED IN EVENT","AZB3","The report points at, or cites, that the problem was caused by some identified or unidentified third party, not the entity making the report.  This third party is not under the control or direction of the reporting entity, thus the report is not able to result in solutions which meet the requirements of a “good solution” (not under the control of the entity). The sub-codes for this area are used to further detail characteristics of the third party"]
["AZB4","CROSS-REFERENCE REQUIRED FOR OTHER SOURCES OF INFORMATION","AZB4","The report points at, or cites, other sources of information where information may be reviewed, which is not contained within this report or supporting documentation.  This is a code that could be used if the report states further investigation is being undertaken, as an example, or that something occurred during this event (such as a mis-operation) for which other reports are required.. The sub-codes for this area are used to further detail other data or information sources to be reviewed when the data becomes available (some future time frame). "]
["A8B1",null,null,"Operating practices have resulted in frequencies which deviate from the expected or desired frequency"]

{"sheet":"Level ABC (full code)","index":4,"n_rows":189,"n_cols":4,"rows_kept":189,"cut":false,"hidden":false,"merged":[]}
["Code","Verbal Description","Code","Definition"]
["A1B1C01","- Design input cannot be met",{"$f":"A2","v":"A1B1C01"},"The criteria and other requirements were so stringent that they could not be met. There were conflicting criteria. Not all of the necessary references were included"]
["A1B1C02","- Design input obsolete",{"$f":"A3","v":"A1B1C02"},"The criteria were out-of-date. An old version of a requirement or specification was used. Process requirements/conditions changed and the changes were omitted from the input. "]
["A1B1C03","- Design input not correct","A1B1C03","The wrong standards or requirements were used. The requirements were transcribed in error"]
["A1B1C04","- Necessary design input not available","A1B1C04","The necessary requirements, codes, standards, etc. were not available to the designer"]
["A1B2C01","- Design output scope LTA","A1B2C01","The design did not consider all the possible scenarios. All the operating conditions, [normal and emergency] were not included in the design"]
["A1B2C02","- Design output not clear","A1B2C02","The drawings were difficult to read. The specifications were difficult to understand. The specification could be interpreted in more than one way. "]
["A1B2C03","- Design output not correct","A1B2C03","The drawings and other specifications were incorrect. The final design output did not include all changes. "]
["A1B2C04","- Inconsistent design output","A1B2C04","There were differences between different output documents. The drawings and other design documents did not agree."]
["A1B2C05","- Design input not addressed in design output","A1B2C05","The specifications did not include all the requirements. Some criteria were left out of the design output. "]
["A1B2C06","– Drawing, specification or data error","A1B2C06","The latest drawing revision was not referenced. The latest vendor information was not included in the design documentation. The correct data was not noted on the design documentation request. "]
["A1B2C07","- Error in equipment or material selection","A1B2C07","The correct vendor identification number was not used for procurement of equipment. The correct grade of stainless steel was not specified for the material. "]
["A1B2C08","- Errors not detectable","A1B2C08","Personnel were unable to detect errors [by way of alarms or instrument readings] during or after the occurrence. A serious error went unnoticed because there was no way to monitor system status."]
["A1B2C09","– Errors not recoverable","A1B2C09","The system was designed such that personnel were unable to recover from error discovered before a failure occurred. "]
["A1B3C01","– Design / documentation not complete","A1B3C01","The designs and other documentation for equipment were incomplete. Items were missing from the documentation. A complete baseline did not exist. "]
["A1B3C02","– Design / documentation not up-to-date","A1B3C02","Drawings and documents were not updated when changes were made. Documents/drawings did not reflect the current status. "]
["A1B3C03","– Design / documentation not controlled","A1B3C03","The design documentation was not controlled per site requirements for document control and records."]
["A1B4C01","- Independent review of design / documentation LTA","A1B4C01","A required review was not performed on the design. The review was not performed by an independent reviewer. The design had problems passing the functional testing. "]
["A1B4C02","- Testing of design / installation LTA","A1B4C02","Testing was not included as part of the design acceptance process. The testing did not verify the operability of the design. Design parameters did not successfully pass all testing criteria. "]
["A1B4C03","- Independent inspection of design / installation LTA","A1B4C03","Independent Inspection attributes were not included in the design installation. Required Hold/Witness points were not verified by Quality Assurance (QA). Hold/Witness points did not pass the acceptance criteria. Commercial Grade Material was not adequately dedicated and documented. "]
["A1B4C04","- Acceptance of design / installation LTA","A1B4C04","The customer had problems with acceptance of the design, testing, and/or verification. "]
["A1B5C01","- Ergonomics LTA","A1B5C01","Inadequate ergonomic design contributed to the occurrence. - The operator was physically incapable of performing the required task.  The operator had to go too far to respond to the alarm.  Personnel mobility or vision was restricted.  An individual had difficulty reaching the equipment or assumed an awkward position to complete a task.  The event was caused because illumination levels were not sufficient for task performance. "]
["A1B5C02","- Physical environment LTA","A1B5C02","Inadequate equipment controls or control systems [e.g., push-buttons, rotary controls, J-handles, key-operated controls, thumb-wheels, multiple switches, joysticks] contributed to the occurrence. The control failed to provide an adequate range of control for the function it performs. The control was inadequately protected from accidental activation. Similar controls were indistinguishable from one another. Controls were in too close proximity of each other. Operating conditions [e.g. room temperature, work location, physical location, restricted vision, personal protective equipment, excessive noise, arrangement or placement of equipment] affected performance of the task. Lighting was inadequate. Noise was a factor. "]
["A1B5C03","- Natural environment LTA","A1B5C03","Exposure to heat, cold, wind, and rain was not included in the design. Earthquake tested devices were not included in the design. System was not designed to withstand flooding, freezing, or high wind conditions. Lightning suppressing devices were not included in the design. The event was caused by excessive exposure of personnel to a hot or cold environment. "]
["A2B1C01","- Calibration LTA","A2B1C01","The equipment involved in the incident was not included in a routine calibration program. Calibrations were performed too infrequently. The calibration did not include all the essential elements. "]
["A2B1C02","- Equipment found outside acceptance criteria",{"$f":"A26","v":"A2B1C02"},"An event occurred as a result of equipment that was found outside of the specified acceptance criteria. The instrument calibration drift was outside of the acceptable range. Process instrumentation was outside of acceptable range criteria due to a standard that was out of calibration. "]
["A2B1C03","- Coordinated tuning or adjustments of instrumentation LTA","A2B1C03","An event occurred as a result of multiple pieces of controls for equipment or instrumentation, where adjustment of one requires the coordinated adjustment(s) of others did not occur, or was performed incorrectly."]
["A2B2C01","- Preventive maintenance for equipment LTA","A2B2C01","An equipment malfunction was caused by a failure to perform scheduled preventive maintenance. Preventive maintenance was not established for the equipment or component that failed. Preventive maintenance was scheduled too infrequently. The preventive maintenance was incomplete. Preventive maintenance was performed on some of the components but not on others. (Note: Preventive maintenance is a maintenance program which is cyclical, it is done based on a repetitive basis based on some characteristic (numbers of operations, time, etc.))"]
["A2B2C02","- Predictive maintenance LTA","A2B2C02","Predictive maintenance was not established for the equipment. The established frequency was inadequate to prevent or detect equipment degradation. The established method used to prevent or detect equipment degradation was inadequate. (Note: Predictive maintenance is a maintenance program which is based on the analysis of some characteristic of operations or equipment, when conditions (other than those of a cyclic nature) indicate it is time to perform the maintenance.)"]
["A2B2C03","- Corrective maintenance LTA","A2B2C03","Corrective maintenance was performed but failed to correct the originating problem. The equipment or component was reassembled improperly during corrective maintenance. Other problems were noted during maintenance activities that were not corrected. The actual job of performing a maintenance activity was complete, but was not performed correctly. "]
["A2B2C04","– Equipment history LTA","A2B2C04","Equipment history / records did not exist for the equipment that malfunctioned. The history for the equipment that malfunctioned was incomplete / inadequate. The history did not contain all the information necessary to assure equipment reliability. Knowledge of equipment history would have prevented the incident or lessened its severity. "]
["A2B3C01","– Start-up testing LTA","A2B3C01","Functional testing did not exist for the equipment or system prior to placing them in service. Start-up testing was inadequate for the equipment or system being placed into service. "]
["A2B3C02","– Inspection / testing LTA","A2B3C02","Required testing / inspection was not established or performed for the equipment involved in the incident. The required testing / inspection was performed at an incorrect frequency. The acceptance criteria for the required testing / inspection were inadequately defined. All essential components were not included in the required testing / inspection. "]
["A2B3C03","– Post-maintenance / post-modification testing LTA","A2B3C03","The post-maintenance or post-modification testing specified was not performed or was performed incorrectly. The post-maintenance or post-modification testing was completed, but the testing requirements were less than adequate. The post-maintenance or post-modification testing was not performed in accordance with the schedule for testing. "]
["A2B4C01","– Material handling LTA","A2B4C01","Material / equipment was damaged during handling. Material / equipment was “mixed up” during handling.  Note: This code is for handling occurring onsite. Problems with handling occurring offsite would be coded under Procurement control LTA [A2B5], Management Methods LTA [A4B1], Means not provided for assuring adequate equipment quality, reliability, or operability [A4B2C08], or Written communication content LTA [A5B2]. "]
["A2B4C02","– Material storage LTA","A2B4C02","The material, equipment or part was stored improperly. The material, equipment, or part was damaged in storage. The material, equipment, or part had weather damage. The material, equipment, or part was stored in an environment [heat, cold, acid fumes, etc.] that damaged it. Inadequate preventive maintenance [cleaning, lubrication, etc.] was performed on spare parts. "]
["A2B4C03","– Material packaging LTA","A2B4C03","Material or equipment was packaged improperly. The material or equipment was damaged because of improper packaging. Material or equipment was exposed to adverse conditions because the packaging had been damaged. "]
["A2B4C04","– Material shipping LTA","A2B4C04","The material / equipment was transported improperly. The material / equipment was damaged during shipping. "]
["A2B4C05","– Shelf life exceeded","A2B4C05","Material, equipment, or parts that had exceeded the shelf life were installed. Materials continued in use after the shelf life was exceeded. "]
["A2B4C06","– Unauthorized material substitution","A2B4C06"," Incorrect materials or parts were substituted. Material or parts were substituted without authorization. The requirements specified no substitution.  Note: This code is for material substitution occurring onsite. Problem with material substitution occurring offsite would be coded under Procurement control LTA [A2B5], Management Methods LTA [A4B1], Means not provided for assuring adequate equipment quality, reliability, or operability [A4B2C08], or Written communication content LTA [A5B2]. "]
["A2B4C07","– Marking / labeling LTA","A2B4C07","There was an error made in the labeling or marking. Equipment identification, labeling, or marking was less than adequate. "]
["A2B5C01","– Control of changes to procurement specification / purchase order LTA","A2B5C01","Changes were made to purchase orders or procurement specifications without the proper review and approvals. The changes resulted in purchase of the wrong material, equipment, or parts. "]
["A2B5C02","– Fabricated item did not meet requirements","A2B5C02","The item of concern was not fabricated according to the requirements specified in the procurement specifications/purchase requisition. "]
["A2B5C03","– Incorrect item received","A2B5C03","An item received was not the one ordered. The inconsistency was not recognized. The item was accepted rather than returned."]
["A2B5C04","– Product acceptance requirements LTA","A2B5C04","The product acceptance requirements were incomplete. The product acceptance requirements did not address all the safety concerns for the item. The requirements did not address all the concerns for efficiency. The product acceptance requirements did not address all the safety concerns for the items. "]
["A2B6C01","– Damaged, defective or failed part","A2B6C01","A part or instrument lacked something essential to perform its intended function. A part (or component of a part) was damaged in the course of nearby activities, resulting in the part’s inability to carry out its intended function. The degraded performance of a part or a component contributed to its failure. Note: this does not explain why the object failed or was defective. Therefore, this node should be multi-coded."]
["A2B6C02","– Defective or failed material","A2B6C02","A component failed because the material used was not adequate for the application. The material used was found to be defective, flawed, or damaged. Note: this does not explain why the object failed or was defective. Therefore, this node should be multiple coded. "]
["A2B6C03","– Defective weld, braze, soldering joint, crimp, hinge, or other connection","A2B6C03","A specific weld/crimp/joint/connection defect or failure. Note: this does not explain why the object failed or was defective. Therefore, this node should be multiple coded. "]
["A2B6C04","– End of life failure","A2B6C04","The failure resulted from equipment or material having reached the end of its expected / normal service life. The failure was a result of the normal aging process for this component. "]
["A2B6C05","– Electrical or instrument noise","A2B6C05","An unwanted signal or disturbance that interfered with the operation of equipment"]
["A2B6C06","– Contaminant","A2B6C06","Failure or degradation of a system or component due to foreign material (i.e., dirt, crud, impurities, trash in river intake, etc.) or radiation damage due to excessive radiation exposure. Note: can be related to any material in an unwanted location. "]
["A2B6C07","- Software failure","A2B6C07","A situation where the controlling software failed, the system froze (or hung up) or other computer-related software issues exist.  It is an \"occurrence\" rather than a true cause, and corrective actions should involve the vendors of the software."]
