-------------- Original message from DR WILLIAM CORCORAN <William.R.Corcoran@...>: --------------

 

Tedd and Jack,   One of the top principles of corrective action programs is, "Solutions Cause Problems."   The whole New Orleans situation was a series of corrective actions for the fundamental decision to build in an area subject to subsidance.  From then on it was a chain of Rube Goldberg fixes. Katrina was the natural phenomenon that came when the fixes had fallen behind the problem.   Some engineering situation are like riding a tiger. You can never get off without getting eaten. Take care,   Bill Corcoran Mission: Saving lives, pain, assets, and careers through thoughtful inquiry. Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.   W. R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation 21 Broadleaf Circle Windsor, CT 06095-1634 860-285-8779   Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com Join the group advancing the practice of root cause analysis/ evaluation  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com   ****Internet Email Confidentiality Footer****   Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it. --- On Thu, 11/19/09, Dillard, Tedd A (E S SF RNA FS 11E) <tedd.dillard@siemens.com> wrote: From: Dillard, Tedd A (E S SF RNA FS 11E) <tedd.dillard@siemens.com> Subject: RE: [Root_Cause_State_of_the_Practice] Expensive Failure of Governmental Self-assessment/ Oversight To: Root_Cause_State_of_the_Practice@yahoogroups.com Date: Thursday, November 19, 2009, 12:18 PM   Jack, I love you man but I hope Ed's comment about engineers ruling the world was a joke. The bad things that you point out about politicians are true but they would also be true of engineers if they did rule anything. The bad things are human things, not related to a title or skill set. Also your comment about knowing what is the right thing to do can be said for a lot of people in a lot of circumstances. But determining the right thing can be very difficult and is only the first step to success. Knowing what to do and getting it done are two very different problems. Besides how many time have you seen an engineering fix for a problem that caused more different but serious problems. And, and I think this is particularly true of engineers, just knowing the answer to a question is not the same thing as getting it done. I believe that because engineers are technically oriented they tend to think that once you have determined the answer to a problem that everyone will agree and implementation is assured. This is rarely the case. People have a lot of reasons and forces to do something different than what may be best.   Tedd From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of jack.stanford@ att.net Sent: Thursday, November 19, 2009 12:02 PM To: Root_Cause_State_ of_the_Practice@ yahoogroups. com Subject: RE: [Root_Cause_ State_of_ the_Practice] Expensive Failure of Governmental Self-assessment/ Oversight Hello, Ed,   If what you said below is true (and it probably is), then the federal government owns a big part of the extent of cause for not helping the state of Louisiana fund the repairs that should have taken place *before* the flooding event in New Orleans took place.  The bad condition was diagnosed, but nothing happened to fix it to the best of my knowledge, until after the fact.  This is what happens when a city exists which basically belongs under water, absent necessary levy/dam repairs.   Should engineers rule the world?  I think so, as an engineer who is at least average knows what the right thing to do is.  I'll bet that this was true in New Orleans years ago.  In ASME, a third of the members are licensed as professional engineers, and I have been one of them for 23 years.  PEs and most engineers know what the right thing to do is, though politicians do not always do the right thing.  That is because they have too many things in their back pockets, like protecting their own states and ignoring the needs of other states.  New Orleans is apparently a classic example of this.  Why would a northern senator or congressman even care about the risk in New Orleans?  They don't, and they won't.    Jack Stanford, PE Section Mentor, ASME New Haven, CT Section Former Chair, Webmaster and Treasurer StanfordJ@ASME. org My understanding is that the Corps of Engineers had recognized weaknesses in the New Orleans levy and had been trying to repair/upgrade it for years. However, the US Congress had higher priorities and would not fund the work. If this is correct, what is the extent of cause?...Where will it happen next?...another reason engineers should rule the world?   Ed Stephenson Causal Analyst Farley Nuclear Plant (334) 814-4587   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: Thursday, November 19, 2009 7:31 AM To: WWWTP_LTBL Katrina Cc: Root_Cause_State_ of_the_Practice@ yahoogroups. com; LTBL Palo Verde; whistleblower411@ yahoogroups. com Subject: [Root_Cause_ State_of_ the_Practice] Expensive Failure of Governmental Self-assessment/ Oversight [3 Attachments]   Scroll down for the story after reading this introduction.   The attached pictures help put this into perspective.   Many of our government agencies and their contractors resist the need to assess their own performance and try to project a picture of competent infallibility. This culture costs us dearly.   Systems Engineering tells us that every system is perfectly designed to produce what it has produced. What are the earlier, better, cheaper, safer, more risk-informed, more compliant ways that the factors can be found before the consequences?   What are the failed barriers here? Do they include the Corps District, the Corps IG, the Army IG, the DOD IG, and the GAO?  What others come to mind?   This incident is just one of may recent occurrences that indicate more Expensive Failures of Governmental Self-assessment/ Oversight.   Press the Reply button and send us your thoughts. Take care,   Bill Corcoran Mission: Saving lives, pain, assets, and careers through thoughtful inquiry. Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.   W. R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation 21 Broadleaf Circle Windsor, CT 06095-1634 860-285-8779   Subscribe to "The Firebird Forum"  TheFirebirdForum- subscribe@ yahoogroups. com Join the group advancing the practice of root cause analysis/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com   ****Internet Email Confidentiality Footer****   Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it. http://news. yahoo.com/ s/ap/20091119/ ap_on_re_ us/us_katrina_ flood_lawsuit Negligence ruling in Katrina floods may cost feds By CAIN BURDEAU, Associated Press Writer Cain Burdeau, Associated Press Writer 1 hr 40 mins ago   NEW ORLEANS – The federal government could be vulnerable to billions of dollars in claims after a judge ruled that the Army Corps of Engineers' failure to properly maintain a navigation channel led to massive flooding in Hurricane Katrina.   U.S. District Judge Stanwood Duval on Wednesday awarded seven plaintiffs $720,000, but the government could eventually be forced to pay much more. The ruling should give more than 100,000 other individuals, businesses and government entities a better shot at claiming damages.   Duval sided with six residents and one business who argued the Army Corps' shoddy oversight of the Mississippi River-Gulf Outlet led to the flooding of New Orleans' Lower 9th Ward and neighboring St. Bernard Parish. He said, however, the corps couldn't be held liable for the flooding of eastern New Orleans, where two of the plaintiffs lived. The ruling is also emotionally resonant for south Louisiana. Many in New Orleans have argued that the flooding in the aftermath of Katrina, which struck the region Aug. 29, 2005, was a manmade disaster caused by the Army Corps' failure to maintain the levee system protecting the city.   "Total devastation could possibly have been avoided if something had been done," said Tanya Smith, one of the plaintiffs. "A lot of this stuff was preventable and they turned a deaf ear to it."   The 36-year-old registered nurse anesthetist lived in Chalmette close to the channel when Katrina hit. She was awarded $317,000 in property damages, the most of any of the plaintiffs.   Duval referred to the corps' approach to maintaining the channel as "monumental negligence."   Joe Bruno, one of the lead lawyers for the plaintiffs, said the ruling underscored the Army Corps' long history of not properly protecting the New Orleans region.   "It's high time we look at the way these guys do business and do a full re-evaluation of the way it does business," Bruno said.   He said he expected the government to appeal.   The corps referred calls seeking comment to the Justice Department. Spokesman Charles Miller said the government would review the judge's ruling before making any decision on how to proceed.   During trial testimony, government lawyers and experts argued the levee system was overwhelmed by the massive storm, and levee breaches couldn't solely be blamed on the shipping channel dug in the 1960s as a short-cut between the Gulf of Mexico and New Orleans.   The corps had also unsuccessfully argued that it is immune from liability because the channel is part of New Orleans' flood control system.   In his 156-page ruling, Duval said he was "utterly convinced" that the corps' failure to shore up the channel "doomed the channel to grow to two to three times its design width" and that "created a more forceful frontal wave attack on the levee" that protected St. Bernard and the Lower 9th Ward.   "The Corps had an opportunity to take a myriad of actions to alleviate this deterioration or rehabilitate this deterioration and failed to do so," Duval said. "Clearly the expression 'talk is cheap' applies here."   Ahead of Duval's ruling, experts had said it would likely have consequences for the way the Army Corps does business nationwide.   Pierce O'Donnell, another lead plaintiffs lawyer, said the ruling was the "first time ever the Army Corps has been held liable for damages for a major catastrophe that it caused." The plaintiffs lawyers would like Congress to set up a compensation fund to speed up payments to the thousands of others whose claims must still be heard in court.   At a one-month trial in May, experts clashed over the causes of flooding and the channel's contribution to it.   Government experts argued the levees and floodwalls would have failed regardless of whether the channel had been dug.   By contrast, the plaintiffs' team of experts said the outlet became a "hurricane highway" that funneled storm surge into New Orleans. They said that without the channel, the flooding would have been minimal.   The lawsuit was the first major case against the federal government over Katrina flooding to go to trial. A decision rested with Duval because a jury cannot try a case against the federal government.

Ed/Jack,

A couple of points.  First, it's levee, not levy.  One's a bank, the other's a
tax.

Secondly (and more seriously), a good read on this subject of how engineer's
manage all the cost-benefit trade-offs in their work is captured in Erik
Hollnagel's latest book, The ETTO Principle: Efficiency-Thoroughness Trade-Off
(Why Things That Go Right Sometimes Go Wrong).  He demonstrates how all the
decisions we make are driven by this principle.  Additonally he points out where
causal analysis in tightly coupled, intractible systems can often focus on the
wrong things.  For those of us who get pretty judgemental about how worthwhile
our RCA's are, this book will certainly challenge our paradigms.

