Root cause analysis at Savannah River plant (nuclear power station)

摘要

A method has been developed at Savannah River plant (USA) to systematically evaluate events, identify their root causes, record the root causes, and analyze the root trends. By providing a systematic method to identify correctable root causes, the system helps the event investigator ask the right questions during the investigation. It also provides an independent safety analysis group and management with statistics indicating existing and developing trouble spots. An example demonstrating the usefulness of the root analysis tree is presented.