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Re: Self-Revealing   Message List  
Reply | Forward Message #6781 of 7304 |
Re: [Root_Cause_State_of_the_Practice] Re: Self-Revealing


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 identification."

I will certainly use that in the future.

Thanks,
B.



"T. Herrmann \(Yahoo\)" <tjhsbh79@...>
Sent by: Root_Cause_State_of_the_Practice@yahoogroups.com

07/07/2009 12:59 PM

Please respond to
Root_Cause_State_of_the_Practice@yahoogroups.com

To
Root_Cause_State_of_the_Practice@yahoogroups.com
cc
Subject
Re: [Root_Cause_State_of_the_Practice] Re: Self-Revealing









Bill C., et. al.,

 
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?
>





Tue Jul 7, 2009 5:33 pm

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Staeve,   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...
DR WILLIAM CORCORAN
drbillcorcoran
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Jul 2, 2009
7:38 pm

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...
DR WILLIAM CORCORAN
drbillcorcoran
Offline Send Email
Jul 3, 2009
1:12 pm

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...
Salot, William
wjsalot
Offline Send Email
Jul 7, 2009
12:55 pm

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...
William R. Corcoran, ...
drbillcorcoran
Offline Send Email
Jul 7, 2009
1:13 pm

Bill C, You are talking about "self-revealing problems". I am talking about "self-revealing factors". I suspect there is a difference. Bill Salot ...
Salot, William
wjsalot
Offline Send Email
Jul 7, 2009
1:31 pm

Good morning, Self Revealing Factor(s) help to paint the complete picture, for resolution and historical documentation. But I believe that the Mystery...
jack.stanford@...
nhasme04
Offline Send Email
Jul 7, 2009
2:23 pm

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...
Bob Latino
reliability2003
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Jul 22, 2009
5:17 pm

Does this mean we will have to refrain from using the term "root-ician" as well? Bob L. Sent by BlackBerry Wireless ________________________________ From:...
Bob Latino
reliability2003
Offline Send Email
Jul 3, 2009
1:21 pm

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...
jack.stanford@...
nhasme04
Offline Send Email
Jul 3, 2009
2:15 pm

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@...
Send Email
Jul 3, 2009
2:20 pm

Googling "event investigation".or "condition investigation" as opposed to "root cause analysis" will show the challenge ahead. Bob L. Sent by BlackBerry...
Bob Latino
reliability2003
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Jul 3, 2009
3:58 pm

Hi Bob Yes, when I took the Apollo Root Cause Analysis course a few years back, they said that it was really a problem solving course, but it was called RCA...
Jack
bcjackca
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Jul 3, 2009
6:49 pm

Gentlemen: Remember the as yet not fully accepted challenge was for a limited trial on this forum only. There was no stipulation that we should force it on...
Salot, William
wjsalot
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Jul 6, 2009
6:25 pm

I believe that what is done is beyond being called an investigation. There is a lot of work done by the analyst(s) with what he/she/they find during...
B Hart
avsafety@...
Send Email
Jul 3, 2009
7:41 pm

Bruce,   Well said.  Thanks and a BZ.   It seems to be difficult to say things in such a way that others understand us.   But it might be worth the effort....
DR WILLIAM CORCORAN
drbillcorcoran
Offline Send Email
Jul 4, 2009
12:10 pm

Bill Salot,   There is a lot of overlap between "self-revealing problems" and "self-revealing factors."   The relationship may be that all "self-revealing...
DR WILLIAM CORCORAN
drbillcorcoran
Offline Send Email
Jul 7, 2009
1:56 pm

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...
Salot, William
wjsalot
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Jul 7, 2009
2:28 pm

Dr. Bill, No straightening required - you got it right. In a message dated 7/7/2009 9:13:50 A.M. Eastern Daylight Time, William.R.Corcoran@......
Oldnuke640@...
oldnuke1234
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Jul 7, 2009
2:48 pm

Bill C., et. al.,   It seems to me that the labels may be getting in the way of the communication.   The objective of effective corrective action programs is...
T. Herrmann (Yahoo)
tjhsbh79
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Jul 7, 2009
4:59 pm

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...
bruce.hart@...
f1474568
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Jul 7, 2009
5:38 pm
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