Bill Rigot

--- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Stephenson, Edwin L.,
Jr." <ELSTEPHE@...> wrote:
>
> Yeah, the statement about engineers ruling was a joke. As engineers, we are
not exempt from making decisions based upon cost as well as risk. If we could do
everything that results in improvement, regardless of cost, we would would
approach technical perfection without possibility of profit. In the nuclear
industry, however, we must always err on the side of safety (and sometimes
reliability) and never take any action that could place our facility in any
condition or configuration that has not been thoroughly analyzed and determined
to keep the plant within ALL design limits and specifications. Even if we can
technically justify crossing that line, the oversight and review process should
be robust enough to ensure that our conclusions are beyond question, and, even
then, our analyses must be approved by appropriate regulatory bodies. Any
engineer could make a bad decision, hopefully to be identified in review.
However, pressures on engineers are no different than those on any other
decision maker. In many cases it still comes down to the proficiency, honesty
and integrity of the individual.
>
> Regarding the levy, I could be wrong, but I believe the Corps of Engineers
funds their projects. In Alabama, we have many Corps of Engineer dams and I
don't think Alabama pays any of the cost associated with them. Some of them have
Alabama Power generators installed in them and the power produced creates profit
for the utility. I also believe that Alabama Power paid for the right to install
those generators in the Corps of Engineers dam (or leases that right). So, if
the Corps on Engineers built the levy, maintains the levy, and upgrades the levy
on their own dime, they should have taken action if problems were identified.
However, if they identified problems and asked Congress for money to address
those problems and were denied, then some possible causes should include: 1.
Inadequate understanding the magnitude of the risk by the Corps; 2. Inadequate
communication between the Corps and Congress for Congress to really understand
the risk; 3. Lack of the Corps to persist in identifying the problems to the
right people in government; 4. Inability of Congressmen to understand the risk;
5. Budgeting priorities based on political bases rather than risk; 6. Lack of
available money to fund the project due to other priorities even if the risk is
understood; 7. Political or financial gain for Congressmen to deny funding for
the project;
>
> We would hate to think that some of these causes could actually exist, but I
certainly would not rule them out until I had proof.
>
> Ed Stephenson
> Causal Analyst
> Farley Nuclear Plant
> (334) 814-4587
>
>
> ________________________________
> From: Root_Cause_State_of_the_Practice@yahoogroups.com
[mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dillard,
Tedd A (E S SF RNA FS 11E)
> Sent: Thursday, November 19, 2009 11:19 AM
> To: Root_Cause_State_of_the_Practice@yahoogroups.com
> Subject: RE: [Root_Cause_State_of_the_Practice] Expensive Failure of
Governmental Self-assessment/ Oversight
>
>
>
> Jack,
> I love you man but I hope Ed's comment about engineers ruling the world was a
joke.
> The bad things that you point out about politicians are true but they would
also be true of engineers if they did rule anything.
> The bad things are human things, not related to a title or skill set.
> Also your comment about knowing what is the right thing to do can be said for
a lot of people in a lot of circumstances.
> But determining the right thing can be very difficult and is only the first
step to success.
> Knowing what to do and getting it done are two very different problems.
> Besides how many time have you seen an engineering fix for a problem that
caused more different but serious problems.
> And, and I think this is particularly true of engineers, just knowing the
answer to a question is not the same thing as getting it done.
> I believe that because engineers are technically oriented they tend to think
that once you have determined the answer to a problem that everyone will agree
and implementation is assured.
> This is rarely the case.
> People have a lot of reasons and forces to do something different than what
may be best.
> Tedd
> ________________________________
> From: Root_Cause_State_of_the_Practice@yahoogroups.com
[mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of
jack.stanford@...
> Sent: Thursday, November 19, 2009 12:02 PM
> To: Root_Cause_State_of_the_Practice@yahoogroups.com
> Subject: RE: [Root_Cause_State_of_the_Practice] Expensive Failure of
Governmental Self-assessment/ Oversight
>
> Hello, Ed,
>
> If what you said below is true (and it probably is), then the federal
government owns a big part of the extent of cause for not helping the state of
Louisiana fund the repairs that should have taken place *before* the flooding
event in New Orleans took place.  The bad condition was diagnosed, but nothing
happened to fix it to the best of my knowledge, until after the fact.  This is
what happens when a city exists which basically belongs under water, absent
necessary levy/dam repairs.
>
> Should engineers rule the world?  I think so, as an engineer who is at least
average knows what the right thing to do is.  I'll bet that this was true in New
Orleans years ago.  In ASME, a third of the members are licensed as professional
engineers, and I have been one of them for 23 years.  PEs and most engineers
know what the right thing to do is, though politicians do not always do the
right thing.  That is because they have too many things in their back pockets,
like protecting their own states and ignoring the needs of other states.  New
Orleans is apparently a classic example of this.  Why would a northern senator
or congressman even care about the risk in New Orleans?  They don't, and they
won't.
>
> Jack Stanford, PE
> Section Mentor, ASME New Haven, CT Section
> Former Chair, Webmaster and Treasurer
> StanfordJ@...<mailto:StanfordJ@...>
>
> My understanding is that the Corps of Engineers had recognized weaknesses in
the New Orleans levy and had been trying to repair/upgrade it for years.
However, the US Congress had higher priorities and would not fund the work. If
this is correct, what is the extent of cause?...Where will it happen
next?...another reason engineers should rule the world?
>
> Ed Stephenson
> Causal Analyst
> Farley Nuclear Plant
> (334) 814-4587
>
>
> ________________________________
> 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: Thursday, November 19, 2009 7:31 AM
> To: WWWTP_LTBL Katrina
> Cc: Root_Cause_State_of_the_Practice@yahoogroups.com; LTBL Palo Verde;
whistleblower411@yahoogroups.com
> Subject: [Root_Cause_State_of_the_Practice] Expensive Failure of Governmental
Self-assessment/ Oversight [3 Attachments]
>
>
>
> Scroll down for the story after reading this introduction.
>
> The attached pictures help put this into perspective.
>
> Many of our government agencies and their contractors resist the need to
assess their own performance and try to project a picture of competent
infallibility. This culture costs us dearly.
>
> Systems Engineering tells us that every system is perfectly designed to
produce what it has produced. What are the earlier, better, cheaper, safer, more
risk-informed, more compliant ways that the factors can be found before the
consequences?
>
> What are the failed barriers here? Do they include the Corps District, the
Corps IG, the Army IG, the DOD IG, and the GAO?  What others come to mind?
>
> This incident is just one of may recent occurrences that indicate more
Expensive Failures of Governmental Self-assessment/ Oversight.
>
> Press the Reply button and send us your thoughts.
>
> Take care,
>
> Bill Corcoran
> Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
> Motto: If you want safety, peace, or justice, then work for competency,
integrity, and transparency.
>
> W. R. Corcoran, Ph.D., P.E.
> Nuclear Safety Review Concepts Corporation
> 21 Broadleaf Circle
> Windsor, CT 06095-1634
> 860-285-8779
>
> Subscribe to "The Firebird Forum" 
TheFirebirdForum-subscribe@yahoogroups.com<mailto:TheFirebirdForum-subscribe@yah\
oogroups.com>
> Join the group advancing the practice of root cause analysis/ evaluation 
Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com<mailto:Root_Cause_Sta\
te_of_the_Practice-subscribe@yahoogroups.com>
>
> ****Internet Email Confidentiality Footer****
>
> Privileged/Confidential Information may be contained in this message. If you
are not the addressee indicated in this message (or responsible for delivery of
the message to such person), you may not copy or deliver this message to anyone.
In such case, you should destroy this message and notify the sender by reply
email. Please advise immediately if you or your employer do not consent to
Internet email for messages of this kind. Opinions, conclusions and other
information in this message that do not relate to the official business of NSRC
Corp. shall be understood as neither given nor endorsed by it.
> ________________________________
> http://news.yahoo.com/s/ap/20091119/ap_on_re_us/us_katrina_flood_lawsuit
> ________________________________
> Negligence ruling in Katrina floods may cost feds
> By CAIN BURDEAU, Associated Press Writer Cain Burdeau, Associated Press Writer
1 hr 40 mins ago
>
> NEW ORLEANS - The federal government could be vulnerable to billions of
dollars in claims after a judge ruled that the Army Corps of Engineers' failure
to properly maintain a navigation channel led to massive flooding in Hurricane
Katrina.
>
> U.S. District Judge Stanwood Duval on Wednesday awarded seven plaintiffs
$720,000, but the government could eventually be forced to pay much more. The
ruling should give more than 100,000 other individuals, businesses and
government entities a better shot at claiming damages.
>
> Duval sided with six residents and one business who argued the Army Corps'
shoddy oversight of the Mississippi River-Gulf Outlet led to the flooding of New
Orleans' Lower 9th Ward and neighboring St. Bernard Parish. He said, however,
the corps couldn't be held liable for the flooding of eastern New Orleans, where
two of the plaintiffs lived.
> The ruling is also emotionally resonant for south Louisiana. Many in New
Orleans have argued that the flooding in the aftermath of Katrina, which struck
the region Aug. 29, 2005, was a manmade disaster caused by the Army Corps'
failure to maintain the levee system protecting the city.
>
> "Total devastation could possibly have been avoided if something had been
done," said Tanya Smith, one of the plaintiffs. "A lot of this stuff was
preventable and they turned a deaf ear to it."
>
> The 36-year-old registered nurse anesthetist lived in Chalmette close to the
channel when Katrina hit. She was awarded $317,000 in property damages, the most
of any of the plaintiffs.
>
> Duval referred to the corps' approach to maintaining the channel as
"monumental negligence."
>
> Joe Bruno, one of the lead lawyers for the plaintiffs, said the ruling
underscored the Army Corps' long history of not properly protecting the New
Orleans region.
>
> "It's high time we look at the way these guys do business and do a full
re-evaluation of the way it does business," Bruno said.
>
> He said he expected the government to appeal.
>
> The corps referred calls seeking comment to the Justice Department. Spokesman
Charles Miller said the government would review the judge's ruling before making
any decision on how to proceed.
>
> During trial testimony, government lawyers and experts argued the levee system
was overwhelmed by the massive storm, and levee breaches couldn't solely be
blamed on the shipping channel dug in the 1960s as a short-cut between the Gulf
of Mexico and New Orleans.
>
> The corps had also unsuccessfully argued that it is immune from liability
because the channel is part of New Orleans' flood control system.
>
> In his 156-page ruling, Duval said he was "utterly convinced" that the corps'
failure to shore up the channel "doomed the channel to grow to two to three
times its design width" and that "created a more forceful frontal wave attack on
the levee" that protected St. Bernard and the Lower 9th Ward.
>
> "The Corps had an opportunity to take a myriad of actions to alleviate this
deterioration or rehabilitate this deterioration and failed to do so," Duval
said. "Clearly the expression 'talk is cheap' applies here."
>
> Ahead of Duval's ruling, experts had said it would likely have consequences
for the way the Army Corps does business nationwide.
>
> Pierce O'Donnell, another lead plaintiffs lawyer, said the ruling was the
"first time ever the Army Corps has been held liable for damages for a major
catastrophe that it caused."
> The plaintiffs lawyers would like Congress to set up a compensation fund to
speed up payments to the thousands of others whose claims must still be heard in
court.
>
> At a one-month trial in May, experts clashed over the causes of flooding and
the channel's contribution to it.
>
> Government experts argued the levees and floodwalls would have failed
regardless of whether the channel had been dug.
>
> By contrast, the plaintiffs' team of experts said the outlet became a
"hurricane highway" that funneled storm surge into New Orleans. They said that
without the channel, the flooding would have been minimal.
>
> The lawsuit was the first major case against the federal government over
Katrina flooding to go to trial. A decision rested with Duval because a jury
cannot try a case against the federal government.
>

-------------- Original message from "Dillard, Tedd A (E S SF RNA FS 11E)" <tedd.dillard@...>: --------------

 

Jack,

I love you man but I hope Ed's comment about engineers ruling the world was a joke.

The bad things that you point out about politicians are true but they would also be true of engineers if they did rule anything.

The bad things are human things, not related to a title or skill set.

Also your comment about knowing what is the right thing to do can be said for a lot of people in a lot of circumstances.

But determining the right thing can be very difficult and is only the first step to success.

Knowing what to do and getting it done are two very different problems.

Besides how many time have you seen an engineering fix for a problem that caused more different but serious problems.

And, and I think this is particularly true of engineers, just knowing the answer to a question is not the same thing as getting it done.

I believe that because engineers are technically oriented they tend to think that once you have determined the answer to a problem that everyone will agree and implementation is assured.

This is rarely the case.

People have a lot of reasons and forces to do something different than what may be best.  

Tedd

---

From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of jack.stanford@att.net
Sent: Thursday, November 19, 2009 12:02 PM
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Subject: RE: [Root_Cause_State_of_the_Practice] Expensive Failure of Governmental Self-assessment/ Oversight

Hello, Ed,

 

If what you said below is true (and it probably is), then the federal government owns a big part of the extent of cause for not helping the state of Louisiana fund the repairs that should have taken place *before* the flooding event in New Orleans took place.  The bad condition was diagnosed, but nothing happened to fix it to the best of my knowledge, until after the fact.  This is what happens when a city exists which basically belongs under water, absent necessary levy/dam repairs.

 

Should engineers rule the world?  I think so, as an engineer who is at least average knows what the right thing to do is.  I'll bet that this was true in New Orleans years ago.  In ASME, a third of the members are licensed as professional engineers, and I have been one of them for 23 years.  PEs and most engineers know what the right thing to do is, though politicians do not always do the right thing.  That is because they have too many things in their back pockets, like protecting their own states and ignoring the needs of other states.  New Orleans is apparently a classic example of this.  Why would a northern senator or congressman even care about the risk in New Orleans?  They don't, and they won't. 

 

Jack Stanford, PE

Section Mentor, ASME New Haven, CT Section

Former Chair, Webmaster and Treasurer

StanfordJ@ASME.org

My understanding is that the Corps of Engineers had recognized weaknesses in the New Orleans levy and had been trying to repair/upgrade it for years. However, the US Congress had higher priorities and would not fund the work. If this is correct, what is the extent of cause?...Where will it happen next?...another reason engineers should rule the world?

 

Ed Stephenson
Causal Analyst
Farley Nuclear Plant
(334) 814-4587

 

---

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: Thursday, November 19, 2009 7:31 AM
To: WWWTP_LTBL Katrina
Cc: Root_Cause_State_of_the_Practice@yahoogroups.com; LTBL Palo Verde; whistleblower411@yahoogroups.com
Subject: [Root_Cause_State_of_the_Practice] Expensive Failure of Governmental Self-assessment/ Oversight [3 Attachments]

 

Scroll down for the story after reading this introduction.   The attached pictures help put this into perspective.   Many of our government agencies and their contractors resist the need to assess their own performance and try to project a picture of competent infallibility. This culture costs us dearly.   Systems Engineering tells us that every system is perfectly designed to produce what it has produced. What are the earlier, better, cheaper, safer, more risk-informed, more compliant ways that the factors can be found before the consequences?   What are the failed barriers here? Do they include the Corps District, the Corps IG, the Army IG, the DOD IG, and the GAO?  What others come to mind?   This incident is just one of may recent occurrences that indicate more Expensive Failures of Governmental Self-assessment/ Oversight.   Press the Reply button and send us your thoughts. Take care,   Bill Corcoran Mission: Saving lives, pain, assets, and careers through thoughtful inquiry. Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.   W. R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation 21 Broadleaf Circle Windsor, CT 06095-1634 860-285-8779   Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com Join the group advancing the practice of root cause analysis/ evaluation  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com   ****Internet Email Confidentiality Footer****   Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it. http://news.yahoo.com/s/ap/20091119/ap_on_re_us/us_katrina_flood_lawsuit Negligence ruling in Katrina floods may cost feds By CAIN BURDEAU, Associated Press Writer Cain Burdeau, Associated Press Writer 1 hr 40 mins ago   NEW ORLEANS – The federal government could be vulnerable to billions of dollars in claims after a judge ruled that the Army Corps of Engineers' failure to properly maintain a navigation channel led to massive flooding in Hurricane Katrina.   U.S. District Judge Stanwood Duval on Wednesday awarded seven plaintiffs $720,000, but the government could eventually be forced to pay much more. The ruling should give more than 100,000 other individuals, businesses and government entities a better shot at claiming damages.   Duval sided with six residents and one business who argued the Army Corps' shoddy oversight of the Mississippi River-Gulf Outlet led to the flooding of New Orleans' Lower 9th Ward and neighboring St. Bernard Parish. He said, however, the corps couldn't be held liable for the flooding of eastern New Orleans, where two of the plaintiffs lived. The ruling is also emotionally resonant for south Louisiana. Many in New Orleans have argued that the flooding in the aftermath of Katrina, which struck the region Aug. 29, 2005, was a manmade disaster caused by the Army Corps' failure to maintain the levee system protecting the city.   "Total devastation could possibly have been avoided if something had been done," said Tanya Smith, one of the plaintiffs. "A lot of this stuff was preventable and they turned a deaf ear to it."   The 36-year-old registered nurse anesthetist lived in Chalmette close to the channel when Katrina hit. She was awarded $317,000 in property damages, the most of any of the plaintiffs.   Duval referred to the corps' approach to maintaining the channel as "monumental negligence."   Joe Bruno, one of the lead lawyers for the plaintiffs, said the ruling underscored the Army Corps' long history of not properly protecting the New Orleans region.   "It's high time we look at the way these guys do business and do a full re-evaluation of the way it does business," Bruno said.   He said he expected the government to appeal.   The corps referred calls seeking comment to the Justice Department. Spokesman Charles Miller said the government would review the judge's ruling before making any decision on how to proceed.   During trial testimony, government lawyers and experts argued the levee system was overwhelmed by the massive storm, and levee breaches couldn't solely be blamed on the shipping channel dug in the 1960s as a short-cut between the Gulf of Mexico and New Orleans.   The corps had also unsuccessfully argued that it is immune from liability because the channel is part of New Orleans' flood control system.   In his 156-page ruling, Duval said he was "utterly convinced" that the corps' failure to shore up the channel "doomed the channel to grow to two to three times its design width" and that "created a more forceful frontal wave attack on the levee" that protected St. Bernard and the Lower 9th Ward.   "The Corps had an opportunity to take a myriad of actions to alleviate this deterioration or rehabilitate this deterioration and failed to do so," Duval said. "Clearly the expression 'talk is cheap' applies here."   Ahead of Duval's ruling, experts had said it would likely have consequences for the way the Army Corps does business nationwide.   Pierce O'Donnell, another lead plaintiffs lawyer, said the ruling was the "first time ever the Army Corps has been held liable for damages for a major catastrophe that it caused." The plaintiffs lawyers would like Congress to set up a compensation fund to speed up payments to the thousands of others whose claims must still be heard in court.   At a one-month trial in May, experts clashed over the causes of flooding and the channel's contribution to it.   Government experts argued the levees and floodwalls would have failed regardless of whether the channel had been dug.   By contrast, the plaintiffs' team of experts said the outlet became a "hurricane highway" that funneled storm surge into New Orleans. They said that without the channel, the flooding would have been minimal.   The lawsuit was the first major case against the federal government over Katrina flooding to go to trial. A decision rested with Duval because a jury cannot try a case against the federal government.

