Needed improvements in the development of systemic corrective actions.

There are indications that corrective actions, as implemented at Sandia National Laboratories are not fully adequate. Review of independent audits spanning multiple years provides evidence of recurring issues within the same or similar operations and programs. Several external audits have directly called into question the ability Sandia's assessment and evaluation processes to prevent recurrence. Examples of repeated findings include lockout/tagout programs, local exhaust ventilation controls and radiological controls. Recurrence clearly shows that there are underlying systemic factors that are not being adequately addressed by corrective actions stemming from causal analyses. Information suggests that improvements in the conduct of causal analyses and, more importantly, in the development of subsequent corrective actions are warranted. Current methodolgies include Management Oversight Risk Tree, developed in the early 1970s and Systemic Factors Analysis. Recommendations for improvements include review of other causal analysis systems, training, improved formality of operations, improved documentation, and a corporate method that uses truly systemic solutions. This report was written some years ago and is being published now to form the foundation for current, follow-on reports being developed. Some outdated material is recognized but is retained for report completeness.