["A2B7C01","- Physical Communication Path LTA","A2B7C01","The physical communication path required for the normal interaction of two pieces of equipment is not allowing or is restricting/interrupting effective machine interaction for normal efficient operation. "]
["A2B7C02","- Data Quality LTA","A2B7C02","The content or quality of required/essential data between two or more pieces of equipment within a system has degraded to a point that the efficiency and accuracy of the system’s performance is less than adequate. Data integrity has been reduced to a less than adequate level for normal operation"]
["A2B7C03","- Supporting Power System LTA","A2B7C03","The power (AC or DC) required for the normal operation of the equipment or system is less than adequate. The power source(s) are under the control of the affected entity. Note:  For power sources that are not under the control of the affected entity see A7B1C02. "]
["A2B7C04","- Undesirable Operation of Coordinated Systems","A2B7C04","An undesirable operation occurs as a result of less than adequate performance of a subsystem. This is usually in the absence of human intervention. "]
["A3B1C01","- Check of work was LTA ","A3B1C01","An individual made an error that would have been detectable and correctable if a check of the completed, or partially completed, work was performed. "]
["A3B1C02","- Step was omitted due to distraction ","A3B1C02","Attention was diverted to another issue during performance of the task and the individual committed an error in performance due to the distraction. "]
["A3B1C03","- Incorrect performance due to mental lapse ","A3B1C03","The individual knew appropriate action(s) to take, but failed to initiate the correct action(s) based on inattention/over-attention. "]
["A3B1C04","- Infrequently performed steps were performed incorrectly ","A3B1C04","An individual was not completely familiar with the tasks required based on not frequently performing the tasks and not operating at a fluency level. "]
["A3B1C05","- Delay in time caused LTA actions ","A3B1C05","An individual performed the wrong actions based on an extended length of time expiring between the time the task was defined and the time the task was completed. "]
["A3B1C06","- Wrong action selected based on similarity with other actions ","A3B1C06","An individual selected a wrong action out of a series of actions that appeared to be the same, but are not. "]
["A3B1C07","- Omission/repeating of steps due to assumptions for completion ","A3B1C07","Individual, based on assumptions, concluded that activity steps were not completed or completed. Based on the perceptions, an error occurred because the incorrect decision or assumption was made. "]
["A3B2C01","- Strong rule incorrectly chosen over other rules ","A3B2C01","Individual chose behavior rules based on the number of times the rule(s) had been used successfully in the past. The more times the rule(s) have been used successfully, the stronger the desire to apply the rule(s) become. "]
["A3B2C02","- Signs to stop were ignored and step performed incorrectly ","A3B2C02","Most activities generate indication of status [both positive and negative]. The human tendency is to focus on the indications of success rather than all the indicators. The negative indicators are the “signs to stop.” “Signs” are not necessarily physical. "]
["A3B2C03","- Too much activity was occurring and error made in problem solving ","A3B2C03","This error was initiated when the individuals committing the error experience information overload. The right set of decisions was not made based on too many details to process mentally. "]
["A3B2C04","- Previous success in use of rule reinforced continued use of rule ","A3B2C04","If a rule for behavior has been used successfully in the past, there is an overwhelming tendency to apply the rule again, even though circumstances no longer warrant the use of the rule. "]
["A3B2C05","- Situation incorrectly identified or represented resulting in wrong rule used ","A3B2C05","Individual interpreted facts based on training and experience that helped form stored mental knowledge from which the individual interpreted the facts. When the individual used the stored knowledge, the right set of training and experience was sometimes not selected based on the existing facts. A broader search of the stored knowledge would have been necessary to explain the existing facts. "]
["A3B3C01","- Attention was given to wrong issues ","A3B3C01","Selective mental processing of information was targeted at the wrong issues and was not focused on the right issues. Often the individual focus was centered around what was psychologically important instead of targeted on what was logically important. "]
["A3B3C02","- LTA conclusion based on sequencing of facts ","A3B3C02","An individual, when establishing a timeline or recalling step-by-step compilation of facts as they occurred in an event, sometimes reordered the sequence which affected the conclusion based on the facts. "]
["A3B3C03","- Individual justified action by focusing on biased evidence ",{"$f":"A71","v":"A3B3C03"},"An individual was overconfident in evaluating the correctness of his/her knowledge. The chosen course of action was selected based on evidence that favored it and contradictory evidence was overlooked. "]
["A3B3C04","- LTA review based on assumption that process will not change ","A3B3C04","Individual believed that no variability existed in the process and overlooked the fact that a change has occurred leading to differing results than normally realized. "]
["A3B3C05","- Incorrect assumption that a correlation existed between two or more facts ","A3B3C05","Wrong assumptions were made based on the belief that two or more facts are related to each other and incorrect actions were taken based on the assumption.   Note: This also covers the case where there is an incorrect assumption that two or more facts do not correlate when they do. "]
["A3B3C06","- Individual underestimated the problem by using past events as basis ","A3B3C06","Individuals tend to oversimplify events. Based on stored knowledge of past events, the individual underestimated problems with the existing event and plans for fewer contingencies than will actually be needed. "]
["A3B4C01","- Individual’s capability to perform work LTA ","A3B4C01"," Sensory/Perceptual Capabilities LTA - The problem was due to less than adequate vision [e.g., poor visual acuity, color blindness, tunnel vision]. The problem was caused by some defect in hearing [e.g., hearing loss, tone deafness]. There was a problem due to some sensory defect [e.g., poor sense of touch or smell].  • Motor/Physical Capabilities LTA - The causal factor was attributable to trouble with inadequate coordination or inadequate strength. The problem was due to inadequate size or stature of the individual involved. Other physical limitations [e.g., shaking, poor reaction time] contributed to the problem.  • Attitude/Psychological Profile LTA - The problem was due to a poor attitude on the part of an individual. The individual involved showed signs of emotional illness. "]
["A3B4C02","- Deliberate violation ","A3B4C02","The action on the part of the individual was a deliberate action to commit human error.   Note: Be very careful in the application of this code. It may take professional diagnosis to determine if the action was intentional or the result of something beyond the control of the individual [A3B3C01]. There is usually some form of personal gain associated with this code. Also, this code relates only to a single individual; group behavior is entirely different. If this code is cited in more than ~5% of the incidents for a given facility, there is most likely some other underlying cause. "]
["A4B1C01","- Management policy guidance / expectations not well-defined, understood or enforced","A4B1C01","Personnel exhibited a lack of understanding of existing policy and/or expectations, or policy/expectations were not well-defined or policy/expectation is not enforced. "]
["A4B1C02","- Job performance standards not adequately defined","A4B1C02","Measurement of effectiveness could not be performed for a specific job function due to lack of defined standards. "]
["A4B1C03","– Management direction created insufficient awareness of the impact of actions on safety / reliability","A4B1C03","Management failed to provide direction regarding safeguards against non-conservative actions by personnel concerning quality, safety or reliability. "]
["A4B1C04","- Management follow-up or monitoring of activities did not identify problems","A4B1C04","Management's methods for monitoring the success of initiatives were ineffective in identifying shortcomings in the implementation. "]
["A4B1C05","- Management assessment did not determine causes of previous event or known problem","A4B1C05","Analysis methods failed to uncover the causal factors of consequential or non-consequential events. "]
["A4B1C06","- Previous industry or in-house experience was not effectively used to prevent recurrence","A4B1C06","Industry or in-house experience relating to a current problem that existed prior to the event, but was not assimilated by the organization.   Note: This code is not necessarily limited to the site’s formal lessons learned program. It can apply to any event of which the facility had been made aware. "]
["A4B1C07","- Responsibility of personnel not well defined or personnel not held accountable","A4B1C07","Responsibility for process elements (procedures, engineering, training, etc.) was not placed with individuals or accountability for failures of those process elements was not placed with individuals. "]
["A4B1C08","- Corrective action responses to a known or repetitive problem was untimely","A4B1C08","Corrective action for known or recurring problem was not performed at or within the proper time. "]
["A4B1C09","- Corrective action for previously identified problem or event was not adequate to prevent recurrence","A4B1C09","Management failed to take meaningful corrective action for consequential or non-consequential events. "]
["A4B2C01","- Too many administrative duties assigned to immediate supervisors","A4B2C01","The administrative load on immediate supervisors adversely affected their ability to supervise ongoing activities.   Note: This is a problem with the management of the supervisor not his/her supervisory methods [A4B4]. This is non-task activities [not actively supervising employees]. Task overload is A4B2C02. "]
["A4B2C02","- Insufficient supervisory resources to provide necessary supervision","A4B2C02","Supervision resource is less than that required by task analysis considering the balance of procedures, supervision and training.   Note: This is a problem with the management of the supervisor not the supervisory methods [A4B4]. This is too many jobs to be actively supervised at once. Non-task [not actively supervising employees] overload is A4B2C01. "]
["A4B2C03","- Insufficient manpower to support identified goal / objective","A4B2C03","Personnel were not available as required by task analysis of goal/objective. "]
["A4B2C04","- Resources not provided to assure adequate training was provided / maintained","A4B2C04","Training resources were not available as required by task analysis. "]
["A4B2C05","- Needed resource changes not approved / funded","A4B2C05","Corrective actions for existing deficiencies that were previously identified were not approved or funded. "]
["A4B2C06","- Means not provided to assure procedures / documents / records were of adequate quality and up-to-date","A4B2C06","A process for changing procedures or other work documents to assure quality and timeliness was nonexistent or inadequate. "]
["A4B2C07","- Means not provided for assuring adequate availability of appropriate materials / tools","A4B2C07","A process for supplying personnel with appropriate materials or tools did not exist. "]
["A4B2C08","- Means not provided for assuring adequate equipment quality, reliability, or operability","A4B2C08","A process for assuring personnel’s equipment was satisfactory did not exist. "]
["A4B2C09","- Personnel selection did not assure match of worker motivations / job descriptions","A4B2C09","Personnel selection processes failed to determine a mismatch between motivation and job description prior to task.   Note: Mismatch with motivations is under this code. Mismatch with skills is under A4B4C09. "]
["A4B2C10","– Means / method not provided for assuring adequate quality of contract services","A4B2C10","A process for assuring quality contract services was being provided was nonexistent or inadequate. "]
["A4B3C01","- Insufficient time for worker to prepare task","A4B3C01","Scheduling of the task did not adequately address the time frame required for accepted worker preparation practices to occur. "]
["A4B3C02","- Insufficient time allotted for task","A4B3C02","Scheduled duration of the task did not adequately address known conditions or account for reasonable emergent issues. "]
["A4B3C03","- Duties not well-distributed among personnel","A4B3C03","The work loading of individuals within a group or team did not adequately address training, experience, task frequency and duration, or other situational factors such that responsibility was inappropriately distributed. "]
["A4B3C04","- Too few workers assigned to task","A4B3C04","Job planning did not allot a realistic number of man-hours or the number of people necessary to complete the task based on the scope of work described. "]
["A4B3C05","- Insufficient number of trained or experienced workers assigned to task","A4B3C05","Though the overall number of personnel assigned matched the planned man-hour allotment, organization methods failed to identify that the personnel assigned did not have adequate experience or training to perform the work. "]
["A4B3C06","- Planning not coordinated with inputs from walkdowns / task analysis","A4B3C06","The job plan did not incorporate information gathered during field visits or task analysis concerning the steps and conditions required for successful completion of the task. "]
["A4B3C07","- Job scoping did not identify potential task interruptions and/or environmental stress","A4B3C07","The work scoping process was not effective in detecting reasonable obstructions to work flow (e.g., shift changes) or the impact of environmental conditions.   Note: This code applies to disruptions of circadian rhythms [biological functions based on 24-hour schedule] caused by scheduling of work. "]
["A4B3C08","- Job scoping did not identify special circumstances and/or conditions","A4B3C08","The work scoping process was not effective in detecting work process elements having a dependency upon other circumstances or conditions. "]
["A4B3C09","- Work planning not coordinated with all departments involved in task","A4B3C09","Interdepartmental communication and teamwork did not support the work flow being planned.   Note: The key word is “coordinated.” By not getting input from affected departments, the work plan is likely not to succeed. "]
