RE: [Root_Cause_State_of_the_Practice] Re: Obvious, not Self-Revealing
Bill C,
Yes, “poor P&IR” could be
a hidden factor.
But an investigation that identifies only
obvious factors, and misses the hidden factors, is of little or no value.
The Texas
City explosion investigation may have revealed only
obvious factors, but that doesn’t mean there were no hidden factors.
It only means the investigation was inadequate.
I think we are on the same page.
Bill Salot
From:Root_Cause_State_of_the_Practice@yahoogroups.com
[mailto:Root_Cause_State_of_the_Practice@yahoogroups.com]
On Behalf Of DR WILLIAM CORCORAN Sent: Tuesday, July 07, 2009 11:50
AM To:Root_Cause_State_of_the_Practice@yahoogroups.com Subject: RE: [Root_Cause_State_of_the_Practice]
Re: Obvious, not Self-Revealing
Bill Salot,
When a consequence results from obvious factors is
one of the not-so-obvious factors that the organization is not very good at
PI&R?
If so, the investigation can be of great value.
E.g., The Texas City explosion investigation
revealed all obvious factors.
Take care,
Bill Corcoran
--- On Tue, 7/7/09, Salot,
William<william.salot@honeywell.com>
wrote:
From: Salot, William
<william.salot@honeywell.com>
Subject: RE: [Root_Cause_State_of_the_Practice] Re: Self-Revealing
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Date: Tuesday, July 7, 2009, 10:27 AM
Bill C,
OK, I will back off of using “self-revealing” as a
synonym for “obvious”.
The point I was trying to make then becomes: a cause analysis
that identifies only obvious factors is of little or no value. It must
uncover hidden or mystery factors.
Do you agree with that?
Bill Salot
From: Root_Cause_State_
of_the_Practice@ yahoogroups. com [mailto: Root_Cause_State_ of_the_Practice@
yahoogroups. com ] On Behalf Of DR
WILLIAM CORCORAN Sent: Tuesday, July 07, 2009
9:56 AM To: Root_Cause_State_
of_the_Practice@ yahoogroups. com Subject: RE: [Root_Cause_
State_of_ the_Practice] Re: Self-Revealing
Bill
Salot,
There
is a lot of overlap between "self-revealing problems" and
"self-revealing factors."
The
relationship may be that all "self-revealing factors" are
problems. They can be harmful factors of actual consequences, expected
consequences, and/or potential consequences.
The
NRC is concerned about those "self-revealing problems" that did
or could be harmful factors of consequences related to the Seven
Cornerstones. See the quotation below.
NRC
uses its Reactor Oversight Process (ROP) to measure plant performance
within the three broad areas of (1) reactor safety, (2) radiation safety,
and (3) security. Within these areas, NRC looks at seven cornerstones: (1)
Initiating Events, (2) Mitigating Systems, (3) Barrier Integrity, (4)
Emergency Preparedness, (5) Occupational Radiation Safety, (6) Public
Radiation Safety, and (7) Physical Protection.
Bill Salot, Â When a consequence results from obvious factors is one of the not-so-obvious factors that the organization is not very good at PI&R? Â If so,...
After an effective investigation reveals, them they are all, obvious factors. Tedd ________________________________ From:...
Dillard, Tedd A (E S ...
tedd.dillard@...
Jul 7, 2009 4:10 pm
Bill C, Yes, "poor P&IR" could be a hidden factor. But an investigation that identifies only obvious factors, and misses the hidden factors, is of little or no...
Bill S. Is there an analogy here to precursors and symptoms? I remember a thread on this a ways back where I believe you used an analogy where a precursor was...
Bob L, Yes, I like the analogy. The fever is obvious. The infection is hidden. Find the infection. Bill Salot ________________________________ From:...
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