-------------- Original message from "BILL" <william.rigot@...>: --------------

 

Ed/Jack,

A couple of points. First, it's levee, not levy. One's a bank, the other's a tax.

Secondly (and more seriously), a good read on this subject of how engineer's manage all the cost-benefit trade-offs in their work is captured in Erik Hollnagel's latest book, The ETTO Principle: Efficiency-Thoroughness Trade-Off (Why Things That Go Right Sometimes Go Wrong). He demonstrates how all the decisions we make are driven by this principle. Additonally he points out where causal analysis in tightly coupled, intractible systems can often focus on the wrong things. For those of us who get pretty judgemental about how worthwhile our RCA's are, this book will certainly challenge our paradigms.

Bill Rigot

--- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Stephenson, Edwin L., Jr." <ELSTEPHE@...> wrote:
>
> Yeah, the statement about engineers ruling was a joke. As engineers, we are not exempt from making decisions based upon cost as well as risk. If we could do everything that results in improvement, regardless of cost, we would would approach technical perfection without possibility of profit. In the nuclear industry, however, we must always err on the side of safety (and sometimes reliability) and never take any action that could place our facility in any condition or configuration that has not been thoroughly analyzed and determined to keep the plant within ALL design limits and specifications. Even if we can technically justify crossing that line, the oversight and review process should be robust enough to ensure that our conclusions are beyond question, and, even then, our analyses must be approved by appropriate regulatory bodies. Any engineer could make a bad decision, hopefully to be identified in review. However, pressures on engineers are no different than those on any other decision maker. In many cases it still comes down to the proficiency, honesty and integrity of the individual.
>
> Regarding the levy, I could be wrong, but I believe the Corps of Engineers funds their projects. In Alabama, we have many Corps of Engineer dams and I don't think Alabama pays any of the cost associated with them. Some of them have Alabama Power generators installed in them and the power produced creates profit for the utility. I also believe that Alabama Power paid for the right to install those generators in the Corps of Engineers dam (or leases that right). So, if the Corps on Engineers built the levy, maintains the levy, and upgrades the levy on their own dime, they should have taken action if problems were identified. However, if they identified problems and asked Congress for money to address those problems and were denied, then some possible causes should include: 1. Inadequate understanding the magnitude of the risk by the Corps; 2. Inadequate communication between the Corps and Congress for Congress to really understand the risk; 3. Lack of the Corps to persist in identifying the problems to the right people in government; 4. Inability of Congressmen to understand the risk; 5. Budgeting priorities based on political bases rather than risk; 6. Lack of available money to fund the project due to other priorities even if the risk is understood; 7. Political or financial gain for Congressmen to deny funding for the project;
>
> We would hate to think that some of these causes could actually exist, but I certainly would not rule them out until I had proof.
>
> Ed Stephenson
> Causal Analyst
> Farley Nuclear Plant
> (334) 814-4587
>
>
> ________________________________
> From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dillard, Tedd A (E S SF RNA FS 11E)
> Sent: Thursday, November 19, 2009 11:19 AM
> To: Root_Cause_State_of_the_Practice@yahoogroups.com
> Subject: RE: [Root_Cause_State_of_the_Practice] Expensive Failure of Governmental Self-assessment/ Oversight
>
>
>
> Jack,
> I love you man but I hope Ed's comment about engineers ruling the world was a joke.
> The bad things that you point out about politicians are true but they would also be true of engineers if they did rule anything.
> The bad things are human things, not related to a title or skill set.
> Also your comment about knowing what is the right thing to do can be said for a lot of people in a lot of circumstances.
> But determining the right thing can be very difficult and is only the first step to success.
> Knowing what to do and getting it done are two very different problems.
> Besides how many time have you seen an engineering fix for a problem that caused more different but serious problems.
> And, and I think this is particularly true of engineers, just knowing the answer to a question is not the same thing as getting it done.
> I believe that because engineers are technically oriented they tend to think that once you have determined the answer to a problem that everyone will agree and implementation is assured.
> This is rarely the case.
> People have a lot of reasons and forces to do something different than what may be best.
> Tedd
> ________________________________
> From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of jack.stanford@...
> Sent: Thursday, November 19, 2009 12:02 PM
> To: Root_Cause_State_of_the_Practice@yahoogroups.com
> Subject: RE: [Root_Cause_State_of_the_Practice] Expensive Failure of Governmental Self-assessment/ Oversight
>
> Hello, Ed,
>
> If what you said below is true (and it probably is), then the federal government owns a big part of the extent of cause for not helping the state of Louisiana fund the repairs that should have taken place *before* the flooding event in New Orleans took place. The bad condition was diagnosed, but nothing happened to fix it to the best of my knowledge, until after the fact. This is what happens when a city exists which basically belongs under water, absent necessary levy/dam repairs.
>
> Should engineers rule the world? I think so, as an engineer who is at least average knows what the right thing to do is. I'll bet that this was true in New Orleans years ago. In ASME, a third of the members are licensed as professional engineers, and I have been one of them for 23 years. PEs and most engineers know what the right thing to do is, though politicians do not always do the right thing. That is because they have too many things in their back pockets, like protecting their own states and ignoring the needs of other states. New Orleans is apparently a classic example of this. Why would a northern senator or congressman even care about the risk in New Orleans? They don't, and they won't.
>
> Jack Stanford, PE
> Section Mentor, ASME New Haven, CT Section
> Former Chair, Webmaster and Treasurer
> StanfordJ@...<mailto:StanfordJ@...>
>
> My understanding is that the Corps of Engineers had recognized weaknesses in the New Orleans levy and had been trying to repair/upgrade it for years. However, the US Congress had higher priorities and would not fund the work. If this is correct, what is the extent of cause?...Where will it happen next?...another reason engineers should rule the world?
>
> Ed Stephenson
> Causal Analyst
> Farley Nuclear Plant
> (334) 814-4587
>
>
> ________________________________
> 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: Thursday, November 19, 2009 7:31 AM
> To: WWWTP_LTBL Katrina
> Cc: Root_Cause_State_of_the_Practice@yahoogroups.com; LTBL Palo Verde; whistleblower411@yahoogroups.com
> Subject: [Root_Cause_State_of_the_Practice] Expensive Failure of Governmental Self-assessment/ Oversight [3 Attachments]
>
>
>
> Scroll down for the story after reading this introduction.
>
> The attached pictures help put this into perspective.
>
> Many of our government agencies and their contractors resist the need to assess their own performance and try to project a picture of competent infallibility. This culture costs us dearly.
>
> Systems Engineering tells us that every system is perfectly designed to produce what it has produced. What are the earlier, better, cheaper, safer, more risk-informed, more compliant ways that the factors can be found before the consequences?
>
> What are the failed barriers here? Do they include the Corps District, the Corps IG, the Army IG, the DOD IG, and the GAO? What others come to mind?
>
> This incident is just one of may recent occurrences that indicate more Expensive Failures of Governmental Self-assessment/ Oversight.
>
> Press the Reply button and send us your thoughts.
>
> Take care,
>
> Bill Corcoran
> Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
> Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
>
> W. R. Corcoran, Ph.D., P.E.
> Nuclear Safety Review Concepts Corporation
> 21 Broadleaf Circle
> Windsor, CT 06095-1634
> 860-285-8779
>
> Subscribe to "The Firebird Forum" TheFirebirdForum-subscribe@yahoogroups.com<mailto:TheFirebirdForum-subscribe@yahoogroups.com>
> Join the group advancing the practice of root cause analysis/ evaluation Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com<mailto:Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com>
>
> ****Internet Email Confidentiality Footer****
>
> Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.
> ________________________________
> http://news.yahoo.com/s/ap/20091119/ap_on_re_us/us_katrina_flood_lawsuit
> ________________________________
> Negligence ruling in Katrina floods may cost feds
> By CAIN BURDEAU, Associated Press Writer Cain Burdeau, Associated Press Writer 1 hr 40 mins ago
>
> NEW ORLEANS - The federal government could be vulnerable to billions of dollars in claims after a judge ruled that the Army Corps of Engineers' failure to properly maintain a navigation channel led to massive flooding in Hurricane Katrina.
>
> U.S. District Judge Stanwood Duval on Wednesday awarded seven plaintiffs $720,000, but the government could eventually be forced to pay much more. The ruling should give more than 100,000 other individuals, businesses and government entities a better shot at claiming damages.
>
> Duval sided with six residents and one business who argued the Army Corps' shoddy oversight of the Mississippi River-Gulf Outlet led to the flooding of New Orleans' Lower 9th Ward and neighboring St. Bernard Parish. He said, however, the corps couldn't be held liable for the flooding of eastern New Orleans, where two of the plaintiffs lived.
> The ruling is also emotionally resonant for south Louisiana. Many in New Orleans have argued that the flooding in the aftermath of Katrina, which struck the region Aug. 29, 2005, was a manmade disaster caused by the Army Corps' failure to maintain the levee system protecting the city.
>
> "Total devastation could possibly have been avoided if something had been done," said Tanya Smith, one of the plaintiffs. "A lot of this stuff was preventable and they turned a deaf ear to it."
>
> The 36-year-old registered nurse anesthetist lived in Chalmette close to the channel when Katrina hit. She was awarded $317,000 in property damages, the most of any of the plaintiffs.
>
> Duval referred to the corps' approach to maintaining the channel as "monumental negligence."
>
> Joe Bruno, one of the lead lawyers for the plaintiffs, said the ruling underscored the Army Corps' long history of not properly protecting the New Orleans region.
>
> "It's high time we look at the way these guys do business and do a full re-evaluation of the way it does business," Bruno said.
>
> He said he expected the government to appeal.
>
> The corps referred calls seeking comment to the Justice Department. Spokesman Charles Miller said the government would review the judge's ruling before making any decision on how to proceed.
>
> During trial testimony, government lawyers and experts argued the levee system was overwhelmed by the massive storm, and levee breaches couldn't solely be blamed on the shipping channel dug in the 1960s as a short-cut between the Gulf of Mexico and New Orleans.
>
> The corps had also unsuccessfully argued that it is immune from liability because the channel is part of New Orleans' flood control system.
>
> In his 156-page ruling, Duval said he was "utterly convinced" that the corps' failure to shore up the channel "doomed the channel to grow to two to three times its design width" and that "created a more forceful frontal wave attack on the levee" that protected St. Bernard and the Lower 9th Ward.
>
> "The Corps had an opportunity to take a myriad of actions to alleviate this deterioration or rehabilitate this deterioration and failed to do so," Duval said. "Clearly the expression 'talk is cheap' applies here."
>
> Ahead of Duval's ruling, experts had said it would likely have consequences for the way the Army Corps does business nationwide.
>
> Pierce O'Donnell, another lead plaintiffs lawyer, said the ruling was the "first time ever the Army Corps has been held liable for damages for a major catastrophe that it caused."
> The plaintiffs lawyers would like Congress to set up a compensation fund to speed up payments to the thousands of others whose claims must still be heard in court.
>
> At a one-month trial in May, experts clashed over the causes of flooding and the channel's contribution to it.
>
> Government experts argued the levees and floodwalls would have failed regardless of whether the channel had been dug.
>
> By contrast, the plaintiffs' team of experts said the outlet became a "hurricane highway" that funneled storm surge into New Orleans. They said that without the channel, the flooding would have been minimal.
>
> The lawsuit was the first major case against the federal government over Katrina flooding to go to trial. A decision rested with Duval because a jury cannot try a case against the federal government.
>

---

From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of jack.stanford@...
Sent: Thursday, November 19, 2009 5:41 PM
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Subject: Re: [Root_Cause_State_of_the_Practice] Re: Expensive Failure of Governmental Self-assessment/ Oversight

Sorry for the misspellings of levee.  At least I was not aware of the correct spelling... 

 

Jack Stanford, PE

 

-------------- Original message from "BILL" <william.rigot@...>: --------------

 

Ed/Jack,

A couple of points. First, it's levee, not levy. One's a bank, the other's a tax.

Secondly (and more seriously), a good read on this subject of how engineer's manage all the cost-benefit trade-offs in their work is captured in Erik Hollnagel's latest book, The ETTO Principle: Efficiency-Thoroughness Trade-Off (Why Things That Go Right Sometimes Go Wrong). He demonstrates how all the decisions we make are driven by this principle. Additonally he points out where causal analysis in tightly coupled, intractible systems can often focus on the wrong things. For those of us who get pretty judgemental about how worthwhile our RCA's are, this book will certainly challenge our paradigms.