["A4B3C10","– Problem performing repetitive tasks and/or subtasks","A4B3C10","The work flow plan repeated tasks or subtasks to the detriment of successful completion of the evolution. "]
["A4B3C11","- Inadequate work package preparation","A4B3C11","Though scoping and planning were adequately performed, the work package did not reflect the information gathered from these activities. The work package did not accurately reflect the work that was to be completed. "]
["A4B4C01","- Tasks and individual accountability not made clear to worker","A4B4C01","Tasks (and the individual accountability for the task) that were outside written guidance or training were not made clear to the worker. "]
["A4B4C02","– Progress / status of task not adequately tracked","A4B4C02","Supervision did not take the appropriate actions to monitor the task progress or status. "]
["A4B4C03","- Appropriate level of in-task supervision not determined prior to task","A4B4C03","Supervision did not adequately assess the task for points of supervisory interaction prior to assignment to workers. "]
["A4B4C04","- Direct supervisory involvement in task interfered with overview role","A4B4C04","Supervision became so involved with the actual task steps that overall command and control were adversely affected. "]
["A4B4C05","- Emphasis on schedule exceeded emphasis on methods / doing a good job","A4B4C05","Accepted standards for methods were not met due to supervision's focus on completing the activity within a certain time frame. "]
["A4B4C06","- Job performance and self-checking standards not properly communicated","A4B4C06","Supervision failed to adequately communicate how standards for job performance and self-checking could be applied to the actual job at hand. "]
["A4B4C07","- Too many concurrent tasks assigned to worker","A4B4C07","Supervision failed to detect that concurrent job assignments for an individual exceeded the individual's abilities. "]
["A4B4C08","- Frequent job or task “shuffling”","A4B4C08","Supervision transferred a worker from one task to another without adequate time to shift attention away from previous task. "]
["A4B4C09","- Assignment did not consider worker's need to use higher-order skills","A4B4C09","Supervision did not consider the worker's talents or innovative strengths that could be used to perform more challenging work. "]
["A4B4C10","- Assignment did not consider effects of worker's previous task","A4B4C10","upervision did not adequately assess the previous task's impact upon the worker's ability to implement the current task. "]
["A4B4C11","- Assignment did not consider worker's ingrained work patterns","A4B4C11","Supervision failed to assess the incompatibility between worker's ingrained work patterns and necessary work patterns for successful completion of the current task. "]
["A4B4C12","- Contact with personnel too infrequent to detect work habit / attitude changes","A4B4C12","Supervision not aware of deviation from desired work habits/attitudes due to lack of interaction with personnel. "]
["A4B4C13","- Provided feedback on negative performance but not on positive performance","A4B4C13","Worker's performance adversely affected by supervision's focus on negative performance feedback. "]
["A4B5C01","-– Problem identification methods did not identify need for change","A4B5C01","Existing problem identification methods did not recognize the difference between actual practices and expectations. "]
["A4B5C02","- Change not implemented in a timely manner","A4B5C02","A change in expectations was not realized in practices within an acceptable time period. "]
["A4B5C03","- Inadequate vendor support of change","A4B5C03","Management failed to adequately assess the ability of vendors to supply products or services in support of changing expectations for a particular objective. "]
["A4B5C04","- Risks / consequences associated with change not adequately reviewed / assessed","A4B5C04","Elements of the process, physical, or cyber (including software) system change were not recognized as having adverse impact or increased risk of adverse impact prior to implementing the change. "]
["A4B5C05","- System interactions not considered","A4B5C05","Changes to processes or physical systems caused interactions with other processes or physical systems that had were not identified prior to implementation. "]
["A4B5C06","– Personnel / department interactions not considered","A4B5C06","Changes to processes created new requirements for interaction between personnel or departments that were not considered in the implementation phase of the change. "]
["A4B5C07","- Effect of change on schedules not adequately addressed","A4B5C07","Changes to processes that resulted in scheduled changes had effects on personnel or equipment that were not addressed in the change implementation. "]
["A4B5C08","- Change-related training / retraining not performed or not adequate","A4B5C08","Changes to processes resulted in a need for new training or revisions to existing training activities that were not performed or were not adequate to meet the needs of the new process.   Note: Use of this code implies application of the process by which the function of Training is notified that a change needs to be made. If training has been notified and the change has not been incorporated, then it is A6B3C03. "]
["A4B5C09","- Change-related documents not developed or revised","A4B5C09","Changes to processes resulted in a need for new forms of written communication which were not created or changes to existing documents which were not revised.   Note: See A1B3 for Engineering or Design documents. "]
["A4B5C10","- Change-related equipment not provided or not revised","A4B5C10","Changes to processes resulting in a need for new or revised software/hardware that was not provided or revised. "]
["A4B5C11","- Changes not adequately communicated","A4B5C11","Changes to processes were not communicated to affected personnel effectively.   Note: This code is for administrative controls. Written communications [detailed instructions] and Training have their own codes [A5B1C05 and A6B3C03, respectively]. "]
["A4B5C12","- Change not identifiable during task","A4B5C12","Changes to processes were not distinguishable from the previous process such that personnel did not modify how they performed the process. "]
["A4B5C13","– Accuracy / effectiveness of change not verified or not validated","A4B5C13","Verification/validation practices for process changes failed to identify inaccurate or ineffective methods. "]
["A5B1C01","- Format deficiencies","A5B1C01","The layout of the written communication made it difficult to follow.  The format differed from that which the user was accustomed to using.  The steps of the procedure were not logically grouped.  Step(s) in the written communication had more than one action or direction to perform.  Some step(s) in the written communication stated one action, which in practice actually required several steps to perform. "]
["A5B1C02","- Improper referencing or branching","A5B1C02","The written communication referred to an excessive number of additional procedures. The written communication contained numerous steps of the type “Calculate limits per procedure XYZ”. The written communication was difficult to follow because of excessive branching to other procedures. The written communication contains numerous steps of the type “If X, then go to procedure ABC. If Y, then go to procedure EFG.” References to the different processes and areas contributed to the event. "]
["A5B1C03","- Checklist LTA",{"$f":"A135","v":"A5B1C03"},"An error was made because each separate action in a step did not have a check-off space provided. The checklist was confusing. Each instruction did not clearly indicate what was required. Insufficient room was provided for the response. The checklist required unique responses for each step. "]
["A5B1C04","- Deficiencies in user aids (charts, etc.)","A5B1C04","An error was made because graphics or drawings were of poor quality. The graphics or drawings were unclear, confusing, or misleading. Graphics, including datasheets, were not legible. "]
["A5B1C05","- Recent changes not made apparent to user","A5B1C05","The written communication user was required to carry out an action different from those he was accustomed to doing. The written communication did not identify that the step for this action had been revised. The written communication user performed the action as the previous revision specified rather than the current revision. "]
["A5B1C06","- Instruction step / information in wrong sequence","A5B1C06","The instructions/steps in the written communication were out of sequence. "]
["A5B1C07","– Unclear / complex wording or grammar","A5B1C07","Wording, grammar or symbols fail too clearly and concisely specify the required action: instructions provided for team of users failed to specify roles of each user.  Considering the training and experience of the user, the written communication was too difficult to understand or follow.  There was insufficient information to identify the appropriate written communication. The written communication was not designed for the “less practiced” user. "]
["A5B2C01","- Limit inaccuracies","A5B2C01"," Limits were not expressed clearly and concisely. Limits or permissible operating ranges were expressed in a ± format instead of absolute numbers. "]
["A5B2C02","- Difficult to implement","A5B2C02","Standards, Policies or Administrative Controls (SPAC) were not followed because no practical way of implementing them existed. Implementation would have hindered production. "]
["A5B2C03","– Data / computations wrong / incomplete","A5B2C03","The error was made because of a mistake in recording or transferring data. Calculations were made incorrectly. The formula or equation was confusing or had multiple steps. "]
["A5B2C04","- Equipment identification LTA","A5B2C04","The equipment identification was too generic. Equipment identification or labeling in the field did not agree with the identification in the procedure. "]
["A5B2C05","- Ambiguous instructions / requirements","A5B2C05","The instructions in the written communication were unclear, uncertain, or interpretable in more than one way.  Different procedures related to the same task contained different requirements. There were conflicting or inconsistent requirements stated in different steps of the same procedure. Requirements were stated in different units. "]
["A5B2C06","- Typographical error","A5B2C06","A typographical error in the written communication caused the event. "]
["A5B2C07","- Facts wrong / requirements not correct","A5B2C07","Specific information in the written communication was incorrect. The written communication contained outdated requirements.  The written communication did not reflect the current status of equipment.  Note: This is for information that is in the written communication. A5B2C08 is for information that is not in the document. "]
["A5B2C08","– Incomplete / situation not covered","A5B2C08","Details of the written communication were incomplete.  Insufficient information was presented.  The written communication did not address situations likely to occur during the completion of the procedure.  Note: This is for information that is not in the written communication.  A5B2C07 is for information that is in the document. "]
["A5B2C09","- Wrong revision used","A5B2C09","The wrong revision of the written communication was used. "]
["A5B3C01","- Lack of written communication","A5B3C01","Some form of written communication did not exist for the job task being performed. "]
["A5B3C02","- Not available or inconvenient for use","A5B3C02","The written communication was not readily available. A copy of the written communication was not available in the designated file or rack. A “master copy” of the written communication was not available for reproductions. Use of the written communication was inconvenient because of working conditions (e.g., radiation areas, tight quarters, plastic suits). "]
["A5B4C01","- Communication between work groups LTA","A5B4C01","Lack of communication between work groups [production, technical, or support] contributed to the incident.  Note: Communication within a work group is most likely related to A4B3 or A4B4 issues. "]
["A5B4C02","- Shift communications LTA","A5B4C02","Lack of communication between management and the shifts contributed to the incident.  Management had not effectively communicated policies to the employees.  Concerns of employees were not communicated to management.  This code extends to miscommunication between supervisors and managers.  There was incorrect, incomplete, or otherwise inadequate communication between workers during a shift.  A more effective method of communication could have been used.  Note: This situation usually involves the relief of one worker by another.  There was incorrect, incomplete, or otherwise inadequate communication between personnel during a shift change.  Note: Turnover between shifts is usually more formal than within-shift turnover.  Use of log-out and log-in procedures is very helpful.  Detailed instructions and other important status information should be exchanged. "]
["A5B4C03","- Correct terminology not used","A5B4C03","Standard or accepted terminology was not used. The communication could be interpreted more than one way.  One piece of equipment had two or more commonly used names.  The terminology could have applied to more than one item.  Note: The same word or phrase can mean different things to different people.  Two people can both feel that communication is accurate when, in fact, it is not because of inconsistent nomenclature.  Regional or non-standard speech may also present a problem. "]
["A5B4C04","– Verification / repeat back not used","A5B4C04","A communication error was caused by failure to repeat back a message to the sender for the purposes of verifying that the message was heard and understood correctly. "]
["A5B4C05","- Information sent but not understood","A5B4C05","A message or instruction was misunderstood because of noise interference.  A message or instruction was misunderstood because it was too long.  The message should have been written instead of oral.  The message could have been shortened or broken up.  Note: Communication can be greatly disrupted by ambient sound levels, general noise, whines, buzzes and the like.  Human speech communication takes place in a narrow frequency band between 600 and 4800 Hz.  This is known as the speech interference zone.  Sounds can mask frequencies of speech in this zone, thereby making communication very difficult.   Note: A related code is Physical Environment LTA [A1B5C02], which addresses noise interference other than speech. "]
["A5B4C06","- Suspected problems not communicated to supervision","A5B4C06","There was incorrect, incomplete or an otherwise lack of communication between personnel and their supervision. The problem was not communicated to supervision.  Different methods of communication could have been used to help personnel communicate with supervision. "]
