Analysis of past incidents at Nuclear Power Plants (NPPs) has shown that incidents are typically caused by a combination of hardware failures and human actions, and that latent rather than active failures dominate. In addition, it is apparent from reviews of past event analyses that repeat-root-cause problems (for minor events) are fairly common. The goal of the root-cause analysis method presented in this paper is to help identify and correct latent conditions that create contexts for human errors, before they are revealed through incidents or accidents.

In this paper, we present the augmented CATILaC methodology. This methodology builds on extended...