Bill Rigot

--- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Stephenson, Edwin L., Jr." <ELSTEPHE@...> wrote:
>
> Yeah, the statement about engineers ruling was a joke. As engineers, we are not exempt from making decisions based upon cost as well as risk. If we could do everything that results in improvement, regardless of cost, we would would approach technical perfection without possibility of profit. In the nuclear industry, however, we must always err on the side of safety (and sometimes reliability) and never take any action that could place our facility in any condition or configuration that has not been thoroughly analyzed and determined to keep the plant within ALL design limits and specifications. Even if we can technically justify crossing that line, the oversight and review process should be robust enough to ensure that our conclusions are beyond question, and, even then, our analyses must be approved by appropriate regulatory bodies. Any engineer could make a bad decision, hopefully to be identified in review. However, pressures on engineers are no different than those on any other decision maker. In many cases it still comes down to the proficiency, honesty and integrity of the individual.
>
> Regarding the levy, I could be wrong, but I believe the Corps of Engineers funds their projects. In Alabama, we have many Corps of Engineer dams and I don't think Alabama pays any of the cost associated with them. Some of them have Alabama Power generators installed in them and the power produced creates profit for the utility. I also believe that Alabama Power paid for the right to install those generators in the Corps of Engineers dam (or leases that right). So, if the Corps on Engineers built the levy, maintains the levy, and upgrades the levy on their own dime, they should have taken action if problems were identified. However, if they identified problems and asked Congress for money to address those problems and were denied, then some possible causes should include: 1. Inadequate understanding the magnitude of the risk by the Corps; 2. Inadequate communication between the Corps and Congress for Congress to really understand the risk; 3. Lack of the Corps to persist in identifying the problems to the right people in government; 4. Inability of Congressmen to understand the risk; 5. Budgeting priorities based on political bases rather than risk; 6. Lack of available money to fund the project due to other priorities even if the risk is understood; 7. Political or financial gain for Congressmen to deny funding for the project;
>
> We would hate to think that some of these causes could actually exist, but I certainly would not rule them out until I had proof.
>
> Ed Stephenson
> Causal Analyst
> Farley Nuclear Plant
> (334) 814-4587
>
>
> ________________________________
> From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dillard, Tedd A (E S SF RNA FS 11E)
> Sent: Thursday, November 19, 2009 11:19 AM
> To: Root_Cause_State_of_the_Practice@yahoogroups.com
> Subject: RE: [Root_Cause_State_of_the_Practice] Expensive Failure of Governmental Self-assessment/ Oversight
>
>
>
> Jack,
> I love you man but I hope Ed's comment about engineers ruling the world was a joke.
> The bad things that you point out about politicians are true but they would also be true of engineers if they did rule anything.
> The bad things are human things, not related to a title or skill set.
> Also your comment about knowing what is the right thing to do can be said for a lot of people in a lot of circumstances.
> But determining the right thing can be very difficult and is only the first step to success.
> Knowing what to do and getting it done are two very different problems.
> Besides how many time have you seen an engineering fix for a problem that caused more different but serious problems.
> And, and I think this is particularly true of engineers, just knowing the answer to a question is not the same thing as getting it done.
> I believe that because engineers are technically oriented they tend to think that once you have determined the answer to a problem that everyone will agree and implementation is assured.
> This is rarely the case.
> People have a lot of reasons and forces to do something different than what may be best.
> Tedd
> ________________________________
> From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of jack.stanford@...
> Sent: Thursday, November 19, 2009 12:02 PM
> To: Root_Cause_State_of_the_Practice@yahoogroups.com
> Subject: RE: [Root_Cause_State_of_the_Practice] Expensive Failure of Governmental Self-assessment/ Oversight
>
> Hello, Ed,
>
> If what you said below is true (and it probably is), then the federal government owns a big part of the extent of cause for not helping the state of Louisiana fund the repairs that should have taken place *before* the flooding event in New Orleans took place. The bad condition was diagnosed, but nothing happened to fix it to the best of my knowledge, until after the fact. This is what happens when a city exists which basically belongs under water, absent necessary levy/dam repairs.
>
> Should engineers rule the world? I think so, as an engineer who is at least average knows what the right thing to do is. I'll bet that this was true in New Orleans years ago. In ASME, a third of the members are licensed as professional engineers, and I have been one of them for 23 years. PEs and most engineers know what the right thing to do is, though politicians do not always do the right thing. That is because they have too many things in their back pockets, like protecting their own states and ignoring the needs of other states. New Orleans is apparently a classic example of this. Why would a northern senator or congressman even care about the risk in New Orleans? They don't, and they won't.
>
> Jack Stanford, PE
> Section Mentor, ASME New Haven, CT Section
> Former Chair, Webmaster and Treasurer
> StanfordJ@...<mailto:StanfordJ@...>
>
> My understanding is that the Corps of Engineers had recognized weaknesses in the New Orleans levy and had been trying to repair/upgrade it for years. However, the US Congress had higher priorities and would not fund the work. If this is correct, what is the extent of cause?...Where will it happen next?...another reason engineers should rule the world?
>
> Ed Stephenson
> Causal Analyst
> Farley Nuclear Plant
> (334) 814-4587
>
>
> ________________________________
> 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: Thursday, November 19, 2009 7:31 AM
> To: WWWTP_LTBL Katrina
> Cc: Root_Cause_State_of_the_Practice@yahoogroups.com; LTBL Palo Verde; whistleblower411@yahoogroups.com
> Subject: [Root_Cause_State_of_the_Practice] Expensive Failure of Governmental Self-assessment/ Oversight [3 Attachments]
>
>
>
> Scroll down for the story after reading this introduction.
>
> The attached pictures help put this into perspective.
>
> Many of our government agencies and their contractors resist the need to assess their own performance and try to project a picture of competent infallibility. This culture costs us dearly.
>
> Systems Engineering tells us that every system is perfectly designed to produce what it has produced. What are the earlier, better, cheaper, safer, more risk-informed, more compliant ways that the factors can be found before the consequences?
>
> What are the failed barriers here? Do they include the Corps District, the Corps IG, the Army IG, the DOD IG, and the GAO? What others come to mind?
>
> This incident is just one of may recent occurrences that indicate more Expensive Failures of Governmental Self-assessment/ Oversight.
>
> Press the Reply button and send us your thoughts.
>
> Take care,
>
> Bill Corcoran
> Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
> Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
>
> W. R. Corcoran, Ph.D., P.E.
> Nuclear Safety Review Concepts Corporation
> 21 Broadleaf Circle
> Windsor, CT 06095-1634
> 860-285-8779
>
> Subscribe to "The Firebird Forum" TheFirebirdForum-subscribe@yahoogroups.com<mailto:TheFirebirdForum-subscribe@yahoogroups.com>
> Join the group advancing the practice of root cause analysis/ evaluation Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com<mailto:Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com>
>
> ****Internet Email Confidentiality Footer****
>
> Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.
> ________________________________
> http://news.yahoo.com/s/ap/20091119/ap_on_re_us/us_katrina_flood_lawsuit
> ________________________________
> Negligence ruling in Katrina floods may cost feds
> By CAIN BURDEAU, Associated Press Writer Cain Burdeau, Associated Press Writer 1 hr 40 mins ago
>
> NEW ORLEANS - The federal government could be vulnerable to billions of dollars in claims after a judge ruled that the Army Corps of Engineers' failure to properly maintain a navigation channel led to massive flooding in Hurricane Katrina.
>
> U.S. District Judge Stanwood Duval on Wednesday awarded seven plaintiffs $720,000, but the government could eventually be forced to pay much more. The ruling should give more than 100,000 other individuals, businesses and government entities a better shot at claiming damages.
>
> Duval sided with six residents and one business who argued the Army Corps' shoddy oversight of the Mississippi River-Gulf Outlet led to the flooding of New Orleans' Lower 9th Ward and neighboring St. Bernard Parish. He said, however, the corps couldn't be held liable for the flooding of eastern New Orleans, where two of the plaintiffs lived.
> The ruling is also emotionally resonant for south Louisiana. Many in New Orleans have argued that the flooding in the aftermath of Katrina, which struck the region Aug. 29, 2005, was a manmade disaster caused by the Army Corps' failure to maintain the levee system protecting the city.
>
> "Total devastation could possibly have been avoided if something had been done," said Tanya Smith, one of the plaintiffs. "A lot of this stuff was preventable and they turned a deaf ear to it."
>
> The 36-year-old registered nurse anesthetist lived in Chalmette close to the channel when Katrina hit. She was awarded $317,000 in property damages, the most of any of the plaintiffs.
>
> Duval referred to the corps' approach to maintaining the channel as "monumental negligence."
>
> Joe Bruno, one of the lead lawyers for the plaintiffs, said the ruling underscored the Army Corps' long history of not properly protecting the New Orleans region.
>
> "It's high time we look at the way these guys do business and do a full re-evaluation of the way it does business," Bruno said.
>
> He said he expected the government to appeal.
>
> The corps referred calls seeking comment to the Justice Department. Spokesman Charles Miller said the government would review the judge's ruling before making any decision on how to proceed.
>
> During trial testimony, government lawyers and experts argued the levee system was overwhelmed by the massive storm, and levee breaches couldn't solely be blamed on the shipping channel dug in the 1960s as a short-cut between the Gulf of Mexico and New Orleans.
>
> The corps had also unsuccessfully argued that it is immune from liability because the channel is part of New Orleans' flood control system.
>
> In his 156-page ruling, Duval said he was "utterly convinced" that the corps' failure to shore up the channel "doomed the channel to grow to two to three times its design width" and that "created a more forceful frontal wave attack on the levee" that protected St. Bernard and the Lower 9th Ward.
>
> "The Corps had an opportunity to take a myriad of actions to alleviate this deterioration or rehabilitate this deterioration and failed to do so," Duval said. "Clearly the expression 'talk is cheap' applies here."
>
> Ahead of Duval's ruling, experts had said it would likely have consequences for the way the Army Corps does business nationwide.
>
> Pierce O'Donnell, another lead plaintiffs lawyer, said the ruling was the "first time ever the Army Corps has been held liable for damages for a major catastrophe that it caused."
> The plaintiffs lawyers would like Congress to set up a compensation fund to speed up payments to the thousands of others whose claims must still be heard in court.
>
> At a one-month trial in May, experts clashed over the causes of flooding and the channel's contribution to it.
>
> Government experts argued the levees and floodwalls would have failed regardless of whether the channel had been dug.
>
> By contrast, the plaintiffs' team of experts said the outlet became a "hurricane highway" that funneled storm surge into New Orleans. They said that without the channel, the flooding would have been minimal.
>
> The lawsuit was the first major case against the federal government over Katrina flooding to go to trial. A decision rested with Duval because a jury cannot try a case against the federal government.
>

OK Dr. Bill,



Here's a shot.



The problem with government oversight is that they suffer from the
WYLFIWYF syndrome (What You Look For Is What You Find).  Because of the
rigidity of their regulations, they only look where their rules direct
them.  As such, they are constantly surprised by abberent behavior.  In
Hollnagel's book, which I referenced below, he suggests that more
successful organizations look at the areas of their business that they
think are going well to try to understand why they appear OK.  When you
look at the QA Rule (highlighted in this month's Firebird Forum), you'll
find that the Rule asks you to do just that.  Unfortunately, managers,
and regulators are programmed to narrowly focus on failures to the
extent that they don't have any disposable time to look at areas that
are under the radar screen.  Look at OSHA, FAA, NRC, Corps of Engineers,
etc.  I think the exception that proves the rule is the oversight
provided by Naval Reactors for the nuclear submarines and aircraft
carriers.  They don't just look at problems, they look at everything.
Their expectation is that you will get better every year.  As such
Commanding Officers, Chief Engineers and Reactor Officers are constantly
under the gun to demonstrate how they are looking at every aspect of
reactor performance to make measurable improvements.



This should apply to levees, levys, levis and levites universally.