["A5B4C07","- No communication method available","A5B4C07","A method or system did not exist for communicating the necessary message or information. The communication system was out of service or otherwise unavailable at the time of the incident. "]
["A6B1C01","- Decision not to train","A6B1C01","The decision was made not to provide specific training on a task. Some employees were not required to receive training. Experience was considered a substitute for training.  Note: Items in this area will generally have multiple codes with an additional entry under “Management Problem”. A6B1 hinges on the Job Task Analysis (JTA). If the JTA was LTA, it is A6B1C01. If the JTA was not completed, it is A6B1C02. If a particular individual’s training was waived regardless of the JTA because of assumed experience it is A6B1C03. "]
["A6B1C02","- Training requirements not identified","A6B1C02","Training on the task was not part of the employee’s training requirements. The necessary training had not been defined for the job description.  Note: A6B1 hinges on the Job Task Analysis (JTA). If the JTA was LTA, it is A6B1C01. If the JTA was not completed, it is A6B1C02. If a particular individual’s training was waived regardless of the JTA because of assumed experience it is A6B1C03. "]
["A6B1C03","- Work incorrectly considered “skill-of-the-craft”","A6B1C03","The work was not a “skill” that could be developed through job experience. The operator did not have appropriate training for the task. Provisions to assure operators have received proper training prior to assignment to this task were not addressed.  Note: A6B1 hinges on the Job Task Analysis (JTA). If the JTA was LTA, it is A6B1C01. If the JTA was not completed, it is A6B1C02. If a particular individual’s training was waived regardless of the JTA because of assumed experience it is A6B1C03. "]
["A6B2C01","- Practice or “hands-on” experience LTA","A6B2C01","The on-the-job training did not provide opportunities to learn skills necessary to perform the job. There was insufficient on-the-job training. There was an inadequate amount of preparation before performing the activity. The employee had not previously performed the task under direct supervision. "]
["A6B2C02","- Testing LTA","A6B2C02","Testing did not cover all the knowledge and skills necessary to do the job. Testing did not adequately reflect the trainee’s ability to perform the job. "]
["A6B2C03","- Refresher training LTA","A6B2C03","Training updates were not performed. Continuing training was not performed to keep employees equipped to perform non-routine tasks. The frequency of continuing training was inadequate. The frequency of refresher training was not sufficient to maintain the required knowledge and skills. "]
["A6B2C04","- Inadequate presentation","A6B2C04","The qualifications for the instructor were inadequate. The qualification did not include all that is necessary to perform training on this task. The instructor who performed the training was not qualified on this task. The training equipment was inadequate. Simulators were not used. The equipment used in training was not like that used on the job. "]
["A6B3C01","- Training objectives LTA","A6B3C01","The task analysis incorrectly identified the knowledge and skills necessary to complete the task. The proper setting in which to train the operator was not identified. The objectives were not written to accurately represent the task analysis. The objective did not satisfy the needs identified in the task analysis. The objectives did not cover all of the requirements necessary to successfully complete the task. "]
["A6B3C02","- Inadequate content","A6B3C02","The lesson content did not address all the training objectives. The lessons did not contain all the information necessary to perform the job.  The knowledge and skills required to perform the task or job were not identified. "]
["A6B3C03","- Training on new work methods LTA","A6B3C03","Training was not provided when the work methods for this task were changed. Training on changes to the procedure for the task was not provided. Training on new equipment used to perform the task was not provided.  Note: Use of this code is when training has been notified that a change needs to be made and the change has not been incorporated. If it is application of the process by which the function of Training is notified that a change needs to be made, then it is A4B5C08. "]
["A6B3C04","- Performance standards LTA","A6B3C04","The requirements for performance on a system were not stringent enough. Meeting the standards for training qualification on a task did not provide sufficient training to perform the task under normal, abnormal, and emergency conditions. "]
["A7B1C01","- Weather or ambient conditions LTA","A7B1C01","Unusual weather or ambient conditions, including hurricanes, tornadoes, flooding, earthquake, and lightning.  Note: This is actually a “nature of occurrence” rather than a true apparent cause.  In other words, this is “what” happened rather than “why” it happened.  If the event did not take into account the effects of weather or ambient conditions on the facility try Design Input LTA [A1B1], Operability of Design/Environment LTA [A1B5], or Change Management LTA [A4B5]. "]
["A7B1C02","– Power failure or transient","A7B1C02","Special cases of power loss that are attributable to outside supplied power.  Note: This is actually a “nature of occurrence” rather than a true apparent cause.  In other words, this is “what” happened rather than “why” it happened.  There are no examples or potential corrective actions for this node.  If the event did not take into account the effects of an external power failure or transient on the facility try Design Input LTA [A1B1], Operability of Design/Environment LTA [A1B5], Management Methods [A4B1], or Change Management LTA [A4B5]. "]
["A7B1C03","– External fire or explosion","A7B1C03","An external fire, explosion, or implosion, to include any fire or explosion within the BPS which extends the event to other elements of the BPS.  Note: This is actually a “nature of occurrence” rather than a true apparent cause. In other words, this is “what” happened rather than “why” it happened. There are no examples or potential corrective actions for this node. If the event did not take into account the effects of an external fire or explosion on the facility try Design Input LTA [A1B1], Operability of Design/Environment LTA [A1B5], Management Methods [A4B1], or Change Management LTA [A4B5]. "]
["A7B1C04","– Other natural phenomena LTA","A7B1C04","This node covers all natural phenomena not addressed by A7B1C01, for example, animal intrusion.  Note: This is actually a “nature of occurrence” rather than a true apparent cause.  In other words, this is “what” happened rather than “why” it happened.  It is included here to round out the logic of the Causal Analysis Tree.  There are no additional examples or potential corrective actions for this node.  If the event did not take into account the effects of other natural phenomena on the facility try Design Input LTA [A1B1], Operability of Design/Environment LTA [A1B5], Management Methods [A4B1], or Change Management LTA [A4B5]. "]
["A7B1C05","- Copper Theft","A7B1C05","This node is an \"occurrence\" rather than a true apparent cause.  In other words, this is \"what happened\" rather than \"why it happened.  It is included here to round out the logic of the Causal Analysis Tree.  There are no additional examples or potential corrective actions for this node."]
["A7B1C06","- Vandalism","A7B1C06","This node is an \"occurrence\" rather than a true apparent cause.  In other words, this is \"what happened\" rather than \"why it happened.  It is included here to round out the logic of the Causal Analysis Tree.  There are no additional examples or potential corrective actions for this node."]
["A7B2C01","– Legacy contamination","A7B2C01","Radiological or hazardous material contamination attributed to past practices.  Note: This is closer to a “nature of occurrence” rather than a true apparent cause.  In other words, this is more of “what” happened rather than “why” it happened.  It usually takes a review of work history or isotopic analysis to determine if the material is actually legacy. "]
["A7B2C02","– Source unknown","A7B2C02","Radiological or hazardous material contamination where the source cannot be reasonably determined.  Note: This is actually a “nature of occurrence” rather than a true apparent cause.  In other words, this is “what” happened rather than “why” it happened.  This node is used when a review of work history or isotopic analysis fails to determine if the material is actually legacy and no corrective action other than control is planned"]
["A7B3C01","- Follow-up LTA","A7B3C01","Vendor has been made aware of a problem, or discovered the problem in some manner, yet the follow-up to address the problem is LTA. \nNote: While how a vendor reacts to, or even investigates, a problem is beyond the control of an organization, the vendor is still expected to take appropriate actions.  The purpose of this code is to identify those vendor actions which are beyond the control of the organization. "]
["A7B3C02","- Vendor Corrective actions LTA","A7B3C02","Corrective actions taken by a vendor did not resolve the problem; actions address symptoms, and not the underlying problem. Root cause analysis (RCA) not undertaken by vendor, or at least was not communicated to the organization subject to the problem being addressed. \nNote: While how a vendor reacts to, or even investigates, a problem is beyond the control of an organization, the vendor is still expected to take appropriate actions.  Problems for which a vendor is made aware are expected to be corrected, and appropriately communicated to users of the product/services. The purpose of this code is to identify those vendor actions which are beyond the control of the organization. "]
["A7B3C03","- Extent-of-condition communications LTA","A7B3C03","Vendor has been made aware of a problem, or discovered the problem in some manner, yet the extent to which this problem exists is not determined (or at least communicated to those using the product). \nNote: While how a vendor reacts to, or even investigates, a problem is beyond the control of an organization, the vendor is still expected to take appropriate actions.  These actions should include purposefully identifying how large the problem may be, and notifying those organizations which may be affected. The purpose of this code is to identify when an appropriate extent-of-condition evaluation has not been conducted (or at least communicated) to appropriate parties who may be affected. "]
["AZB1C01","- Multiple, parallel causal sequences exist","AZB1C01","Multiple effects or sequences exist which led to the event, and no common cause of these sequences can be identified.  As a result, no distinct root cause can be determined."]
["AZB1C02","- Context out-of-scope of analysis","AZB1C02","In reviewing the event, it was determined that the specific root cause cannot be easily determined as there are historical issues/decisions indicated, and the context of those issues/decisions are missing or cannot be evaluated.\nNote: This is intended to recognize that decisions may have been made in the past, for business, engineering, or other technical/financial reasons, which are beyond the scope of the current regime of the organization. "]
["AZB1C03","- No cause uncovered after exhaustive testing","AZB1C03","After complete and thorough testing and inspection of mechanical and/or computer systems, no specific cause could be identified."]
["AZB2C01","Apparent cause analysis only ","AZB2C01","An apparent cause is defined as a determination based on the evaluator’s judgment and experience. The emphasis of an apparent cause analysis is primarily to correct a particular event or problem without a special effort to identify the underlying system or process problems that may have contributed to the problem. A proper corrective action plan often cannot be determined based on apparent causes. By only looking at apparent causes, the underlying root cause may be overlooked allowing a reoccurrence of the deficiency leading to the event. Note if report states weather as more than an initiating cause, AZB2C03 might be appropriate"]
["AZB2C02","No causal sequence established or identified ","AZB2C02","This code is used when the root cause cannot be identified due to the report not having a causal sequence established or identified. This code can also be used when the time sequence is used incorrectly because the cause sequence is different"]
["AZB2C03","Attributed to weather beyond initiating cause","AZB2C03","This code is used when non-extreme weather events (such as lightening) are attributed for cause beyond the system design. This code is not appropriate for extreme weather that exceeds normal system design (tornados, hurricanes, etc). "]
["AZB3C01","Other entity cited as involved in event","AZB3C01","The report cites that some other NERC-registered entity was a contributing party to this event, and that entity is responsible for taking corrective actions"]
["AZB3C02","Vendor or contractor cited as involved in event","AZB3C02","The report cites that some vendor or contractor was a contributing party to this event, and that party is responsible for taking corrective actions"]
["AZB4C01","Requires secondary review once appropriate reports are received","AZB4C01","The report cites (or implies from its content) that some additional reporting will be taking place, at some future timeframe (not available for the report). For completeness, a secondary review will be needed once appropriate reports (such as a Misoperation report as part of PRC-004 process or entity-cited additional investigation report) is received"]
["AZB4C02","Requires secondary review once additional outside investigative report is received","AZB4C02","The report cites (or implies from its content) that some additional investigation is taken place, and a follow-up report from that investigation may shed light on this event.  This investigation is not completed, and thus its results are not included in this EA report. For completeness, a secondary review will be needed once this outside report is received"]

{"sheet":"Selecting Codes","index":5,"n_rows":8,"n_cols":6,"rows_kept":8,"cut":false,"hidden":false,"merged":[[0,1,0,5],[1,1,1,5],[2,1,2,5]]}
[null,"1.  Select the appropriate grouping of the Level A Descriptions"]
[null,"2.  After selecting a Level A description, you then pick the appropriate Level B description.  IF NOT selected, the block will show any previous selections, which may not be correct!"]
[null,"3. Once Level A and Level B selections are made, select the appropriate Level C description.  IF NOT selected, the block will show any previous selections, which may not be correct!"]
