It seems to me that the labels may be getting in the way
of the communication.
The objective of effective corrective action programs
is to first prevent undesired conditions and outcomes (let me label these
as "problems" for discussion purposes), next to detect problems
as early as possible and then to correct the identified problems in a way
that addresses the immediate concern, implements interim actions to prevent
a repeat of the problem or other similar problems and then implements cost-effective,
long-lasting measures to prevent similar and related problems.
The PI&R process is intended to identify and resolve
problems. The NRC performs periodic focused PI&R inspections and also
addresses PI&R as part of the regular inspection process. In
addition, INPO/WANO performs focused evaluations of the plant PI&R/corrective
action program effectiveness.
Since proving future problems were prevented is difficult,
the process mainly focuses on a look at a snapshot in time to see how well
the plant did on identifying problems before they resulted in significant
conditions adverse to quality or had a large impact on plant risk. The
ones that the plant identified as part of scheduled surveillance, maintenance
and inspection activities or as an extent review from a problem investigation
are typically characterized as "licensee-identified". Others,
such as plant scrams, external leaks, failure in service, etc. are typically
characterized as "self-revealing".
The way I used to phrase it with our folks to help them
get the idea is to ask the question, "Did we find it, or did it find
us?".
The ratio of:
- we found it / it found us
told us a lot about how good we were at problem identification.
The ratio of:
- new problem / repeat problem
told us a lot about how good we were at problem resolution.
We can argue forever about what gets put into each bucket
(and there are people who will always want to "cook the books"
to show they are better than they actually are), but the idea was to go
back to these first principles to evaluate the effectiveness of our PI&R
capability.
Terry Herrmann
--- On Tue, 7/7/09, William R. Corcoran, Ph.D.,P.E. <William.R.Corcoran@...>
wrote:
From: William R. Corcoran, Ph.D.,P.E. <William.R.Corcoran@...>
Subject: [Root_Cause_State_of_the_Practice] Re: Self-Revealing
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Date: Tuesday, July 7, 2009, 7:12 AM
Bill Salot,
In the nuclear power community the NRC has a minimalistic inspection program,
called the Reactor Oversight Program (ROP),that is justified by each licensee
having a good Problem Identification and Resolution (PI&R) function.
If the PI&R function is not robust the basis of the NRC's process crumbles.
The theory is that if the licensees are finding their own problems the
NRC can back off and be "risk-informed. "
If the vast majority of harmful factors are surfaced by PI&R all is
well. These are called "licensee-identifie d" problems. The others
are called "self-revealing" problems and NRC-identified problems.
There are a few other identification modes that are left ambiguous.
If the "self-revealing" problems and NRC-identified problems
are few and non-significant the system is working. Otherwise??? ??
I expect that ON, OFSG, and Terry Herrmann will straighten me out on this.
I hope this helps.
Stay well.
All the best.
Bill Corcoran
--- In Root_Cause_State_
of_the_Practice@ yahoogroups. com, "Salot,
William" <william.salot@ ...> wrote:
>
> Bill C and Steve N,
>
>
>
> I have seldom used the term "self-revealing" , but, now
that you have
> bought it up, I see a potentially powerful use for it.
>
>
>
> First, let me ask, Steve, how were you thinking of using it?
>
>
>
> Second, what I had in mind is that most "factors" on a "factor
tree" are
> "self-revealing" , by clear evidence, common knowledge,
simple deduction,
> etc. "Self-revealing" factors are obvious answers to the
question:
> "What combination of "factors" directly resulted in
___?"
>
>
>
> Here is where the power lies: If a "factor tree" ends up
with nothing
> but "self-revealing" factors, there is something wrong with
the "factor
> tree".
>
>
>
> We don't analyze things to identify their "self-revealing"
factors. We
> analyze for unknowns.
>
>
>
> What did we fail to do that allowed ___ to happen? The answers to
that
> question constitute unknown factors that underlie the adverse event.
> Let's call it them "mystery" factors. They are the opposite
of
> "self-revealing" . They also add drama to the process.
>
>
>
> What did we fail to do that allowed the "mystery" factors
to go
> unrecognized? That seldom-asked question takes us to an even deeper
> level. Maybe we should ask it more often.
>
>
>
> 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: Friday, July 03, 2009 9:13 AM
> To: SteveNikolai; Root_Cause_State!