Bill Rigot
--- In Root_Cause_State_of_the_Practice@yahoogroups.com, DR WILLIAM
CORCORAN <William.R.Corcoran@...> wrote:
>
> I thought I was starting a serious discussion of how our government
wastes our money and promotes slaughter and mayhem by ineffective
self-assessment.
> �
> Silly me.
> �
> It turned out to be a great thread on philosophy, spelling and
frivolity.
> �
> Can you see your way through to turning it around?
> �
> Or would you like to contribute more philosophy, spelling and
frivolity?
>
>
>
> Take care,
> �
> Bill Corcoran
> Mission: Saving lives, pain, assets, and careers through thoughtful
inquiry.
> Motto: If you want safety, peace, or justice, then work for
competency, integrity, and transparency.
> �
> W. R. Corcoran, Ph.D., P.E.
> Nuclear Safety Review Concepts Corporation
> 21 Broadleaf Circle
> Windsor, CT 06095-1634
> 860-285-8779
>
> �
> Subscribe to "The Firebird Forum" �
TheFirebirdForum-subscribe@yahoogroups.com
> Join the group advancing the practice of root cause analysis/
evaluation� �
Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com
> �
> ****Internet Email Confidentiality Footer****
> �
> Privileged/Confidential Information may be contained in this message.
If you are not the addressee indicated in this message (or responsible
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and notify the sender by reply email. Please advise immediately if you
or your employer do not consent to Internet email for messages of this
kind. Opinions, conclusions and other information in this message that
do not relate to the official business of� NSRC Corp.� shall be
understood as neither given nor endorsed by it.
>
> --- On Fri, 11/20/09, Dillard, Tedd A (E S SF RNA FS 11E)
tedd.dillard@... wrote:
>
>
> From: Dillard, Tedd A (E S SF RNA FS 11E) tedd.dillard@...
> Subject: RE: [Root_Cause_State_of_the_Practice] Re: Expensive Failure
of Governmental Self-assessment/ Oversight
> To: Root_Cause_State_of_the_Practice@yahoogroups.com
> Date: Friday, November 20, 2009, 9:27 AM
>
>
> �
>
>
>
>
> Or denim pants.
>
>
>
> From: Root_Cause_State_ of_the_Practice@ yahoogroups. com
[mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf
Of Stephenson, Edwin L., Jr.
> Sent: Friday, November 20, 2009 8:30 AM
> To: 'Root_Cause_ State_of_ the_Practice@ yahoogroups. com'
> Subject: RE: [Root_Cause_ State_of_ the_Practice] Re: Expensive
Failure of Governmental Self-assessment/ Oversight
>
>
> �
>
>
> I thought it had something to do with the tribes of Israel.
> �
> Ed Stephenson
> Causal Analyst
> Farley Nuclear Plant
> (334) 814-4587
> �
>
>
>
>
> From: Root_Cause_State_ of_the_Practice@ yahoogroups. com
[mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf
Of jack.stanford@ att.net
> Sent: Thursday, November 19, 2009 5:41 PM
> To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
> Subject: Re: [Root_Cause_ State_of_ the_Practice] Re: Expensive
Failure of Governmental Self-assessment/ Oversight
>
>
>
>
> Sorry for the misspellings of levee.�  At least I was not aware of
the correct spelling...�
> �
> Jack Stanford, PE
> �
> ------------ -- Original message from "BILL" <william.rigot@ srs.gov>:
------------ --
>
> �
>
> Ed/Jack,
>
> A couple of points. First, it's levee, not levy. One's a bank, the
other's a tax.
>
> Secondly (and more seriously), a good read on this subject of how
engineer's manage all the cost-benefit trade-offs in their work is
captured in Erik Hollnagel's latest book, The ETTO Principle:
Efficiency-Thorough ness Trade-Off (Why Things That Go Right Sometimes
Go Wrong). He demonstrates how all the decisions we make are driven by
this principle. Additonally he points out where causal analysis in
tightly coupled, intractible systems can often focus on the wrong
things. For those of us who get pretty judgemental about how worthwhile
our RCA's are, this book will certainly challenge our paradigms.
>
> Bill Rigot
>
> --- In Root_Cause_State_ of_the_Practice@ yahoogroups. com,
"Stephenson, Edwin L., Jr." ELSTEPHE@ .> wrote:
> >
> > Yeah, the statement about engineers ruling was a joke. As engineers,
we are not exempt from making decisions based upon cost as well as risk.
If we could do everything that results in improvement, regardless of
cost, we would would approach technical perfection without possibility
of profit. In the nuclear industry, however, we must always err on the
side of safety (and sometimes reliability) and never take any action
that could place our facility in any condition or configuration that has
not been thoroughly analyzed and determined to keep the plant within ALL
design limits and specifications. Even if we can technically justify
crossing that line, the oversight and review process should be robust
enough to ensure that our conclusions are beyond question, and, even
then, our analyses must be approved by appropriate regulatory bodies.
Any engineer could make a bad decision, hopefully to be identified in
review. However, pressures on engineers are no
> different than those on any other decision maker. In many cases it
still comes down to the proficiency, honesty and integrity of the
individual.
> >
> > Regarding the levy, I could be wrong, but I believe the Corps of
Engineers funds their projects. In Alabama, we have many Corps of
Engineer dams and I don't think Alabama pays any of the cost associated
with them. Some of them have Alabama Power generators installed in them
and the power produced creates profit for the utility. I also believe
that Alabama Power paid for the right to install those generators in the
Corps of Engineers dam (or leases that right). So, if the Corps on
Engineers built the levy, maintains the levy, and upgrades the levy on
their own dime, they should have taken action if problems were
identified. However, if they identified problems and asked Congress for
money to address those problems and were denied, then some possible
causes should include: 1. Inadequate understanding the magnitude of the
risk by the Corps; 2. Inadequate communication between the Corps and
Congress for Congress to really understand the risk; 3. Lack of
> the Corps to persist in identifying the problems to the right people
in government; 4. Inability of Congressmen to understand the risk; 5.
Budgeting priorities based on political bases rather than risk; 6. Lack
of available money to fund the project due to other priorities even if
the risk is understood; 7. Political or financial gain for Congressmen
to deny funding for the project;
> >
> > We would hate to think that some of these causes could actually
exist, but I certainly would not rule them out until I had proof.
> >
> > Ed Stephenson
> > Causal Analyst
> > Farley Nuclear Plant
> > (334) 814-4587
> >
> >
> > ____________ _________ _________ __
> > From: Root_Cause_State_ of_the_Practice@ yahoogroups. com
[mailto:Root_Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf
Of Dillard, Tedd A (E S SF RNA FS 11E)
> > Sent: Thursday, November 19, 2009 11:19 AM
> > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
> > Subject: RE: [Root_Cause_ State_of_ the_Practice] Expensive Failure
of Governmental Self-assessment/ Oversight
> >
> >
> >
> > Jack,
> > I love you man but I hope Ed's comment about engineers ruling the
world was a joke.
> > The bad things that you point out about politicians are true but
they would also be true of engineers if they did rule anything.
> > The bad things are human things, not related to a title or skill
set.
> > Also your comment about knowing what is the right thing to do can be
said for a lot of people in a lot of circumstances.
> > But determining the right thing can be very difficult and is only
the first step to success.
> > Knowing what to do and getting it done are two very different
problems.
> > Besides how many time have you seen an engineering fix for a problem
that caused more different but serious problems.
> > And, and I think this is particularly true of engineers, just
knowing the answer to a question is not the same thing as getting it
done.
> > I believe that because engineers are technically oriented they tend
to think that once you have determined the answer to a problem that
everyone will agree and implementation is assured.
> > This is rarely the case.
> > People have a lot of reasons and forces to do something different
than what may be best.
> > Tedd
> > ____________ _________ _________ __
> > From: Root_Cause_State_ of_the_Practice@ yahoogroups. com
[mailto:Root_Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf
Of jack.stanford@ ...
> > Sent: Thursday, November 19, 2009 12:02 PM
> > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
> > Subject: RE: [Root_Cause_ State_of_ the_Practice] Expensive Failure
of Governmental Self-assessment/ Oversight
> >
> > Hello, Ed,
> >
> > If what you said below is true (and it probably is), then the
federal government owns a big part of the extent of cause for not
helping the state of Louisiana fund the repairs that should have taken
place *before* the flooding event in New Orleans took place. The bad
condition was diagnosed, but nothing happened to fix it to the best of
my knowledge, until after the fact. This is what happens when a city
exists which basically belongs under water, absent necessary levy/dam
repairs.
> >
> > Should engineers rule the world? I think so, as an engineer who is
at least average knows what the right thing to do is. I'll bet that this
was true in New Orleans years ago. In ASME, a third of the members are
licensed as professional engineers, and I have been one of them for 23
years. PEs and most engineers know what the right thing to do is, though
politicians do not always do the right thing. That is because they have
too many things in their back pockets, like protecting their own states
and ignoring the needs of other states. New Orleans is apparently a
classic example of this. Why would a northern senator or congressman
even care about the risk in New Orleans? They don't, and they won't.
> >
> > Jack Stanford, PE
> > Section Mentor, ASME New Haven, CT Section
> > Former Chair, Webmaster and Treasurer
> > StanfordJ@ .<mailto: StanfordJ@ ...>
> >
> > My understanding is that the Corps of Engineers had recognized
weaknesses in the New Orleans levy and had been trying to repair/upgrade
it for years. However, the US Congress had higher priorities and would
not fund the work. If this is correct, what is the extent of
cause?...Where will it happen next?...another reason engineers should
rule the world?
> >
> > Ed Stephenson
> > Causal Analyst
> > Farley Nuclear Plant
> > (334) 814-4587
> >
> >
> > ____________ _________ _________ __
> > 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: Thursday, November 19, 2009 7:31 AM
> > To: WWWTP_LTBL Katrina
> > Cc: Root_Cause_State_ of_the_Practice@ yahoogroups. com; LTBL Palo
Verde; whistleblower411@ yahoogroups. com
> > Subject: [Root_Cause_ State_of_ the_Practice] Expensive Failure of
Governmental Self-assessment/ Oversight [3 Attachments]
> >
> >
> >
> > Scroll down for the story after reading this introduction.
> >
> > The attached pictures help put this into perspective.
> >
> > Many of our government agencies and their contractors resist the
need to assess their own performance and try to project a picture of
competent infallibility. This culture costs us dearly.
> >
> > Systems Engineering tells us that every system is perfectly designed
to produce what it has produced. What are the earlier, better, cheaper,
safer, more risk-informed, more compliant ways that the factors can be
found before the consequences?
> >
> > What are the failed barriers here? Do they include the Corps
District, the Corps IG, the Army IG, the DOD IG, and the GAO? What
others come to mind?
> >
> > This incident is just one of may recent occurrences that indicate
more Expensive Failures of Governmental Self-assessment/ Oversight.
> >
> > Press the Reply button and send us your thoughts.
> >
> > Take care,
> >
> > Bill Corcoran
> > Mission: Saving lives, pain, assets, and careers through thoughtful
inquiry.
> > Motto: If you want safety, peace, or justice, then work for
competency, integrity, and transparency.
> >
> > W. R. Corcoran, Ph.D., P.E.
> > Nuclear Safety Review Concepts Corporation
> > 21 Broadleaf Circle
> > Windsor, CT 06095-1634
> > 860-285-8779
> >
> > Subscribe to "The Firebird Forum" TheFirebirdForum- subscribe@
yahoogroups. com<mailto:TheFirebirdForum- subscribe@ yahoogroups. com>
> > Join the group advancing the practice of root cause analysis/
evaluation Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups.
com<mailto:Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups.
com>
> >
> > ****Internet Email Confidentiality Footer****
> >
> > Privileged/Confiden tial Information may be contained in this
message. If you are not the addressee indicated in this message (or
responsible for delivery of the message to such person), you may not
copy or deliver this message to anyone. In such case, you should destroy
this message and notify the sender by reply email. Please advise
immediately if you or your employer do not consent to Internet email for
messages of this kind. Opinions, conclusions and other information in
this message that do not relate to the official business of NSRC Corp.
shall be understood as neither given nor endorsed by it.
> > ____________ _________ _________ __
> > http://news. yahoo.com/ s/ap/20091119/ ap_on_re_ us/us_katrina_
flood_lawsuit
> > ____________ _________ _________ __
> > Negligence ruling in Katrina floods may cost feds
> > By CAIN BURDEAU, Associated Press Writer Cain Burdeau, Associated
Press Writer 1 hr 40 mins ago
> >
> > NEW ORLEANS - The federal government could be vulnerable to billions
of dollars in claims after a judge ruled that the Army Corps of
Engineers' failure to properly maintain a navigation channel led to
massive flooding in Hurricane Katrina.
> >
> > U.S. District Judge Stanwood Duval on Wednesday awarded seven
plaintiffs $720,000, but the government could eventually be forced to
pay much more. The ruling should give more than 100,000 other
individuals, businesses and government entities a better shot at
claiming damages.
> >
> > Duval sided with six residents and one business who argued the Army
Corps' shoddy oversight of the Mississippi River-Gulf Outlet led to the
flooding of New Orleans' Lower 9th Ward and neighboring St. Bernard
Parish. He said, however, the corps couldn't be held liable for the
flooding of eastern New Orleans, where two of the plaintiffs lived.
> > The ruling is also emotionally resonant for south Louisiana. Many in
New Orleans have argued that the flooding in the aftermath of Katrina,
which struck the region Aug. 29, 2005, was a manmade disaster caused by
the Army Corps' failure to maintain the levee system protecting the
city.
> >
> > "Total devastation could possibly have been avoided if something had
been done," said Tanya Smith, one of the plaintiffs. "A lot of this
stuff was preventable and they turned a deaf ear to it."
> >
> > The 36-year-old registered nurse anesthetist lived in Chalmette
close to the channel when Katrina hit. She was awarded $317,000 in
property damages, the most of any of the plaintiffs.
> >
> > Duval referred to the corps' approach to maintaining the channel as
"monumental negligence."
> >
> > Joe Bruno, one of the lead lawyers for the plaintiffs, said the
ruling underscored the Army Corps' long history of not properly
protecting the New Orleans region.
> >
> > "It's high time we look at the way these guys do business and do a
full re-evaluation of the way it does business," Bruno said.
> >
> > He said he expected the government to appeal.
> >
> > The corps referred calls seeking comment to the Justice Department.
Spokesman Charles Miller said the government would review the judge's
ruling before making any decision on how to proceed.
> >
> > During trial testimony, government lawyers and experts argued the
levee system was overwhelmed by the massive storm, and levee breaches
couldn't solely be blamed on the shipping channel dug in the 1960s as a
short-cut between the Gulf of Mexico and New Orleans.
> >
> > The corps had also unsuccessfully argued that it is immune from
liability because the channel is part of New Orleans' flood control
system.
> >
> > In his 156-page ruling, Duval said he was "utterly convinced" that
the corps' failure to shore up the channel "doomed the channel to grow
to two to three times its design width" and that "created a more
forceful frontal wave attack on the levee" that protected St. Bernard
and the Lower 9th Ward.
> >
> > "The Corps had an opportunity to take a myriad of actions to
alleviate this deterioration or rehabilitate this deterioration and
failed to do so," Duval said. "Clearly the expression 'talk is cheap'
applies here."
> >
> > Ahead of Duval's ruling, experts had said it would likely have
consequences for the way the Army Corps does business nationwide.
> >
> > Pierce O'Donnell, another lead plaintiffs lawyer, said the ruling
was the "first time ever the Army Corps has been held liable for damages
for a major catastrophe that it caused."
> > The plaintiffs lawyers would like Congress to set up a compensation
fund to speed up payments to the thousands of others whose claims must
still be heard in court.
> >
> > At a one-month trial in May, experts clashed over the causes of
flooding and the channel's contribution to it.
> >
> > Government experts argued the levees and floodwalls would have
failed regardless of whether the channel had been dug.
> >
> > By contrast, the plaintiffs' team of experts said the outlet became
a "hurricane highway" that funneled storm surge into New Orleans. They
said that without the channel, the flooding would have been minimal.
> >
> > The lawsuit was the first major case against the federal government
over Katrina flooding to go to trial. A decision rested with Duval
because a jury cannot try a case against the federal government.
> >
>