["Pick the Level A Code Description","Level A Code selected is ",null,"Level B Code Selected is",null,"Level C Code Selected is"]
["Equipment/Material",{"$f":"VLOOKUP(Information_to_determine_cause_LTA,'Level A'!$B$2:$C$12,2,FALSE)","v":"A2"},"CALIBRATION FOR INSTRUMENTS LTA",{"$f":"IF(C5=\"\",\"\",VLOOKUP(C5,'Level AB'!$B$2:$D$39,2,FALSE))","v":"A2B1"},"- Coordinated tuning or adjustments of instrumentation LTA",{"$f":"IF(E5=\"\",\"\",VLOOKUP(E5,'Level ABC (full code)'!$B$2:$D$189,2,FALSE))","v":"A2B1C03"}]
[]
["Defined as:",null,"Defined as:",null,"Defined as:"]
[{"$f":"IF(A5=\"\",\"\",VLOOKUP(A5,'Level A'!$B$2:$D$12,3,FALSE))","v":"Is defined as an event or condition resulting from the failure, malfunction, or deterioration of equipment or parts, including instruments or material. "},null,{"$f":"IF(C5=\"\",\"\",VLOOKUP(C5,'Level AB'!$B$2:$D$39,3,FALSE))","v":"Calibrations did not include all the essential elements. Equipment as-found condition was less than adequate. "},null,{"$f":"IF(E5=\"\",\"\",VLOOKUP(E5,'Level ABC (full code)'!$B$2:$D$189,3,FALSE))","v":"An event occurred as a result of multiple pieces of controls for equipment or instrumentation, where adjustment of one requires the coordinated adjustment(s) of others did not occur, or was performed incorrectly."}]

{"sheet":"Error Precursors(Area-Element)","index":6,"n_rows":164,"n_cols":5,"rows_kept":164,"cut":false,"hidden":true,"merged":[]}
["Error Precursor Area","Element","Code","LevelC_Code_Description","LevelC_Code_Definition"]
["Task Demands","High workload [memory requirements]","A4B4C07",{"$f":"VLOOKUP($C2,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Too many concurrent tasks assigned to worker"},{"$f":"VLOOKUP($C2,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Supervision failed to detect that concurrent job assignments for an individual exceeded the individual's abilities. "}]
["Task Demands","High workload [memory requirements]","A5B2C05",{"$f":"VLOOKUP(C3,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Ambiguous instructions / requirements"},{"$f":"VLOOKUP($C3,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The instructions in the written communication were unclear, uncertain, or interpretable in more than one way.  Different procedures related to the same task contained different requirements. There were conflicting or inconsistent requirements stated in different steps of the same procedure. Requirements were stated in different units. "}]
["Task Demands","High workload [memory requirements]","A5B2C08",{"$f":"VLOOKUP(C4,'Full Code'!$A$2:$B$221,2,FALSE)","v":"– Incomplete / situation not covered"},{"$f":"VLOOKUP($C4,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Details of the written communication were incomplete.  Insufficient information was presented.  The written communication did not address situations likely to occur during the completion of the procedure.  Note: This is for information that is not in the written communication.  A5B2C07 is for information that is in the document. "}]
["Task Demands","Time pressure [in a hurry]","A4B3C02",{"$f":"VLOOKUP(C5,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Insufficient time allotted for task"},{"$f":"VLOOKUP($C5,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Scheduled duration of the task did not adequately address known conditions or account for reasonable emergent issues. "}]
["Task Demands","Time pressure [in a hurry]","A4B3C07",{"$f":"VLOOKUP(C6,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Job scoping did not identify potential task interruptions and/or environmental stress"},{"$f":"VLOOKUP($C6,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The work scoping process was not effective in detecting reasonable obstructions to work flow (e.g., shift changes) or the impact of environmental conditions.   Note: This code applies to disruptions of circadian rhythms [biological functions based on 24-hour schedule] caused by scheduling of work. "}]
["Task Demands","Simultaneous, multiple tasks","A4B3C07",{"$f":"VLOOKUP(C7,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Job scoping did not identify potential task interruptions and/or environmental stress"},{"$f":"VLOOKUP($C7,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The work scoping process was not effective in detecting reasonable obstructions to work flow (e.g., shift changes) or the impact of environmental conditions.   Note: This code applies to disruptions of circadian rhythms [biological functions based on 24-hour schedule] caused by scheduling of work. "}]
["Task Demands","Simultaneous, multiple tasks","A4B4C07",{"$f":"VLOOKUP(C8,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Too many concurrent tasks assigned to worker"},{"$f":"VLOOKUP($C8,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Supervision failed to detect that concurrent job assignments for an individual exceeded the individual's abilities. "}]
["Task Demands","Repetitive action/monotony","A4B3C07",{"$f":"VLOOKUP(C9,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Job scoping did not identify potential task interruptions and/or environmental stress"},{"$f":"VLOOKUP($C9,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The work scoping process was not effective in detecting reasonable obstructions to work flow (e.g., shift changes) or the impact of environmental conditions.   Note: This code applies to disruptions of circadian rhythms [biological functions based on 24-hour schedule] caused by scheduling of work. "}]
["Task Demands","Repetitive action/monotony","A4B3C10",{"$f":"VLOOKUP(C10,'Full Code'!$A$2:$B$221,2,FALSE)","v":"– Problem performing repetitive tasks and/or subtasks"},{"$f":"VLOOKUP($C10,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The work flow plan repeated tasks or subtasks to the detriment of successful completion of the evolution. "}]
["Task Demands","Irrecoverable actions","A1B2C09",{"$f":"VLOOKUP(C11,'Full Code'!$A$2:$B$221,2,FALSE)","v":"– Errors not recoverable"},{"$f":"VLOOKUP($C11,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The system was designed such that personnel were unable to recover from error discovered before a failure occurred. "}]
["Task Demands","Interpretation requirements","A1B5C01",{"$f":"VLOOKUP(C12,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Ergonomics LTA"},{"$f":"VLOOKUP($C12,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Inadequate ergonomic design contributed to the occurrence. - The operator was physically incapable of performing the required task.  The operator had to go too far to respond to the alarm.  Personnel mobility or vision was restricted.  An individual had difficulty reaching the equipment or assumed an awkward position to complete a task.  The event was caused because illumination levels were not sufficient for task performance. "}]
["Task Demands","Interpretation requirements","A1B5C02",{"$f":"VLOOKUP(C13,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Physical environment LTA"},{"$f":"VLOOKUP($C13,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Inadequate equipment controls or control systems [e.g., push-buttons, rotary controls, J-handles, key-operated controls, thumb-wheels, multiple switches, joysticks] contributed to the occurrence. The control failed to provide an adequate range of control for the function it performs. The control was inadequately protected from accidental activation. Similar controls were indistinguishable from one another. Controls were in too close proximity of each other. Operating conditions [e.g. room temperature, work location, physical location, restricted vision, personal protective equipment, excessive noise, arrangement or placement of equipment] affected performance of the task. Lighting was inadequate. Noise was a factor. "}]
["Task Demands","Interpretation requirements","A3B3",{"$f":"VLOOKUP(C14,'Full Code'!$A$2:$B$221,2,FALSE)","v":"KNOWLEDGE BASED ERROR"},{"$f":"VLOOKUP($C14,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The problem was solved without using stored rules for behavior. The involved personnel were in a problem solving/troubleshooting mode. Note: Some people find it easier to think of this node as “Lack of Knowledge Based Error” since the essential gap is experiential. "}]
["Task Demands","Interpretation requirements","A4B1C01",{"$f":"VLOOKUP(C15,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Management policy guidance / expectations not well-defined, understood or enforced"},{"$f":"VLOOKUP($C15,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Personnel exhibited a lack of understanding of existing policy and/or expectations, or policy/expectations were not well-defined or policy/expectation is not enforced. "}]
["Task Demands","Interpretation requirements","A4B4C01",{"$f":"VLOOKUP(C16,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Tasks and individual accountability not made clear to worker"},{"$f":"VLOOKUP($C16,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Tasks (and the individual accountability for the task) that were outside written guidance or training were not made clear to the worker. "}]
["Task Demands","Interpretation requirements","A5B2C05",{"$f":"VLOOKUP(C17,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Ambiguous instructions / requirements"},{"$f":"VLOOKUP($C17,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The instructions in the written communication were unclear, uncertain, or interpretable in more than one way.  Different procedures related to the same task contained different requirements. There were conflicting or inconsistent requirements stated in different steps of the same procedure. Requirements were stated in different units. "}]
["Task Demands","Interpretation requirements","A5B2C08",{"$f":"VLOOKUP(C18,'Full Code'!$A$2:$B$221,2,FALSE)","v":"– Incomplete / situation not covered"},{"$f":"VLOOKUP($C18,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Details of the written communication were incomplete.  Insufficient information was presented.  The written communication did not address situations likely to occur during the completion of the procedure.  Note: This is for information that is not in the written communication.  A5B2C07 is for information that is in the document. "}]
["Task Demands","Interpretation requirements","A5B4C03",{"$f":"VLOOKUP(C19,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Correct terminology not used"},{"$f":"VLOOKUP($C19,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Standard or accepted terminology was not used. The communication could be interpreted more than one way.  One piece of equipment had two or more commonly used names.  The terminology could have applied to more than one item.  Note: The same word or phrase can mean different things to different people.  Two people can both feel that communication is accurate when, in fact, it is not because of inconsistent nomenclature.  Regional or non-standard speech may also present a problem. "}]
["Task Demands","Interpretation requirements","A5B4C04",{"$f":"VLOOKUP(C20,'Full Code'!$A$2:$B$221,2,FALSE)","v":"– Verification / repeat back not used"},{"$f":"VLOOKUP($C20,'Full Code'!$A$2:$C$221,3,FALSE)","v":"A communication error was caused by failure to repeat back a message to the sender for the purposes of verifying that the message was heard and understood correctly. "}]
["Task Demands","Interpretation requirements","A5B4C05",{"$f":"VLOOKUP(C21,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Information sent but not understood"},{"$f":"VLOOKUP($C21,'Full Code'!$A$2:$C$221,3,FALSE)","v":"A message or instruction was misunderstood because of noise interference.  A message or instruction was misunderstood because it was too long.  The message should have been written instead of oral.  The message could have been shortened or broken up.  Note: Communication can be greatly disrupted by ambient sound levels, general noise, whines, buzzes and the like.  Human speech communication takes place in a narrow frequency band between 600 and 4800 Hz.  This is known as the speech interference zone.  Sounds can mask frequencies of speech in this zone, thereby making communication very difficult.   Note: A related code is Physical Environment LTA [A1B5C02], which addresses noise interference other than speech. "}]
["Task Demands","Unclear goals, roles or responsibilities","A4B1C07",{"$f":"VLOOKUP(C22,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Responsibility of personnel not well defined or personnel not held accountable"},{"$f":"VLOOKUP($C22,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Responsibility for process elements (procedures, engineering, training, etc.) was not placed with individuals or accountability for failures of those process elements was not placed with individuals. "}]
["Task Demands","Unclear goals, roles or responsibilities","A4B4C01",{"$f":"VLOOKUP(C23,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Tasks and individual accountability not made clear to worker"},{"$f":"VLOOKUP($C23,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Tasks (and the individual accountability for the task) that were outside written guidance or training were not made clear to the worker. "}]
["Task Demands","Unclear goals, roles or responsibilities","A5B2C02",{"$f":"VLOOKUP(C24,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Difficult to implement"},{"$f":"VLOOKUP($C24,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Standards, Policies or Administrative Controls (SPAC) were not followed because no practical way of implementing them existed. Implementation would have hindered production. "}]
["Task Demands","Unclear goals, roles or responsibilities","A5B2C05",{"$f":"VLOOKUP(C25,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Ambiguous instructions / requirements"},{"$f":"VLOOKUP($C25,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The instructions in the written communication were unclear, uncertain, or interpretable in more than one way.  Different procedures related to the same task contained different requirements. There were conflicting or inconsistent requirements stated in different steps of the same procedure. Requirements were stated in different units. "}]
["Task Demands","Unclear goals, roles or responsibilities","A5B2C07",{"$f":"VLOOKUP(C26,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Facts wrong / requirements not correct"},{"$f":"VLOOKUP($C26,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Specific information in the written communication was incorrect. The written communication contained outdated requirements.  The written communication did not reflect the current status of equipment.  Note: This is for information that is in the written communication. A5B2C08 is for information that is not in the document. "}]
["Task Demands","Unclear goals, roles or responsibilities","A5B2C08",{"$f":"VLOOKUP(C27,'Full Code'!$A$2:$B$221,2,FALSE)","v":"– Incomplete / situation not covered"},{"$f":"VLOOKUP($C27,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Details of the written communication were incomplete.  Insufficient information was presented.  The written communication did not address situations likely to occur during the completion of the procedure.  Note: This is for information that is not in the written communication.  A5B2C07 is for information that is in the document. "}]
["Task Demands","Unclear goals, roles or responsibilities","A5B3C02",{"$f":"VLOOKUP(C28,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Not available or inconvenient for use"},{"$f":"VLOOKUP($C28,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The written communication was not readily available. A copy of the written communication was not available in the designated file or rack. A “master copy” of the written communication was not available for reproductions. Use of the written communication was inconvenient because of working conditions (e.g., radiation areas, tight quarters, plastic suits). "}]
["Task Demands","Unclear goals, roles or responsibilities","A6B3C01",{"$f":"VLOOKUP(C29,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Training objectives LTA"},{"$f":"VLOOKUP($C29,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The task analysis incorrectly identified the knowledge and skills necessary to complete the task. The proper setting in which to train the operator was not identified. The objectives were not written to accurately represent the task analysis. The objective did not satisfy the needs identified in the task analysis. The objectives did not cover all of the requirements necessary to successfully complete the task. "}]