_ of_the_Practice@ yahoogroups. com
> Cc: Root_Cause_State_
of_the_Practice@ yahoogroups. com
> Subject: Re: [Root_Cause_ State_of_ the_Practice] Re: Self-Revealing
>
>
>
> Steve and all,
>
>
>
> The Rootician's Dictionary is at
>
> http://tech.
groups.yahoo. com/group/ Root_Cause_ State_of_ the_Practice/ data
> base
> <http://tech.
groups.yahoo. com/group/ Root_Cause_ State_of_ the_Practice/ dat
> abase>
>
>
>
> Try searching it on the following:
>
> 1. self-reveal
> 2. self reveal
>
> If there is more to be said on that topic please hit the REPLY button
> and type away.
>
>
>
> Take care,
>
> Bill Corcoran
>
>
>
>
>
> --- On Thu, 7/2/09, DR WILLIAM CORCORAN
> <William.R.Corcoran @...> wrote:
>
>
> From: DR WILLIAM CORCORAN <William.R.Corcoran @...>
> Subject: [Root_Cause_ State_of_ the_Practice] Re: Self-Revealing
> To: "SteveNikolai" <Steve.Nikolai@ ...>
> Cc: Root_Cause_State_
of_the_Practice! @ yahoogroups. com
> Date: Thursday, July 2, 2009, 3:38 PM
>
> Steve,
>
>
>
> Thanks for the question.
>
>
>
> I will add a definition of "Self-revealing. "
>
>
>
> But before I do I'm going to ask the 650 or so members of the root
cause
> e-group (and you as well) if they have any official definitions.
>
>
>
> To me a self-revealing item (problem, factor, consequence. ..) is
one
> that calls attention to itself without the need for inspections,
> self-assessments, audits, or the like.
>
>
>
> Am I getting close?
>
> Take care,
>
> Bill Corcoran
>
> --- On Thu, 7/2/09, Nikolai, Steve <Steve.Nikolai@ fpl.com>
wrote:
>
>
> From: Nikolai, Steve <Steve.Nikolai@ fpl.com>
> Subject: Self-Revealing
> To: "firebird.one@ alum.MIT. edu" <firebird.one@ alum.MIT.
edu>
> Date: Thursday, July 2, 2009, 12:04 PM
>
> Hi Dr. Bill,
>
> I'm still doing causal analysis at Point Beach, and a question has
been
> brought up about self-revealing. Now we're trying to define it. I
> looked through your Rooter's Dictionary that I keep handy but didn't
see
> it in there. Do you have a definition for it?
>
Staeve, Â Thanks for the question. Â I will add a definition of "Self-revealing." Â But before I do I'm going to ask the 650 or so members of the root cause...
Steve and all,  The Rootician's Dictionary is at http://tech.groups.yahoo.com/group/Root_Cause_State_of_the_Practice/database  Try searching it on the...
Bill C and Steve N, I have seldom used the term "self-revealing", but, now that you have bought it up, I see a potentially powerful use for it. First, let me...
Bill Salot, In the nuclear power community the NRC has a minimalistic inspection program, called the Reactor Oversight Program (ROP),that is justified by each...
Good morning, Self Revealing Factor(s) help to paint the complete picture, for resolution and historical documentation. But I believe that the Mystery...
The contents of this e-mail (and any attachments) are confidential, may be privileged and may contain copyright material. You may only reproduce or distribute...
Does this mean we will have to refrain from using the term "root-ician" as well? Bob L. Sent by BlackBerry Wireless ________________________________ From:...
Bob, I suppose that we can continue to use the term root-ician, but I really do believe that we need to avoid using the term Root Cause Analysis. Using that...
Good point Bob! I was thinking the same thing awhile back as we started down this road of eliminating root cause. If you follow the logic of how we eliminate...
Dillard, Tedd A (E S ...
tedd.dillard@...
Jul 3, 2009 2:20 pm
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B Hart
avsafety@...
Jul 3, 2009 7:41 pm
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Bill Salot, Â There is a lot of overlap between "self-revealing problems" and "self-revealing factors." Â The relationship may be that all "self-revealing...
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...
Bill C., et. al., Â It seems to me that the labels may be getting in the way of the communication. Â The objective of effective corrective action programs is...
Terry, Once again you hit the nail on the head. I especially like: "The ratio of: '- we found it / it found us' told us a lot about how good we were at problem...