---

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, November 20, 2009 10:18 AM
To: Dr. Bill Corcoran
Subject: [Root_Cause_State_of_the_Practice] NRC SEEKS PUBLIC COMMENT ON DRAFT SAFETY CULTURE POLICY

 

What are the most up-to-date INPO, NEI, IAEA, and DOE documents that should be considered in an intelligent response to this request below?   If you don't know the answer to that question, could you suggest who might know parts of the answer? Take care,   Bill Corcoran Mission: Saving lives, pain, assets, and careers through thoughtful inquiry. Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.   W. R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation 21 Broadleaf Circle Windsor, CT 06095-1634 860-285-8779   Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com Join the group advancing the practice of root cause analysis/ evaluation  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com   ****Internet Email Confidentiality Footer****   Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.   NRC NEWS U.S. NUCLEAR REGULATORY COMMISSION Office of Public Affairs              Telephone: 301/415-8200 Washington, D.C. 20555-0001 E-mail: opa.resource@nrc.gov Site: http://www.nrc.gov No. 09-185 November 12, 2009 NRC SEEKS PUBLIC COMMENT ON DRAFT SAFETY CULTURE POLICY FOR NUCLEAR FACILITIES AND NUCLEAR MATERIAL USERS The Nuclear Regulatory Commission has issued for public comment a draft policy statement on “safety culture,” including the Commission’s expectation that any NRC-regulated organization will establish and maintain a positive safety culture.             The Commission addressed the safe conduct of nuclear power plant operations in a 1989 policy statement and a safety-conscious work environment in a 1996 policy statement. After years of work in this area, and after the experience of incorporating aspects of safety culture into the Reactor Oversight Process effort, the Commission has approved issuing a draft policy statement that sets forth its expectation that all licensees and certificate holders establish and maintain a safety culture that protects public health and safety and the common defense and security. The draft policy defines safety culture as: “That assembly of characteristics, attitudes and behaviors in organizations and individuals which establishes that as an overriding priority, nuclear safety and security issues receive the attention warranted by their significance.” A safety culture should include a work environment where personnel feel free to raise safety and security concerns without fearing retaliation, as well as prompt and thorough identification, evaluation and resolution of those concerns. The NRC is strongly committed to promoting a positive safety culture among the organizations it regulates. The NRC is interested in the public’s comments in several areas, including: ·       Does the draft policy’s safety culture definition need further clarification? ·       What specific safety culture characteristics relevant to particular types of NRC licensees should the draft policy address? ·       What characteristics in the draft policy do not contribute to safety culture? ·       How can the NRC better involve stakeholders in addressing safety culture? Comments on the changes will be accepted until Feb. 4, 2010, following publication of the draft safety culture policy statement in the Federal Register, (http://edocket.access.gpo.gov/2009/pdf/E9-26816.pdf). Comments may be mailed to: Alexander Sapountzis, Office of Enforcement, Mail Stop O4 A15A, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or e-mailed to: alexander.sapountzis@....    # # # News releases are available through a free listserv subscription at the following Web address:  http://www.nrc.gov/public-involve/listserver.html. The NRC homepage at www.nrc.gov also offers a SUBSCRIBE link. E-mail notifications are sent to subscribers when news releases are posted to NRC's Web site.

-------------- Original message from DR WILLIAM CORCORAN <William.R.Corcoran@...>: --------------

 

I thought I was starting a serious discussion of how our government wastes our money and promotes slaughter and mayhem by ineffective self-assessment.   Silly me.   It turned out to be a great thread on philosophy, spelling and frivolity.   Can you see your way through to turning it around?   Or would you like to contribute more philosophy, spelling and frivolity? Take care,   Bill Corcoran Mission: Saving lives, pain, assets, and careers through thoughtful inquiry. Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.   W. R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation 21 Broadleaf Circle Windsor, CT 06095-1634 860-285-8779   Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com Join the group advancing the practice of root cause analysis/ evaluation  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com   ****Internet Email Confidentiality Footer****   Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it. --- On Fri, 11/20/09, Dillard, Tedd A (E S SF RNA FS 11E) <tedd.dillard@siemens.com> wrote: From: Dillard, Tedd A (E S SF RNA FS 11E) <tedd.dillard@siemens.com> Subject: RE: [Root_Cause_State_of_the_Practice] Re: Expensive Failure of Governmental Self-assessment/ Oversight To: Root_Cause_State_of_the_Practice@yahoogroups.com Date: Friday, November 20, 2009, 9:27 AM   Or denim pants. From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of Stephenson, Edwin L., Jr. Sent: Friday, November 20, 2009 8:30 AM To: 'Root_Cause_ State_of_ the_Practice@ yahoogroups. com' Subject: RE: [Root_Cause_ State_of_ the_Practice] Re: Expensive Failure of Governmental Self-assessment/ Oversight   I thought it had something to do with the tribes of Israel.   Ed Stephenson Causal Analyst Farley Nuclear Plant (334) 814-4587   From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of jack.stanford@ att.net Sent: Thursday, November 19, 2009 5:41 PM To: Root_Cause_State_ of_the_Practice@ yahoogroups. com Subject: Re: [Root_Cause_ State_of_ the_Practice] Re: Expensive Failure of Governmental Self-assessment/ Oversight Sorry for the misspellings of levee.  At least I was not aware of the correct spelling...    Jack Stanford, PE   ------------ -- Original message from "BILL" <william.rigot@ srs.gov>: ------------ --   Ed/Jack, A couple of points. First, it's levee, not levy. One's a bank, the other's a tax. Secondly (and more seriously), a good read on this subject of how engineer's manage all the cost-benefit trade-offs in their work is captured in Erik Hollnagel's latest book, The ETTO Principle: Efficiency-Thorough ness Trade-Off (Why Things That Go Right Sometimes Go Wrong). He demonstrates how all the decisions we make are driven by this principle. Additonally he points out where causal analysis in tightly coupled, intractible systems can often focus on the wrong things. For those of us who get pretty judgemental about how worthwhile our RCA's are, this book will certainly challenge our paradigms. Bill Rigot --- In Root_Cause_State_ of_the_Practice@ yahoogroups. com, "Stephenson, Edwin L., Jr." <ELSTEPHE@.. .> wrote: > > Yeah, the statement about engineers ruling was a joke. As engineers, we are not exempt from making decisions based upon cost as well as risk. If we could do everything that results in improvement, regardless of cost, we would would approach technical perfection without possibility of profit. In the nuclear industry, however, we must always err on the side of safety (and sometimes reliability) and never take any action that could place our facility in any condition or configuration that has not been thoroughly analyzed and determined to keep the plant within ALL design limits and specifications. Even if we can technically justify crossing that line, the oversight and review process should be robust enough to ensure that our conclusions are beyond question, and, even then, our analyses must be approved by appropriate regulatory bodies. Any engineer could make a bad decision, hopefully to be identified in review. However, pressures on engineers are no different than those on any other decision maker. In many cases it still comes down to the proficiency, honesty and integrity of the individual. > > Regarding the levy, I could be wrong, but I believe the Corps of Engineers funds their projects. In Alabama, we have many Corps of Engineer dams and I don't think Alabama pays any of the cost associated with them. Some of them have Alabama Power generators installed in them and the power produced creates profit for the utility. I also believe that Alabama Power paid for the right to install those generators in the Corps of Engineers dam (or leases that right). So, if the Corps on Engineers built the levy, maintains the levy, and upgrades the levy on their own dime, they should have taken action if problems were identified. However, if they identified problems and asked Congress for money to address those problems and were denied, then some possible causes should include: 1. Inadequate understanding the magnitude of the risk by the Corps; 2. Inadequate communication between the Corps and Congress for Congress to really understand the risk; 3. Lack of the Corps to persist in identifying the problems to the right people in government; 4. Inability of Congressmen to understand the risk; 5. Budgeting priorities based on political bases rather than risk; 6. Lack of available money to fund the project due to other priorities even if the risk is understood; 7. Political or financial gain for Congressmen to deny funding for the project; > > We would hate to think that some of these causes could actually exist, but I certainly would not rule them out until I had proof. > > Ed Stephenson > Causal Analyst > Farley Nuclear Plant > (334) 814-4587 > > > ____________ _________ _________ __ > From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of Dillard, Tedd A (E S SF RNA FS 11E) > Sent: Thursday, November 19, 2009 11:19 AM > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com > Subject: RE: [Root_Cause_ State_of_ the_Practice] Expensive Failure of Governmental Self-assessment/ Oversight > > > > Jack, > I love you man but I hope Ed's comment about engineers ruling the world was a joke. > The bad things that you point out about politicians are true but they would also be true of engineers if they did rule anything. > The bad things are human things, not related to a title or skill set. > Also your comment about knowing what is the right thing to do can be said for a lot of people in a lot of circumstances. > But determining the right thing can be very difficult and is only the first step to success. > Knowing what to do and getting it done are two very different problems. > Besides how many time have you seen an engineering fix for a problem that caused more different but serious problems. > And, and I think this is particularly true of engineers, just knowing the answer to a question is not the same thing as getting it done. > I believe that because engineers are technically oriented they tend to think that once you have determined the answer to a problem that everyone will agree and implementation is assured. > This is rarely the case. > People have a lot of reasons and forces to do something different than what may be best. > Tedd > ____________ _________ _________ __ > From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of jack.stanford@ ... > Sent: Thursday, November 19, 2009 12:02 PM > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com > Subject: RE: [Root_Cause_ State_of_ the_Practice] Expensive Failure of Governmental Self-assessment/ Oversight > > Hello, Ed, > > If what you said below is true (and it probably is), then the federal government owns a big part of the extent of cause for not helping the state of Louisiana fund the repairs that should have taken place *before* the flooding event in New Orleans took place. The bad condition was diagnosed, but nothing happened to fix it to the best of my knowledge, until after the fact. This is what happens when a city exists which basically belongs under water, absent necessary levy/dam repairs. > > Should engineers rule the world? I think so, as an engineer who is at least average knows what the right thing to do is. I'll bet that this was true in New Orleans years ago. In ASME, a third of the members are licensed as professional engineers, and I have been one of them for 23 years. PEs and most engineers know what the right thing to do is, though politicians do not always do the right thing. That is because they have too many things in their back pockets, like protecting their own states and ignoring the needs of other states. New Orleans is apparently a classic example of this. Why would a northern senator or congressman even care about the risk in New Orleans? They don't, and they won't. > > Jack Stanford, PE > Section Mentor, ASME New Haven, CT Section > Former Chair, Webmaster and Treasurer > StanfordJ@.. .<mailto: StanfordJ@ ...> > > My understanding is that the Corps of Engineers had recognized weaknesses in the New Orleans levy and had been trying to repair/upgrade it for years. However, the US Congress had higher priorities and would not fund the work. If this is correct, what is the extent of cause?...Where will it happen next?...another reason engineers should rule the world? > > Ed Stephenson > Causal Analyst > Farley Nuclear Plant > (334) 814-4587 > > > ____________ _________ _________ __ > 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: Thursday, November 19, 2009 7:31 AM > To: WWWTP_LTBL Katrina > Cc: Root_Cause_State_ of_the_Practice@ yahoogroups. com; LTBL Palo Verde; whistleblower411@ yahoogroups. com > Subject: [Root_Cause_ State_of_ the_Practice] Expensive Failure of Governmental Self-assessment/ Oversight [3 Attachments] > > > > Scroll down for the story after reading this introduction. > > The attached pictures help put this into perspective. > > Many of our government agencies and their contractors resist the need to assess their own performance and try to project a picture of competent infallibility. This culture costs us dearly. > > Systems Engineering tells us that every system is perfectly designed to produce what it has produced. What are the earlier, better, cheaper, safer, more risk-informed, more compliant ways that the factors can be found before the consequences? > > What are the failed barriers here? Do they include the Corps District, the Corps IG, the Army IG, the DOD IG, and the GAO? What others come to mind? > > This incident is just one of may recent occurrences that indicate more Expensive Failures of Governmental Self-assessment/ Oversight. > > Press the Reply button and send us your thoughts. > > Take care, > > Bill Corcoran > Mission: Saving lives, pain, assets, and careers through thoughtful inquiry. > Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency. > > W. R. Corcoran, Ph.D., P.E. > Nuclear Safety Review Concepts Corporation > 21 Broadleaf Circle > Windsor, CT 06095-1634 > 860-285-8779 > > Subscribe to "The Firebird Forum" TheFirebirdForum- subscribe@ yahoogroups. com<mailto:TheFirebirdForum- subscribe@ yahoogroups. com> > Join the group advancing the practice of root cause analysis/ evaluation Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com<mailto:Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com> > > ****Internet Email Confidentiality Footer**** > > Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it. > ____________ _________ _________ __ > http://news. yahoo.com/ s/ap/20091119/ ap_on_re_ us/us_katrina_ flood_lawsuit > ____________ _________ _________ __ > Negligence ruling in Katrina floods may cost feds > By CAIN BURDEAU, Associated Press Writer Cain Burdeau, Associated Press Writer 1 hr 40 mins ago > > NEW ORLEANS - The federal government could be vulnerable to billions of dollars in claims after a judge ruled that the Army Corps of Engineers' failure to properly maintain a navigation channel led to massive flooding in Hurricane Katrina. > > U.S. District Judge Stanwood Duval on Wednesday awarded seven plaintiffs $720,000, but the government could eventually be forced to pay much more. The ruling should give more than 100,000 other individuals, businesses and government entities a better shot at claiming damages. > > Duval sided with six residents and one business who argued the Army Corps' shoddy oversight of the Mississippi River-Gulf Outlet led to the flooding of New Orleans' Lower 9th Ward and neighboring St. Bernard Parish. He said, however, the corps couldn't be held liable for the flooding of eastern New Orleans, where two of the plaintiffs lived. > The ruling is also emotionally resonant for south Louisiana. Many in New Orleans have argued that the flooding in the aftermath of Katrina, which struck the region Aug. 29, 2005, was a manmade disaster caused by the Army Corps' failure to maintain the levee system protecting the city. > > "Total devastation could possibly have been avoided if something had been done," said Tanya Smith, one of the plaintiffs. "A lot of this stuff was preventable and they turned a deaf ear to it." > > The 36-year-old registered nurse anesthetist lived in Chalmette close to the channel when Katrina hit. She was awarded $317,000 in property damages, the most of any of the plaintiffs. > > Duval referred to the corps' approach to maintaining the channel as "monumental negligence." > > Joe Bruno, one of the lead lawyers for the plaintiffs, said the ruling underscored the Army Corps' long history of not properly protecting the New Orleans region. > > "It's high time we look at the way these guys do business and do a full re-evaluation of the way it does business," Bruno said. > > He said he expected the government to appeal. > > The corps referred calls seeking comment to the Justice Department. Spokesman Charles Miller said the government would review the judge's ruling before making any decision on how to proceed. > > During trial testimony, government lawyers and experts argued the levee system was overwhelmed by the massive storm, and levee breaches couldn't solely be blamed on the shipping channel dug in the 1960s as a short-cut between the Gulf of Mexico and New Orleans. > > The corps had also unsuccessfully argued that it is immune from liability because the channel is part of New Orleans' flood control system. > > In his 156-page ruling, Duval said he was "utterly convinced" that the corps' failure to shore up the channel "doomed the channel to grow to two to three times its design width" and that "created a more forceful frontal wave attack on the levee" that protected St. Bernard and the Lower 9th Ward. > > "The Corps had an opportunity to take a myriad of actions to alleviate this deterioration or rehabilitate this deterioration and failed to do so," Duval said. "Clearly the expression 'talk is cheap' applies here." > > Ahead of Duval's ruling, experts had said it would likely have consequences for the way the Army Corps does business nationwide. > > Pierce O'Donnell, another lead plaintiffs lawyer, said the ruling was the "first time ever the Army Corps has been held liable for damages for a major catastrophe that it caused." > The plaintiffs lawyers would like Congress to set up a compensation fund to speed up payments to the thousands of others whose claims must still be heard in court. > > At a one-month trial in May, experts clashed over the causes of flooding and the channel's contribution to it. > > Government experts argued the levees and floodwalls would have failed regardless of whether the channel had been dug. > > By contrast, the plaintiffs' team of experts said the outlet became a "hurricane highway" that funneled storm surge into New Orleans. They said that without the channel, the flooding would have been minimal. > > The lawsuit was the first major case against the federal government over Katrina flooding to go to trial. A decision rested with Duval because a jury cannot try a case against the federal government. >