["Task Demands","Lack of or unclear standards","A4B1C01",{"$f":"VLOOKUP(C30,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Management policy guidance / expectations not well-defined, understood or enforced"},{"$f":"VLOOKUP($C30,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Personnel exhibited a lack of understanding of existing policy and/or expectations, or policy/expectations were not well-defined or policy/expectation is not enforced. "}]
["Task Demands","Lack of or unclear standards","A5B2C08",{"$f":"VLOOKUP(C31,'Full Code'!$A$2:$B$221,2,FALSE)","v":"– Incomplete / situation not covered"},{"$f":"VLOOKUP($C31,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Details of the written communication were incomplete.  Insufficient information was presented.  The written communication did not address situations likely to occur during the completion of the procedure.  Note: This is for information that is not in the written communication.  A5B2C07 is for information that is in the document. "}]
["Work Environment","Distractions / interruptions","A1B5C02",{"$f":"VLOOKUP(C32,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Physical environment LTA"},{"$f":"VLOOKUP($C32,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Inadequate equipment controls or control systems [e.g., push-buttons, rotary controls, J-handles, key-operated controls, thumb-wheels, multiple switches, joysticks] contributed to the occurrence. The control failed to provide an adequate range of control for the function it performs. The control was inadequately protected from accidental activation. Similar controls were indistinguishable from one another. Controls were in too close proximity of each other. Operating conditions [e.g. room temperature, work location, physical location, restricted vision, personal protective equipment, excessive noise, arrangement or placement of equipment] affected performance of the task. Lighting was inadequate. Noise was a factor. "}]
["Work Environment","Distractions / interruptions","A4B3C07",{"$f":"VLOOKUP(C33,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Job scoping did not identify potential task interruptions and/or environmental stress"},{"$f":"VLOOKUP($C33,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The work scoping process was not effective in detecting reasonable obstructions to work flow (e.g., shift changes) or the impact of environmental conditions.   Note: This code applies to disruptions of circadian rhythms [biological functions based on 24-hour schedule] caused by scheduling of work. "}]
["Work Environment","Distractions / interruptions","A4B4C07",{"$f":"VLOOKUP(C34,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Too many concurrent tasks assigned to worker"},{"$f":"VLOOKUP($C34,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Supervision failed to detect that concurrent job assignments for an individual exceeded the individual's abilities. "}]
["Work Environment","Changes / departures from routine","A4B3C07",{"$f":"VLOOKUP(C35,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Job scoping did not identify potential task interruptions and/or environmental stress"},{"$f":"VLOOKUP($C35,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The work scoping process was not effective in detecting reasonable obstructions to work flow (e.g., shift changes) or the impact of environmental conditions.   Note: This code applies to disruptions of circadian rhythms [biological functions based on 24-hour schedule] caused by scheduling of work. "}]
["Work Environment","Changes / departures from routine","A4B4C01",{"$f":"VLOOKUP(C36,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Tasks and individual accountability not made clear to worker"},{"$f":"VLOOKUP($C36,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Tasks (and the individual accountability for the task) that were outside written guidance or training were not made clear to the worker. "}]
["Work Environment","Changes / departures from routine","A6B3C02",{"$f":"VLOOKUP(C37,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Inadequate content"},{"$f":"VLOOKUP($C37,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The lesson content did not address all the training objectives. The lessons did not contain all the information necessary to perform the job.  The knowledge and skills required to perform the task or job were not identified. "}]
["Work Environment","Confusing procedure / vague guidance","A4B4C01",{"$f":"VLOOKUP(C38,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Tasks and individual accountability not made clear to worker"},{"$f":"VLOOKUP($C38,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Tasks (and the individual accountability for the task) that were outside written guidance or training were not made clear to the worker. "}]
["Work Environment","Confusing procedure / vague guidance","A5B1C01",{"$f":"VLOOKUP(C39,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Format deficiencies"},{"$f":"VLOOKUP($C39,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The layout of the written communication made it difficult to follow.  The format differed from that which the user was accustomed to using.  The steps of the procedure were not logically grouped.  Step(s) in the written communication had more than one action or direction to perform.  Some step(s) in the written communication stated one action, which in practice actually required several steps to perform. "}]
["Work Environment","Confusing procedure / vague guidance","A5B1C07",{"$f":"VLOOKUP(C40,'Full Code'!$A$2:$B$221,2,FALSE)","v":"– Unclear / complex wording or grammar"},{"$f":"VLOOKUP($C40,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Wording, grammar or symbols fail too clearly and concisely specify the required action: instructions provided for team of users failed to specify roles of each user.  Considering the training and experience of the user, the written communication was too difficult to understand or follow.  There was insufficient information to identify the appropriate written communication. The written communication was not designed for the “less practiced” user. "}]
["Work Environment","Confusing procedure / vague guidance","A5B2C05",{"$f":"VLOOKUP(C41,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Ambiguous instructions / requirements"},{"$f":"VLOOKUP($C41,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The instructions in the written communication were unclear, uncertain, or interpretable in more than one way.  Different procedures related to the same task contained different requirements. There were conflicting or inconsistent requirements stated in different steps of the same procedure. Requirements were stated in different units. "}]
["Work Environment","Confusing procedure / vague guidance","A5B2C08",{"$f":"VLOOKUP(C42,'Full Code'!$A$2:$B$221,2,FALSE)","v":"– Incomplete / situation not covered"},{"$f":"VLOOKUP($C42,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Details of the written communication were incomplete.  Insufficient information was presented.  The written communication did not address situations likely to occur during the completion of the procedure.  Note: This is for information that is not in the written communication.  A5B2C07 is for information that is in the document. "}]
["Work Environment","Confusing displays / controls","A1B5C01",{"$f":"VLOOKUP(C43,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Ergonomics LTA"},{"$f":"VLOOKUP($C43,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Inadequate ergonomic design contributed to the occurrence. - The operator was physically incapable of performing the required task.  The operator had to go too far to respond to the alarm.  Personnel mobility or vision was restricted.  An individual had difficulty reaching the equipment or assumed an awkward position to complete a task.  The event was caused because illumination levels were not sufficient for task performance. "}]
["Work Environment","Confusing displays / controls","A2B4C07",{"$f":"VLOOKUP(C44,'Full Code'!$A$2:$B$221,2,FALSE)","v":"– Marking / labeling LTA"},{"$f":"VLOOKUP($C44,'Full Code'!$A$2:$C$221,3,FALSE)","v":"There was an error made in the labeling or marking. Equipment identification, labeling, or marking was less than adequate. "}]
["Work Environment","Work-arounds; Out of Service instrumentation","A1B5C01",{"$f":"VLOOKUP(C45,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Ergonomics LTA"},{"$f":"VLOOKUP($C45,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Inadequate ergonomic design contributed to the occurrence. - The operator was physically incapable of performing the required task.  The operator had to go too far to respond to the alarm.  Personnel mobility or vision was restricted.  An individual had difficulty reaching the equipment or assumed an awkward position to complete a task.  The event was caused because illumination levels were not sufficient for task performance. "}]
["Work Environment","Work-arounds; Out of Service instrumentation","A2B1C01",{"$f":"VLOOKUP(C46,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Calibration LTA"},{"$f":"VLOOKUP($C46,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The equipment involved in the incident was not included in a routine calibration program. Calibrations were performed too infrequently. The calibration did not include all the essential elements. "}]
["Work Environment","Work-arounds; Out of Service instrumentation","A2B2C01",{"$f":"VLOOKUP(C47,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Preventive maintenance for equipment LTA"},{"$f":"VLOOKUP($C47,'Full Code'!$A$2:$C$221,3,FALSE)","v":"An equipment malfunction was caused by a failure to perform scheduled preventive maintenance. Preventive maintenance was not established for the equipment or component that failed. Preventive maintenance was scheduled too infrequently. The preventive maintenance was incomplete. Preventive maintenance was performed on some of the components but not on others. (Note: Preventive maintenance is a maintenance program which is cyclical, it is done based on a repetitive basis based on some characteristic (numbers of operations, time, etc.))"}]
["Work Environment","Work-arounds; Out of Service instrumentation","A4B4C01",{"$f":"VLOOKUP(C48,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Tasks and individual accountability not made clear to worker"},{"$f":"VLOOKUP($C48,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Tasks (and the individual accountability for the task) that were outside written guidance or training were not made clear to the worker. "}]
["Work Environment","Work-arounds; Out of Service instrumentation","A5B2C08",{"$f":"VLOOKUP(C49,'Full Code'!$A$2:$B$221,2,FALSE)","v":"– Incomplete / situation not covered"},{"$f":"VLOOKUP($C49,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Details of the written communication were incomplete.  Insufficient information was presented.  The written communication did not address situations likely to occur during the completion of the procedure.  Note: This is for information that is not in the written communication.  A5B2C07 is for information that is in the document. "}]
["Work Environment","Work-arounds; Out of Service instrumentation","A6B3C02",{"$f":"VLOOKUP(C50,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Inadequate content"},{"$f":"VLOOKUP($C50,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The lesson content did not address all the training objectives. The lessons did not contain all the information necessary to perform the job.  The knowledge and skills required to perform the task or job were not identified. "}]
["Work Environment","Hidden system response","A1B2C08",{"$f":"VLOOKUP(C51,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Errors not detectable"},{"$f":"VLOOKUP($C51,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Personnel were unable to detect errors [by way of alarms or instrument readings] during or after the occurrence. A serious error went unnoticed because there was no way to monitor system status."}]
["Work Environment","Unexpected equipment conditions","A1B5C01",{"$f":"VLOOKUP(C52,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Ergonomics LTA"},{"$f":"VLOOKUP($C52,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Inadequate ergonomic design contributed to the occurrence. - The operator was physically incapable of performing the required task.  The operator had to go too far to respond to the alarm.  Personnel mobility or vision was restricted.  An individual had difficulty reaching the equipment or assumed an awkward position to complete a task.  The event was caused because illumination levels were not sufficient for task performance. "}]
["Work Environment","Unexpected equipment conditions","A2B1C01",{"$f":"VLOOKUP(C53,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Calibration LTA"},{"$f":"VLOOKUP($C53,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The equipment involved in the incident was not included in a routine calibration program. Calibrations were performed too infrequently. The calibration did not include all the essential elements. "}]
["Work Environment","Unexpected equipment conditions","A2B2C01",{"$f":"VLOOKUP(C54,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Preventive maintenance for equipment LTA"},{"$f":"VLOOKUP($C54,'Full Code'!$A$2:$C$221,3,FALSE)","v":"An equipment malfunction was caused by a failure to perform scheduled preventive maintenance. Preventive maintenance was not established for the equipment or component that failed. Preventive maintenance was scheduled too infrequently. The preventive maintenance was incomplete. Preventive maintenance was performed on some of the components but not on others. (Note: Preventive maintenance is a maintenance program which is cyclical, it is done based on a repetitive basis based on some characteristic (numbers of operations, time, etc.))"}]
["Work Environment","Unexpected equipment conditions","A2B2C04",{"$f":"VLOOKUP(C55,'Full Code'!$A$2:$B$221,2,FALSE)","v":"– Equipment history LTA"},{"$f":"VLOOKUP($C55,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Equipment history / records did not exist for the equipment that malfunctioned. The history for the equipment that malfunctioned was incomplete / inadequate. The history did not contain all the information necessary to assure equipment reliability. Knowledge of equipment history would have prevented the incident or lessened its severity. "}]
["Work Environment","Unexpected equipment conditions","A2B3C02",{"$f":"VLOOKUP(C56,'Full Code'!$A$2:$B$221,2,FALSE)","v":"– Inspection / testing LTA"},{"$f":"VLOOKUP($C56,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Required testing / inspection was not established or performed for the equipment involved in the incident. The required testing / inspection was performed at an incorrect frequency. The acceptance criteria for the required testing / inspection were inadequately defined. All essential components were not included in the required testing / inspection. "}]
["Work Environment","Unexpected equipment conditions","A2B4C04",{"$f":"VLOOKUP(C57,'Full Code'!$A$2:$B$221,2,FALSE)","v":"– Material shipping LTA"},{"$f":"VLOOKUP($C57,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The material / equipment was transported improperly. The material / equipment was damaged during shipping. "}]
["Work Environment","Unexpected equipment conditions","A4B3C07",{"$f":"VLOOKUP(C58,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Job scoping did not identify potential task interruptions and/or environmental stress"},{"$f":"VLOOKUP($C58,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The work scoping process was not effective in detecting reasonable obstructions to work flow (e.g., shift changes) or the impact of environmental conditions.   Note: This code applies to disruptions of circadian rhythms [biological functions based on 24-hour schedule] caused by scheduling of work. "}]
["Work Environment","Unexpected equipment conditions","A4B3C08",{"$f":"VLOOKUP(C59,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Job scoping did not identify special circumstances and/or conditions"},{"$f":"VLOOKUP($C59,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The work scoping process was not effective in detecting work process elements having a dependency upon other circumstances or conditions. "}]
["Work Environment","Unexpected equipment conditions","A4B3C11",{"$f":"VLOOKUP(C60,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Inadequate work package preparation"},{"$f":"VLOOKUP($C60,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Though scoping and planning were adequately performed, the work package did not reflect the information gathered from these activities. The work package did not accurately reflect the work that was to be completed. "}]
["Work Environment","Lack of alternative indication","A1B2C01",{"$f":"VLOOKUP(C61,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Design output scope LTA"},{"$f":"VLOOKUP($C61,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The design did not consider all the possible scenarios. All the operating conditions, [normal and emergency] were not included in the design"}]
["Individual capabilities","Unfamiliar with task/first time","A4B2C01",{"$f":"VLOOKUP(C62,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Too many administrative duties assigned to immediate supervisors"},{"$f":"VLOOKUP($C62,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The administrative load on immediate supervisors adversely affected their ability to supervise ongoing activities.   Note: This is a problem with the management of the supervisor not his/her supervisory methods [A4B4]. This is non-task activities [not actively supervising employees]. Task overload is A4B2C02. "}]
["Individual capabilities","Unfamiliar with task/first time","A4B2C02",{"$f":"VLOOKUP(C63,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Insufficient supervisory resources to provide necessary supervision"},{"$f":"VLOOKUP($C63,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Supervision resource is less than that required by task analysis considering the balance of procedures, supervision and training.   Note: This is a problem with the management of the supervisor not the supervisory methods [A4B4]. This is too many jobs to be actively supervised at once. Non-task [not actively supervising employees] overload is A4B2C01. "}]
["Individual capabilities","Unfamiliar with task/first time","A4B4",{"$f":"VLOOKUP(C64,'Full Code'!$A$2:$B$221,2,FALSE)","v":"SUPERVISORY METHODS LTA"},{"$f":"VLOOKUP($C64,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Causes that can be traced back to the immediate supervision and evaluated techniques that were used to monitor, direct and control work assignments. Note: this is supervision as a function not as a title. A manager can be the supervisor of another manager or a non-supervisor [by title] can be functioning as a supervisor. Problems with other than immediate supervision are coded under A4B1, A4B2 or A4B5 [which does not say that immediate supervision problems cannot be multiple coded under those B nodes]. "}]
["Individual capabilities","Unfamiliar with task/first time","A6B1C01",{"$f":"VLOOKUP(C65,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Decision not to train"},{"$f":"VLOOKUP($C65,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The decision was made not to provide specific training on a task. Some employees were not required to receive training. Experience was considered a substitute for training.  Note: Items in this area will generally have multiple codes with an additional entry under “Management Problem”. A6B1 hinges on the Job Task Analysis (JTA). If the JTA was LTA, it is A6B1C01. If the JTA was not completed, it is A6B1C02. If a particular individual’s training was waived regardless of the JTA because of assumed experience it is A6B1C03. "}]
["Individual capabilities","Unfamiliar with task/first time","A6B1C02",{"$f":"VLOOKUP(C66,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Training requirements not identified"},{"$f":"VLOOKUP($C66,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Training on the task was not part of the employee’s training requirements. The necessary training had not been defined for the job description.  Note: A6B1 hinges on the Job Task Analysis (JTA). If the JTA was LTA, it is A6B1C01. If the JTA was not completed, it is A6B1C02. If a particular individual’s training was waived regardless of the JTA because of assumed experience it is A6B1C03. "}]
["Individual capabilities","Unfamiliar with task/first time","A6B1C03",{"$f":"VLOOKUP(C67,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Work incorrectly considered “skill-of-the-craft”"},{"$f":"VLOOKUP($C67,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The work was not a “skill” that could be developed through job experience. The operator did not have appropriate training for the task. Provisions to assure operators have received proper training prior to assignment to this task were not addressed.  Note: A6B1 hinges on the Job Task Analysis (JTA). If the JTA was LTA, it is A6B1C01. If the JTA was not completed, it is A6B1C02. If a particular individual’s training was waived regardless of the JTA because of assumed experience it is A6B1C03. "}]
["Individual capabilities","Unfamiliar with task/first time","A6B2C01",{"$f":"VLOOKUP(C68,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Practice or “hands-on” experience LTA"},{"$f":"VLOOKUP($C68,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The on-the-job training did not provide opportunities to learn skills necessary to perform the job. There was insufficient on-the-job training. There was an inadequate amount of preparation before performing the activity. The employee had not previously performed the task under direct supervision. "}]
["Individual capabilities","Lack of knowledge [mental model]","A3B3",{"$f":"VLOOKUP(C69,'Full Code'!$A$2:$B$221,2,FALSE)","v":"KNOWLEDGE BASED ERROR"},{"$f":"VLOOKUP($C69,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The problem was solved without using stored rules for behavior. The involved personnel were in a problem solving/troubleshooting mode. Note: Some people find it easier to think of this node as “Lack of Knowledge Based Error” since the essential gap is experiential. "}]
["Individual capabilities","Lack of knowledge [mental model]","A6B1C01",{"$f":"VLOOKUP(C70,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Decision not to train"},{"$f":"VLOOKUP($C70,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The decision was made not to provide specific training on a task. Some employees were not required to receive training. Experience was considered a substitute for training.  Note: Items in this area will generally have multiple codes with an additional entry under “Management Problem”. A6B1 hinges on the Job Task Analysis (JTA). If the JTA was LTA, it is A6B1C01. If the JTA was not completed, it is A6B1C02. If a particular individual’s training was waived regardless of the JTA because of assumed experience it is A6B1C03. "}]
["Individual capabilities","Lack of knowledge [mental model]","A6B1C02",{"$f":"VLOOKUP(C71,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Training requirements not identified"},{"$f":"VLOOKUP($C71,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Training on the task was not part of the employee’s training requirements. The necessary training had not been defined for the job description.  Note: A6B1 hinges on the Job Task Analysis (JTA). If the JTA was LTA, it is A6B1C01. If the JTA was not completed, it is A6B1C02. If a particular individual’s training was waived regardless of the JTA because of assumed experience it is A6B1C03. "}]
["Individual capabilities","Lack of knowledge [mental model]","A6B3C02",{"$f":"VLOOKUP(C72,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Inadequate content"},{"$f":"VLOOKUP($C72,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The lesson content did not address all the training objectives. The lessons did not contain all the information necessary to perform the job.  The knowledge and skills required to perform the task or job were not identified. "}]
["Individual capabilities","Imprecise communication habits","A5B4C03",{"$f":"VLOOKUP(C73,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Correct terminology not used"},{"$f":"VLOOKUP($C73,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Standard or accepted terminology was not used. The communication could be interpreted more than one way.  One piece of equipment had two or more commonly used names.  The terminology could have applied to more than one item.  Note: The same word or phrase can mean different things to different people.  Two people can both feel that communication is accurate when, in fact, it is not because of inconsistent nomenclature.  Regional or non-standard speech may also present a problem. "}]
["Individual capabilities","Imprecise communication habits","A5B4C04",{"$f":"VLOOKUP(C74,'Full Code'!$A$2:$B$221,2,FALSE)","v":"– Verification / repeat back not used"},{"$f":"VLOOKUP($C74,'Full Code'!$A$2:$C$221,3,FALSE)","v":"A communication error was caused by failure to repeat back a message to the sender for the purposes of verifying that the message was heard and understood correctly. "}]
["Individual capabilities","Imprecise communication habits","A5B4C05",{"$f":"VLOOKUP(C75,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Information sent but not understood"},{"$f":"VLOOKUP($C75,'Full Code'!$A$2:$C$221,3,FALSE)","v":"A message or instruction was misunderstood because of noise interference.  A message or instruction was misunderstood because it was too long.  The message should have been written instead of oral.  The message could have been shortened or broken up.  Note: Communication can be greatly disrupted by ambient sound levels, general noise, whines, buzzes and the like.  Human speech communication takes place in a narrow frequency band between 600 and 4800 Hz.  This is known as the speech interference zone.  Sounds can mask frequencies of speech in this zone, thereby making communication very difficult.   Note: A related code is Physical Environment LTA [A1B5C02], which addresses noise interference other than speech. "}]
["Individual capabilities","Lack of proficiency / inexperience","A6B2C01",{"$f":"VLOOKUP(C76,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Practice or “hands-on” experience LTA"},{"$f":"VLOOKUP($C76,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The on-the-job training did not provide opportunities to learn skills necessary to perform the job. There was insufficient on-the-job training. There was an inadequate amount of preparation before performing the activity. The employee had not previously performed the task under direct supervision. "}]
["Individual capabilities","New technique not used before","A4B2C01",{"$f":"VLOOKUP(C77,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Too many administrative duties assigned to immediate supervisors"},{"$f":"VLOOKUP($C77,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The administrative load on immediate supervisors adversely affected their ability to supervise ongoing activities.   Note: This is a problem with the management of the supervisor not his/her supervisory methods [A4B4]. This is non-task activities [not actively supervising employees]. Task overload is A4B2C02. "}]
["Individual capabilities","New technique not used before","A4B2C02",{"$f":"VLOOKUP(C78,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Insufficient supervisory resources to provide necessary supervision"},{"$f":"VLOOKUP($C78,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Supervision resource is less than that required by task analysis considering the balance of procedures, supervision and training.   Note: This is a problem with the management of the supervisor not the supervisory methods [A4B4]. This is too many jobs to be actively supervised at once. Non-task [not actively supervising employees] overload is A4B2C01. "}]
["Individual capabilities","New technique not used before","A4B4",{"$f":"VLOOKUP(C79,'Full Code'!$A$2:$B$221,2,FALSE)","v":"SUPERVISORY METHODS LTA"},{"$f":"VLOOKUP($C79,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Causes that can be traced back to the immediate supervision and evaluated techniques that were used to monitor, direct and control work assignments. Note: this is supervision as a function not as a title. A manager can be the supervisor of another manager or a non-supervisor [by title] can be functioning as a supervisor. Problems with other than immediate supervision are coded under A4B1, A4B2 or A4B5 [which does not say that immediate supervision problems cannot be multiple coded under those B nodes]. "}]
["Individual capabilities","New technique not used before","A6B1C01",{"$f":"VLOOKUP(C80,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Decision not to train"},{"$f":"VLOOKUP($C80,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The decision was made not to provide specific training on a task. Some employees were not required to receive training. Experience was considered a substitute for training.  Note: Items in this area will generally have multiple codes with an additional entry under “Management Problem”. A6B1 hinges on the Job Task Analysis (JTA). If the JTA was LTA, it is A6B1C01. If the JTA was not completed, it is A6B1C02. If a particular individual’s training was waived regardless of the JTA because of assumed experience it is A6B1C03. "}]
["Individual capabilities","New technique not used before","A6B1C02",{"$f":"VLOOKUP(C81,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Training requirements not identified"},{"$f":"VLOOKUP($C81,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Training on the task was not part of the employee’s training requirements. The necessary training had not been defined for the job description.  Note: A6B1 hinges on the Job Task Analysis (JTA). If the JTA was LTA, it is A6B1C01. If the JTA was not completed, it is A6B1C02. If a particular individual’s training was waived regardless of the JTA because of assumed experience it is A6B1C03. "}]
["Individual capabilities","New technique not used before","A6B3C03",{"$f":"VLOOKUP(C82,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Training on new work methods LTA"},{"$f":"VLOOKUP($C82,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Training was not provided when the work methods for this task were changed. Training on changes to the procedure for the task was not provided. Training on new equipment used to perform the task was not provided.  Note: Use of this code is when training has been notified that a change needs to be made and the change has not been incorporated. If it is application of the process by which the function of Training is notified that a change needs to be made, then it is A4B5C08. "}]
["Individual capabilities","Unsystematic problem-solving skills","A3B4C01",{"$f":"VLOOKUP(C83,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Individual’s capability to perform work LTA "},{"$f":"VLOOKUP($C83,'Full Code'!$A$2:$C$221,3,FALSE)","v":" Sensory/Perceptual Capabilities LTA - The problem was due to less than adequate vision [e.g., poor visual acuity, color blindness, tunnel vision]. The problem was caused by some defect in hearing [e.g., hearing loss, tone deafness]. There was a problem due to some sensory defect [e.g., poor sense of touch or smell].  • Motor/Physical Capabilities LTA - The causal factor was attributable to trouble with inadequate coordination or inadequate strength. The problem was due to inadequate size or stature of the individual involved. Other physical limitations [e.g., shaking, poor reaction time] contributed to the problem.  • Attitude/Psychological Profile LTA - The problem was due to a poor attitude on the part of an individual. The individual involved showed signs of emotional illness. "}]
["Individual capabilities","‘Can do’ attitude for crucial task","A3B3C01",{"$f":"VLOOKUP(C84,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Attention was given to wrong issues "},{"$f":"VLOOKUP($C84,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Selective mental processing of information was targeted at the wrong issues and was not focused on the right issues. Often the individual focus was centered around what was psychologically important instead of targeted on what was logically important. "}]
["Individual capabilities","‘Can do’ attitude for crucial task","A4B4C01",{"$f":"VLOOKUP(C85,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Tasks and individual accountability not made clear to worker"},{"$f":"VLOOKUP($C85,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Tasks (and the individual accountability for the task) that were outside written guidance or training were not made clear to the worker. "}]
["Individual capabilities","Illness or fatigue","A3B4C01",{"$f":"VLOOKUP(C86,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Individual’s capability to perform work LTA "},{"$f":"VLOOKUP($C86,'Full Code'!$A$2:$C$221,3,FALSE)","v":" Sensory/Perceptual Capabilities LTA - The problem was due to less than adequate vision [e.g., poor visual acuity, color blindness, tunnel vision]. The problem was caused by some defect in hearing [e.g., hearing loss, tone deafness]. There was a problem due to some sensory defect [e.g., poor sense of touch or smell].  • Motor/Physical Capabilities LTA - The causal factor was attributable to trouble with inadequate coordination or inadequate strength. The problem was due to inadequate size or stature of the individual involved. Other physical limitations [e.g., shaking, poor reaction time] contributed to the problem.  • Attitude/Psychological Profile LTA - The problem was due to a poor attitude on the part of an individual. The individual involved showed signs of emotional illness. "}]