----- Original Message -----

From: jack.stanford@...

To: Root_Cause_State_of_the_Practice@yahoogroups.com

Sent: Friday, November 20, 2009 3:40 PM

Subject: RE: [Root_Cause_State_of_the_Practice] Re: Expensive Failure of Governmental Self-assessment/ Oversight

Dr. Bill,

 

I found Bill Rigot's correction of my spelling error to be necessary and a good move on his part.  I also do not find your websites to be frivolous and find the philosophical chat to be just fine and useful.  That is just where I stand today.  It does not appear to me that we agree on this.

 

TTFN, regards,

 

Jack Stanford, PE

StanfordJ@...

 

-------------- Original message from DR WILLIAM CORCORAN <William.R.Corcoran@...>: --------------

 

I thought I was starting a serious discussion of how our government wastes our money and promotes slaughter and mayhem by ineffective self-assessment.   Silly me.   It turned out to be a great thread on philosophy, spelling and frivolity.   Can you see your way through to turning it around?   Or would you like to contribute more philosophy, spelling and frivolity? Take care,   Bill Corcoran Mission: Saving lives, pain, assets, and careers through thoughtful inquiry. Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.   W. R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation 21 Broadleaf Circle Windsor, CT 06095-1634 860-285-8779   Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com Join the group advancing the practice of root cause analysis/ evaluation  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com   ****Internet Email Confidentiality Footer****   Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it. --- On Fri, 11/20/09, Dillard, Tedd A (E S SF RNA FS 11E) <tedd.dillard@siemens.com> wrote: From: Dillard, Tedd A (E S SF RNA FS 11E) <tedd.dillard@siemens.com> Subject: RE: [Root_Cause_State_of_the_Practice] Re: Expensive Failure of Governmental Self-assessment/ Oversight To: Root_Cause_State_of_the_Practice@yahoogroups.com Date: Friday, November 20, 2009, 9:27 AM   Or denim pants. From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of Stephenson, Edwin L., Jr. Sent: Friday, November 20, 2009 8:30 AM To: 'Root_Cause_ State_of_ the_Practice@ yahoogroups. com' Subject: RE: [Root_Cause_ State_of_ the_Practice] Re: Expensive Failure of Governmental Self-assessment/ Oversight   I thought it had something to do with the tribes of Israel.   Ed Stephenson Causal Analyst Farley Nuclear Plant (334) 814-4587   From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of jack.stanford@ att.net Sent: Thursday, November 19, 2009 5:41 PM To: Root_Cause_State_ of_the_Practice@ yahoogroups. com Subject: Re: [Root_Cause_ State_of_ the_Practice] Re: Expensive Failure of Governmental Self-assessment/ Oversight Sorry for the misspellings of levee.  At least I was not aware of the correct spelling...    Jack Stanford, PE   ------------ -- Original message from "BILL" <william.rigot@ srs.gov>: ------------ --   Ed/Jack, A couple of points. First, it's levee, not levy. One's a bank, the other's a tax. Secondly (and more seriously), a good read on this subject of how engineer's manage all the cost-benefit trade-offs in their work is captured in Erik Hollnagel's latest book, The ETTO Principle: Efficiency-Thorough ness Trade-Off (Why Things That Go Right Sometimes Go Wrong). He demonstrates how all the decisions we make are driven by this principle. Additonally he points out where causal analysis in tightly coupled, intractible systems can often focus on the wrong things. For those of us who get pretty judgemental about how worthwhile our RCA's are, this book will certainly challenge our paradigms. Bill Rigot --- In Root_Cause_State_ of_the_Practice@ yahoogroups. com, "Stephenson, Edwin L., Jr." <ELSTEPHE@.. .> wrote: > > Yeah, the statement about engineers ruling was a joke. As engineers, we are not exempt from making decisions based upon cost as well as risk. If we could do everything that results in improvement, regardless of cost, we would would approach technical perfection without possibility of profit. In the nuclear industry, however, we must always err on the side of safety (and sometimes reliability) and never take any action that could place our facility in any condition or configuration that has not been thoroughly analyzed and determined to keep the plant within ALL design limits and specifications. Even if we can technically justify crossing that line, the oversight and review process should be robust enough to ensure that our conclusions are beyond question, and, even then, our analyses must be approved by appropriate regulatory bodies. Any engineer could make a bad decision, hopefully to be identified in review. However, pressures on engineers are no different than those on any other decision maker. In many cases it still comes down to the proficiency, honesty and integrity of the individual. > > Regarding the levy, I could be wrong, but I believe the Corps of Engineers funds their projects. In Alabama, we have many Corps of Engineer dams and I don't think Alabama pays any of the cost associated with them. Some of them have Alabama Power generators installed in them and the power produced creates profit for the utility. I also believe that Alabama Power paid for the right to install those generators in the Corps of Engineers dam (or leases that right). So, if the Corps on Engineers built the levy, maintains the levy, and upgrades the levy on their own dime, they should have taken action if problems were identified. However, if they identified problems and asked Congress for money to address those problems and were denied, then some possible causes should include: 1. Inadequate understanding the magnitude of the risk by the Corps; 2. Inadequate communication between the Corps and Congress for Congress to really understand the risk; 3. Lack of the Corps to persist in identifying the problems to the right people in government; 4. Inability of Congressmen to understand the risk; 5. Budgeting priorities based on political bases rather than risk; 6. Lack of available money to fund the project due to other priorities even if the risk is understood; 7. Political or financial gain for Congressmen to deny funding for the project; > > We would hate to think that some of these causes could actually exist, but I certainly would not rule them out until I had proof. > > Ed Stephenson > Causal Analyst > Farley Nuclear Plant > (334) 814-4587 > > > ____________ _________ _________ __ > From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of Dillard, Tedd A (E S SF RNA FS 11E) > Sent: Thursday, November 19, 2009 11:19 AM > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com > Subject: RE: [Root_Cause_ State_of_ the_Practice] Expensive Failure of Governmental Self-assessment/ Oversight > > > > Jack, > I love you man but I hope Ed's comment about engineers ruling the world was a joke. > The bad things that you point out about politicians are true but they would also be true of engineers if they did rule anything. > The bad things are human things, not related to a title or skill set. > Also your comment about knowing what is the right thing to do can be said for a lot of people in a lot of circumstances. > But determining the right thing can be very difficult and is only the first step to success. > Knowing what to do and getting it done are two very different problems. > Besides how many time have you seen an engineering fix for a problem that caused more different but serious problems. > And, and I think this is particularly true of engineers, just knowing the answer to a question is not the same thing as getting it done. > I believe that because engineers are technically oriented they tend to think that once you have determined the answer to a problem that everyone will agree and implementation is assured. > This is rarely the case. > People have a lot of reasons and forces to do something different than what may be best. > Tedd > ____________ _________ _________ __ > From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of jack.stanford@ ... > Sent: Thursday, November 19, 2009 12:02 PM > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com > Subject: RE: [Root_Cause_ State_of_ the_Practice] Expensive Failure of Governmental Self-assessment/ Oversight > > Hello, Ed, > > If what you said below is true (and it probably is), then the federal government owns a big part of the extent of cause for not helping the state of Louisiana fund the repairs that should have taken place *before* the flooding event in New Orleans took place. The bad condition was diagnosed, but nothing happened to fix it to the best of my knowledge, until after the fact. This is what happens when a city exists which basically belongs under water, absent necessary levy/dam repairs. > > Should engineers rule the world? I think so, as an engineer who is at least average knows what the right thing to do is. I'll bet that this was true in New Orleans years ago. In ASME, a third of the members are licensed as professional engineers, and I have been one of them for 23 years. PEs and most engineers know what the right thing to do is, though politicians do not always do the right thing. That is because they have too many things in their back pockets, like protecting their own states and ignoring the needs of other states. New Orleans is apparently a classic example of this. Why would a northern senator or congressman even care about the risk in New Orleans? They don't, and they won't. > > Jack Stanford, PE > Section Mentor, ASME New Haven, CT Section > Former Chair, Webmaster and Treasurer > StanfordJ@.. .<mailto: StanfordJ@ ...> > > My understanding is that the Corps of Engineers had recognized weaknesses in the New Orleans levy and had been trying to repair/upgrade it for years. However, the US Congress had higher priorities and would not fund the work. If this is correct, what is the extent of cause?...Where will it happen next?...another reason engineers should rule the world? > > Ed Stephenson > Causal Analyst > Farley Nuclear Plant > (334) 814-4587 > > > ____________ _________ _________ __ > 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: Thursday, November 19, 2009 7:31 AM > To: WWWTP_LTBL Katrina > Cc: Root_Cause_State_ of_the_Practice@ yahoogroups. com; LTBL Palo Verde; whistleblower411@ yahoogroups. com > Subject: [Root_Cause_ State_of_ the_Practice] Expensive Failure of Governmental Self-assessment/ Oversight [3 Attachments] > > > > Scroll down for the story after reading this introduction. > > The attached pictures help put this into perspective. > > Many of our government agencies and their contractors resist the need to assess their own performance and try to project a picture of competent infallibility. This culture costs us dearly. > > Systems Engineering tells us that every system is perfectly designed to produce what it has produced. What are the earlier, better, cheaper, safer, more risk-informed, more compliant ways that the factors can be found before the consequences? > > What are the failed barriers here? Do they include the Corps District, the Corps IG, the Army IG, the DOD IG, and the GAO? What others come to mind? > > This incident is just one of may recent occurrences that indicate more Expensive Failures of Governmental Self-assessment/ Oversight. > > Press the Reply button and send us your thoughts. > > Take care, > > Bill Corcoran > Mission: Saving lives, pain, assets, and careers through thoughtful inquiry. > Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency. > > W. R. Corcoran, Ph.D., P.E. > Nuclear Safety Review Concepts Corporation > 21 Broadleaf Circle > Windsor, CT 06095-1634 > 860-285-8779 > > Subscribe to "The Firebird Forum" TheFirebirdForum- subscribe@ yahoogroups. com<mailto:TheFirebirdForum- subscribe@ yahoogroups. com> > Join the group advancing the practice of root cause analysis/ evaluation Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com<mailto:Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com> > > ****Internet Email Confidentiality Footer**** > > Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it. > ____________ _________ _________ __ > http://news. yahoo.com/ s/ap/20091119/ ap_on_re_ us/us_katrina_ flood_lawsuit > ____________ _________ _________ __ > Negligence ruling in Katrina floods may cost feds > By CAIN BURDEAU, Associated Press Writer Cain Burdeau, Associated Press Writer 1 hr 40 mins ago > > NEW ORLEANS - The federal government could be vulnerable to billions of dollars in claims after a judge ruled that the Army Corps of Engineers' failure to properly maintain a navigation channel led to massive flooding in Hurricane Katrina. > > U.S. District Judge Stanwood Duval on Wednesday awarded seven plaintiffs $720,000, but the government could eventually be forced to pay much more. The ruling should give more than 100,000 other individuals, businesses and government entities a better shot at claiming damages. > > Duval sided with six residents and one business who argued the Army Corps' shoddy oversight of the Mississippi River-Gulf Outlet led to the flooding of New Orleans' Lower 9th Ward and neighboring St. Bernard Parish. He said, however, the corps couldn't be held liable for the flooding of eastern New Orleans, where two of the plaintiffs lived. > The ruling is also emotionally resonant for south Louisiana. Many in New Orleans have argued that the flooding in the aftermath of Katrina, which struck the region Aug. 29, 2005, was a manmade disaster caused by the Army Corps' failure to maintain the levee system protecting the city. > > "Total devastation could possibly have been avoided if something had been done," said Tanya Smith, one of the plaintiffs. "A lot of this stuff was preventable and they turned a deaf ear to it." > > The 36-year-old registered nurse anesthetist lived in Chalmette close to the channel when Katrina hit. She was awarded $317,000 in property damages, the most of any of the plaintiffs. > > Duval referred to the corps' approach to maintaining the channel as "monumental negligence." > > Joe Bruno, one of the lead lawyers for the plaintiffs, said the ruling underscored the Army Corps' long history of not properly protecting the New Orleans region. > > "It's high time we look at the way these guys do business and do a full re-evaluation of the way it does business," Bruno said. > > He said he expected the government to appeal. > > The corps referred calls seeking comment to the Justice Department. Spokesman Charles Miller said the government would review the judge's ruling before making any decision on how to proceed. > > During trial testimony, government lawyers and experts argued the levee system was overwhelmed by the massive storm, and levee breaches couldn't solely be blamed on the shipping channel dug in the 1960s as a short-cut between the Gulf of Mexico and New Orleans. > > The corps had also unsuccessfully argued that it is immune from liability because the channel is part of New Orleans' flood control system. > > In his 156-page ruling, Duval said he was "utterly convinced" that the corps' failure to shore up the channel "doomed the channel to grow to two to three times its design width" and that "created a more forceful frontal wave attack on the levee" that protected St. Bernard and the Lower 9th Ward. > > "The Corps had an opportunity to take a myriad of actions to alleviate this deterioration or rehabilitate this deterioration and failed to do so," Duval said. "Clearly the expression 'talk is cheap' applies here." > > Ahead of Duval's ruling, experts had said it would likely have consequences for the way the Army Corps does business nationwide. > > Pierce O'Donnell, another lead plaintiffs lawyer, said the ruling was the "first time ever the Army Corps has been held liable for damages for a major catastrophe that it caused." > The plaintiffs lawyers would like Congress to set up a compensation fund to speed up payments to the thousands of others whose claims must still be heard in court. > > At a one-month trial in May, experts clashed over the causes of flooding and the channel's contribution to it. > > Government experts argued the levees and floodwalls would have failed regardless of whether the channel had been dug. > > By contrast, the plaintiffs' team of experts said the outlet became a "hurricane highway" that funneled storm surge into New Orleans. They said that without the channel, the flooding would have been minimal. > > The lawsuit was the first major case against the federal government over Katrina flooding to go to trial. A decision rested with Duval because a jury cannot try a case against the federal government. >