["Individual capabilities","Illness or fatigue","A4B1C01",{"$f":"VLOOKUP(C87,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Management policy guidance / expectations not well-defined, understood or enforced"},{"$f":"VLOOKUP($C87,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Personnel exhibited a lack of understanding of existing policy and/or expectations, or policy/expectations were not well-defined or policy/expectation is not enforced. "}]
["Individual capabilities","Illness or fatigue","A4B2C03",{"$f":"VLOOKUP(C88,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Insufficient manpower to support identified goal / objective"},{"$f":"VLOOKUP($C88,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Personnel were not available as required by task analysis of goal/objective. "}]
["Individual capabilities","Illness or fatigue","A4B3C07",{"$f":"VLOOKUP(C89,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Job scoping did not identify potential task interruptions and/or environmental stress"},{"$f":"VLOOKUP($C89,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The work scoping process was not effective in detecting reasonable obstructions to work flow (e.g., shift changes) or the impact of environmental conditions.   Note: This code applies to disruptions of circadian rhythms [biological functions based on 24-hour schedule] caused by scheduling of work. "}]
["Human nature","Stress","A3B4C01",{"$f":"VLOOKUP(C90,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Individual’s capability to perform work LTA "},{"$f":"VLOOKUP($C90,'Full Code'!$A$2:$C$221,3,FALSE)","v":" Sensory/Perceptual Capabilities LTA - The problem was due to less than adequate vision [e.g., poor visual acuity, color blindness, tunnel vision]. The problem was caused by some defect in hearing [e.g., hearing loss, tone deafness]. There was a problem due to some sensory defect [e.g., poor sense of touch or smell].  • Motor/Physical Capabilities LTA - The causal factor was attributable to trouble with inadequate coordination or inadequate strength. The problem was due to inadequate size or stature of the individual involved. Other physical limitations [e.g., shaking, poor reaction time] contributed to the problem.  • Attitude/Psychological Profile LTA - The problem was due to a poor attitude on the part of an individual. The individual involved showed signs of emotional illness. "}]
["Human nature","Stress","A4B3C07",{"$f":"VLOOKUP(C91,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Job scoping did not identify potential task interruptions and/or environmental stress"},{"$f":"VLOOKUP($C91,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The work scoping process was not effective in detecting reasonable obstructions to work flow (e.g., shift changes) or the impact of environmental conditions.   Note: This code applies to disruptions of circadian rhythms [biological functions based on 24-hour schedule] caused by scheduling of work. "}]
["Human nature","Stress","A4B4C11",{"$f":"VLOOKUP(C92,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Assignment did not consider worker's ingrained work patterns"},{"$f":"VLOOKUP($C92,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Supervision failed to assess the incompatibility between worker's ingrained work patterns and necessary work patterns for successful completion of the current task. "}]
["Human nature","Habit patterns","A4B4C11",{"$f":"VLOOKUP(C93,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Assignment did not consider worker's ingrained work patterns"},{"$f":"VLOOKUP($C93,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Supervision failed to assess the incompatibility between worker's ingrained work patterns and necessary work patterns for successful completion of the current task. "}]
["Human nature","Habit patterns","A5B1C03",{"$f":"VLOOKUP(C94,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Checklist LTA"},{"$f":"VLOOKUP($C94,'Full Code'!$A$2:$C$221,3,FALSE)","v":"An error was made because each separate action in a step did not have a check-off space provided. The checklist was confusing. Each instruction did not clearly indicate what was required. Insufficient room was provided for the response. The checklist required unique responses for each step. "}]
["Human nature","Habit patterns","A5B3C01",{"$f":"VLOOKUP(C95,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Lack of written communication"},{"$f":"VLOOKUP($C95,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Some form of written communication did not exist for the job task being performed. "}]
["Human nature","Assumptions","A3B3",{"$f":"VLOOKUP(C96,'Full Code'!$A$2:$B$221,2,FALSE)","v":"KNOWLEDGE BASED ERROR"},{"$f":"VLOOKUP($C96,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The problem was solved without using stored rules for behavior. The involved personnel were in a problem solving/troubleshooting mode. Note: Some people find it easier to think of this node as “Lack of Knowledge Based Error” since the essential gap is experiential. "}]
["Human nature","Complacency / overconfidence","A3B1",{"$f":"VLOOKUP(C97,'Full Code'!$A$2:$B$221,2,FALSE)","v":"SKILL BASED ERROR"},{"$f":"VLOOKUP($C97,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Inattention or over-attention to performance of work affected the event. "}]
["Human nature","Mind set [intention]","A4B3C01",{"$f":"VLOOKUP(C98,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Insufficient time for worker to prepare task"},{"$f":"VLOOKUP($C98,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Scheduling of the task did not adequately address the time frame required for accepted worker preparation practices to occur. "}]
["Human nature","Mind set [intention]","A3B4C02",{"$f":"VLOOKUP(C99,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Deliberate violation "},{"$f":"VLOOKUP($C99,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The action on the part of the individual was a deliberate action to commit human error.   Note: Be very careful in the application of this code. It may take professional diagnosis to determine if the action was intentional or the result of something beyond the control of the individual [A3B3C01]. There is usually some form of personal gain associated with this code. Also, this code relates only to a single individual; group behavior is entirely different. If this code is cited in more than ~5% of the incidents for a given facility, there is most likely some other underlying cause. "}]
["Human nature","Mind set [intention]","A4B4C01",{"$f":"VLOOKUP(C100,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Tasks and individual accountability not made clear to worker"},{"$f":"VLOOKUP($C100,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Tasks (and the individual accountability for the task) that were outside written guidance or training were not made clear to the worker. "}]
["Human nature","Mind set [intention]","A6B1C01",{"$f":"VLOOKUP(C101,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Decision not to train"},{"$f":"VLOOKUP($C101,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The decision was made not to provide specific training on a task. Some employees were not required to receive training. Experience was considered a substitute for training.  Note: Items in this area will generally have multiple codes with an additional entry under “Management Problem”. A6B1 hinges on the Job Task Analysis (JTA). If the JTA was LTA, it is A6B1C01. If the JTA was not completed, it is A6B1C02. If a particular individual’s training was waived regardless of the JTA because of assumed experience it is A6B1C03. "}]
["Human nature","Mind set [intention]","A6B1C02",{"$f":"VLOOKUP(C102,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Training requirements not identified"},{"$f":"VLOOKUP($C102,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Training on the task was not part of the employee’s training requirements. The necessary training had not been defined for the job description.  Note: A6B1 hinges on the Job Task Analysis (JTA). If the JTA was LTA, it is A6B1C01. If the JTA was not completed, it is A6B1C02. If a particular individual’s training was waived regardless of the JTA because of assumed experience it is A6B1C03. "}]
["Human nature","Inaccurate risk perception","A4B1C03",{"$f":"VLOOKUP(C103,'Full Code'!$A$2:$B$221,2,FALSE)","v":"– Management direction created insufficient awareness of the impact of actions on safety / reliability"},{"$f":"VLOOKUP($C103,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Management failed to provide direction regarding safeguards against non-conservative actions by personnel concerning quality, safety or reliability. "}]
["Human nature","Inaccurate risk perception","A4B3C07",{"$f":"VLOOKUP(C104,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Job scoping did not identify potential task interruptions and/or environmental stress"},{"$f":"VLOOKUP($C104,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The work scoping process was not effective in detecting reasonable obstructions to work flow (e.g., shift changes) or the impact of environmental conditions.   Note: This code applies to disruptions of circadian rhythms [biological functions based on 24-hour schedule] caused by scheduling of work. "}]
["Human nature","Inaccurate risk perception","A4B5C04",{"$f":"VLOOKUP(C105,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Risks / consequences associated with change not adequately reviewed / assessed"},{"$f":"VLOOKUP($C105,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Elements of the process, physical, or cyber (including software) system change were not recognized as having adverse impact or increased risk of adverse impact prior to implementing the change. "}]
["Human nature","Inaccurate risk perception","A6B1C01",{"$f":"VLOOKUP(C106,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Decision not to train"},{"$f":"VLOOKUP($C106,'Full Code'!$A$2:$C$221,3,FALSE)","v":"The decision was made not to provide specific training on a task. Some employees were not required to receive training. Experience was considered a substitute for training.  Note: Items in this area will generally have multiple codes with an additional entry under “Management Problem”. A6B1 hinges on the Job Task Analysis (JTA). If the JTA was LTA, it is A6B1C01. If the JTA was not completed, it is A6B1C02. If a particular individual’s training was waived regardless of the JTA because of assumed experience it is A6B1C03. "}]
["Human nature","Inaccurate risk perception","A6B1C02",{"$f":"VLOOKUP(C107,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Training requirements not identified"},{"$f":"VLOOKUP($C107,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Training on the task was not part of the employee’s training requirements. The necessary training had not been defined for the job description.  Note: A6B1 hinges on the Job Task Analysis (JTA). If the JTA was LTA, it is A6B1C01. If the JTA was not completed, it is A6B1C02. If a particular individual’s training was waived regardless of the JTA because of assumed experience it is A6B1C03. "}]
["Human nature","Mental shortcuts [biases]","A3B3C03",{"$f":"VLOOKUP(C108,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Individual justified action by focusing on biased evidence "},{"$f":"VLOOKUP($C108,'Full Code'!$A$2:$C$221,3,FALSE)","v":"An individual was overconfident in evaluating the correctness of his/her knowledge. The chosen course of action was selected based on evidence that favored it and contradictory evidence was overlooked. "}]
["Human nature","Mental shortcuts [biases]","A3B3C04",{"$f":"VLOOKUP(C109,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- LTA review based on assumption that process will not change "},{"$f":"VLOOKUP($C109,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Individual believed that no variability existed in the process and overlooked the fact that a change has occurred leading to differing results than normally realized. "}]
["Human nature","Mental shortcuts [biases]","A3B3C05",{"$f":"VLOOKUP(C110,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Incorrect assumption that a correlation existed between two or more facts "},{"$f":"VLOOKUP($C110,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Wrong assumptions were made based on the belief that two or more facts are related to each other and incorrect actions were taken based on the assumption.   Note: This also covers the case where there is an incorrect assumption that two or more facts do not correlate when they do. "}]
["Human nature","Mental shortcuts [biases]","A3B3C06",{"$f":"VLOOKUP(C111,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Individual underestimated the problem by using past events as basis "},{"$f":"VLOOKUP($C111,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Individuals tend to oversimplify events. Based on stored knowledge of past events, the individual underestimated problems with the existing event and plans for fewer contingencies than will actually be needed. "}]
["Human nature","Limited short term memory","A3B4C01",{"$f":"VLOOKUP(C112,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Individual’s capability to perform work LTA "},{"$f":"VLOOKUP($C112,'Full Code'!$A$2:$C$221,3,FALSE)","v":" Sensory/Perceptual Capabilities LTA - The problem was due to less than adequate vision [e.g., poor visual acuity, color blindness, tunnel vision]. The problem was caused by some defect in hearing [e.g., hearing loss, tone deafness]. There was a problem due to some sensory defect [e.g., poor sense of touch or smell].  • Motor/Physical Capabilities LTA - The causal factor was attributable to trouble with inadequate coordination or inadequate strength. The problem was due to inadequate size or stature of the individual involved. Other physical limitations [e.g., shaking, poor reaction time] contributed to the problem.  • Attitude/Psychological Profile LTA - The problem was due to a poor attitude on the part of an individual. The individual involved showed signs of emotional illness. "}]
["Human nature","Limited short term memory","A4B4C07",{"$f":"VLOOKUP(C113,'Full Code'!$A$2:$B$221,2,FALSE)","v":"- Too many concurrent tasks assigned to worker"},{"$f":"VLOOKUP($C113,'Full Code'!$A$2:$C$221,3,FALSE)","v":"Supervision failed to detect that concurrent job assignments for an individual exceeded the individual's abilities. "}]
[]
[]
[]
[]
[]
[]
[]
["Task Demands","High workload [memory requirements]"]
["Task Demands","Time pressure [in a hurry]"]
["Task Demands","Simultaneous, multiple tasks"]
["Task Demands","Repetitive action/monotony"]
["Task Demands","Irrecoverable actions"]
["Task Demands","Interpretation requirements"]
["Task Demands","Unclear goals, roles or responsibilities"]
["Task Demands","Lack of or unclear standards"]
["Work Environment","Distractions / interruptions"]
["Work Environment","Changes / departures from routine"]
["Work Environment","Confusing procedure / vague guidance"]
["Work Environment","Confusing displays / controls"]
["Work Environment","Work-arounds; Out of Service instrumentation"]
["Work Environment","Hidden system response"]
["Work Environment","Unexpected equipment conditions"]
["Work Environment","Lack of alternative indication"]
["Individual capabilities","Unfamiliar with task/first time"]
["Individual capabilities","Lack of knowledge [mental model]"]
["Individual capabilities","Imprecise communication habits"]
["Individual capabilities","Lack of proficiency / inexperience"]
["Individual capabilities","New technique not used before"]
["Individual capabilities","Unsystematic problem-solving skills"]
["Individual capabilities","‘Can do’ attitude for crucial task"]
["Individual capabilities","Illness or fatigue"]
["Human nature","Stress"]
["Human nature","Habit patterns"]
["Human nature","Assumptions"]
["Human nature","Complacency / overconfidence"]
["Human nature","Mind set [intention]"]
["Human nature","Inaccurate risk perception"]
["Human nature","Mental shortcuts [biases]"]
["Human nature","Limited short term memory"]
[]
[]
[]
[]
[]
[]
[]
[]
["Task Demands"]
["Work Environment"]
["Individual capabilities"]
["Human nature"]

{"sheet":"Error Precursor Selections","index":7,"n_rows":2,"n_cols":1,"rows_kept":2,"cut":false,"hidden":true,"merged":[]}
["Error Precursor Type"]
["Task Demands"]