----- Original Message -----

From: DR WILLIAM CORCORAN

To: Root_Cause_State_of_the_Practice@yahoogroups.com

Sent: Saturday, November 21, 2009 1:56 AM

Subject: Re: [Root_Cause_State_of_the_Practice] Re: Expensive Failure of Governmental Self-assessment/ Oversight

 

Change "promotes" to "tolerates and facilitates."   Here's the revised statement:   "I thought I was starting a serious discussion of how our government wastes our money and tolerates and facilitates slaughter and mayhem by ineffective self-assessment. "   Here's my kick-off recommendation:   NRC and OSHA should have formal Corrective Action Programs (CAPs) to identify and fix their own problems and these CAPs should be similar to the best ones at nuclear power plants. Take care,   Bill Corcoran Mission: Saving lives, pain, assets, and careers through thoughtful inquiry. Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.   W. R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation 21 Broadleaf Circle Windsor, CT 06095-1634 860-285-8779   Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com Join the group advancing the practice of root cause analysis/ evaluation  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com   ****Internet Email Confidentiality Footer****   Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it. --- On Fri, 11/20/09, Mike <mpeckham@rogers.com> wrote: From: Mike <mpeckham@rogers.com> Subject: Re: [Root_Cause_State_of_the_Practice] Re: Expensive Failure of Governmental Self-assessment/ Oversight To: Root_Cause_State_of_the_Practice@yahoogroups.com Date: Friday, November 20, 2009, 6:28 PM    Bill C.   Take a look at your words....   "promotes slaughter and mayhem by ineffective self-assessment"   You really believe that our goverment "promotes... .."?   If you want a serious discussion than perhaps some serious and thoughtful statements are in order.   Regards   Mike     ----- Original Message ----- From: jack.stanford@ att.net To: Root_Cause_State_ of_the_Practice@ yahoogroups. com Sent: Friday, November 20, 2009 3:40 PM Subject: RE: [Root_Cause_ State_of_ the_Practice] Re: Expensive Failure of Governmental Self-assessment/ Oversight Dr. Bill,   I found Bill Rigot's correction of my spelling error to be necessary and a good move on his part.  I also do not find your websites to be frivolous and find the philosophical chat to be just fine and useful.  That is just where I stand today.  It does not appear to me that we agree on this.   TTFN, regards,   Jack Stanford, PE StanfordJ@ASME. org   ------------ -- Original message from DR WILLIAM CORCORAN <William.R.Corcoran@ 1959.USNA. com>: ------------ --   I thought I was starting a serious discussion of how our government wastes our money and promotes slaughter and mayhem by ineffective self-assessment.   Silly me.   It turned out to be a great thread on philosophy, spelling and frivolity.   Can you see your way through to turning it around?   Or would you like to contribute more philosophy, spelling and frivolity? Take care,   Bill Corcoran Mission: Saving lives, pain, assets, and careers through thoughtful inquiry. Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.   W. R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation 21 Broadleaf Circle Windsor, CT 06095-1634 860-285-8779   Subscribe to "The Firebird Forum"  TheFirebirdForum- subscribe@ yahoogroups. com Join the group advancing the practice of root cause analysis/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com   ****Internet Email Confidentiality Footer****   Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it. --- On Fri, 11/20/09, Dillard, Tedd A (E S SF RNA FS 11E) <tedd.dillard@ siemens.com> wrote: From: Dillard, Tedd A (E S SF RNA FS 11E) <tedd.dillard@ siemens.com> Subject: RE: [Root_Cause_ State_of_ the_Practice] Re: Expensive Failure of Governmental Self-assessment/ Oversight To: Root_Cause_State_ of_the_Practice@ yahoogroups. com Date: Friday, November 20, 2009, 9:27 AM   Or denim pants. From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of Stephenson, Edwin L., Jr. Sent: Friday, November 20, 2009 8:30 AM To: 'Root_Cause_ State_of_ the_Practice@ yahoogroups. com' Subject: RE: [Root_Cause_ State_of_ the_Practice] Re: Expensive Failure of Governmental Self-assessment/ Oversight   I thought it had something to do with the tribes of Israel.   Ed Stephenson Causal Analyst Farley Nuclear Plant (334) 814-4587   From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of jack.stanford@ att.net Sent: Thursday, November 19, 2009 5:41 PM To: Root_Cause_State_ of_the_Practice@ yahoogroups. com Subject: Re: [Root_Cause_ State_of_ the_Practice] Re: Expensive Failure of Governmental Self-assessment/ Oversight Sorry for the misspellings of levee.  At least I was not aware of the correct spelling...    Jack Stanford, PE   ------------ -- Original message from "BILL" <william.rigot@ srs.gov>: ------------ --   Ed/Jack, A couple of points. First, it's levee, not levy. One's a bank, the other's a tax. Secondly (and more seriously), a good read on this subject of how engineer's manage all the cost-benefit trade-offs in their work is captured in Erik Hollnagel's latest book, The ETTO Principle: Efficiency-Thorough ness Trade-Off (Why Things That Go Right Sometimes Go Wrong). He demonstrates how all the decisions we make are driven by this principle. Additonally he points out where causal analysis in tightly coupled, intractible systems can often focus on the wrong things. For those of us who get pretty judgemental about how worthwhile our RCA's are, this book will certainly challenge our paradigms. Bill Rigot --- In Root_Cause_State_ of_the_Practice@ yahoogroups. com, "Stephenson, Edwin L., Jr." <ELSTEPHE@.. .> wrote: > > Yeah, the statement about engineers ruling was a joke. As engineers, we are not exempt from making decisions based upon cost as well as risk. If we could do everything that results in improvement, regardless of cost, we would would approach technical perfection without possibility of profit. In the nuclear industry, however, we must always err on the side of safety (and sometimes reliability) and never take any action that could place our facility in any condition or configuration that has not been thoroughly analyzed and determined to keep the plant within ALL design limits and specifications. Even if we can technically justify crossing that line, the oversight and review process should be robust enough to ensure that our conclusions are beyond question, and, even then, our analyses must be approved by appropriate regulatory bodies. Any engineer could make a bad decision, hopefully to be identified in review. However, pressures on engineers are no different than those on any other decision maker. In many cases it still comes down to the proficiency, honesty and integrity of the individual. > > Regarding the levy, I could be wrong, but I believe the Corps of Engineers funds their projects. In Alabama, we have many Corps of Engineer dams and I don't think Alabama pays any of the cost associated with them. Some of them have Alabama Power generators installed in them and the power produced creates profit for the utility. I also believe that Alabama Power paid for the right to install those generators in the Corps of Engineers dam (or leases that right). So, if the Corps on Engineers built the levy, maintains the levy, and upgrades the levy on their own dime, they should have taken action if problems were identified. However, if they identified problems and asked Congress for money to address those problems and were denied, then some possible causes should include: 1. Inadequate understanding the magnitude of the risk by the Corps; 2. Inadequate communication between the Corps and Congress for Congress to really understand the risk; 3. Lack of the Corps to persist in identifying the problems to the right people in government; 4. Inability of Congressmen to understand the risk; 5. Budgeting priorities based on political bases rather than risk; 6. Lack of available money to fund the project due to other priorities even if the risk is understood; 7. Political or financial gain for Congressmen to deny funding for the project; > > We would hate to think that some of these causes could actually exist, but I certainly would not rule them out until I had proof. > > Ed Stephenson > Causal Analyst > Farley Nuclear Plant > (334) 814-4587 > > > ____________ _________ _________ __ > From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of Dillard, Tedd A (E S SF RNA FS 11E) > Sent: Thursday, November 19, 2009 11:19 AM > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com > Subject: RE: [Root_Cause_ State_of_ the_Practice] Expensive Failure of Governmental Self-assessment/ Oversight > > > > Jack, > I love you man but I hope Ed's comment about engineers ruling the world was a joke. > The bad things that you point out about politicians are true but they would also be true of engineers if they did rule anything. > The bad things are human things, not related to a title or skill set. > Also your comment about knowing what is the right thing to do can be said for a lot of people in a lot of circumstances. > But determining the right thing can be very difficult and is only the first step to success. > Knowing what to do and getting it done are two very different problems. > Besides how many time have you seen an engineering fix for a problem that caused more different but serious problems. > And, and I think this is particularly true of engineers, just knowing the answer to a question is not the same thing as getting it done. > I believe that because engineers are technically oriented they tend to think that once you have determined the answer to a problem that everyone will agree and implementation is assured. > This is rarely the case. > People have a lot of reasons and forces to do something different than what may be best. > Tedd > ____________ _________ _________ __ > From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of jack.stanford@ ... > Sent: Thursday, November 19, 2009 12:02 PM > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com > Subject: RE: [Root_Cause_ State_of_ the_Practice] Expensive Failure of Governmental Self-assessment/ Oversight > > Hello, Ed, > > If what you said below is true (and it probably is), then the federal government owns a big part of the extent of cause for not helping the state of Louisiana fund the repairs that should have taken place *before* the flooding event in New Orleans took place. The bad condition was diagnosed, but nothing happened to fix it to the best of my knowledge, until after the fact. This is what happens when a city exists which basically belongs under water, absent necessary levy/dam repairs. > > Should engineers rule the world? I think so, as an engineer who is at least average knows what the right thing to do is. I'll bet that this was true in New Orleans years ago. In ASME, a third of the members are licensed as professional engineers, and I have been one of them for 23 years. PEs and most engineers know what the right thing to do is, though politicians do not always do the right thing. That is because they have too many things in their back pockets, like protecting their own states and ignoring the needs of other states. New Orleans is apparently a classic example of this. Why would a northern senator or congressman even care about the risk in New Orleans? They don't, and they won't. > > Jack Stanford, PE > Section Mentor, ASME New Haven, CT Section > Former Chair, Webmaster and Treasurer > StanfordJ@.. .<mailto: StanfordJ@ ...> > > My understanding is that the Corps of Engineers had recognized weaknesses in the New Orleans levy and had been trying to repair/upgrade it for years. However, the US Congress had higher priorities and would not fund the work. If this is correct, what is the extent of cause?...Where will it happen next?...another reason engineers should rule the world? > > Ed Stephenson > Causal Analyst > Farley Nuclear Plant > (334) 814-4587 > > > ____________ _________ _________ __ > 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: Thursday, November 19, 2009 7:31 AM > To: WWWTP_LTBL Katrina > Cc: Root_Cause_State_ of_the_Practice@ yahoogroups. com; LTBL Palo Verde; whistleblower411@ yahoogroups. com > Subject: [Root_Cause_ State_of_ the_Practice] Expensive Failure of Governmental Self-assessment/ Oversight [3 Attachments] > > > > Scroll down for the story after reading this introduction. > > The attached pictures help put this into perspective. > > Many of our government agencies and their contractors resist the need to assess their own performance and try to project a picture of competent infallibility. This culture costs us dearly. > > Systems Engineering tells us that every system is perfectly designed to produce what it has produced. What are the earlier, better, cheaper, safer, more risk-informed, more compliant ways that the factors can be found before the consequences? > > What are the failed barriers here? Do they include the Corps District, the Corps IG, the Army IG, the DOD IG, and the GAO? What others come to mind? > > This incident is just one of may recent occurrences that indicate more Expensive Failures of Governmental Self-assessment/ Oversight. > > Press the Reply button and send us your thoughts. > > Take care, > > Bill Corcoran > Mission: Saving lives, pain, assets, and careers through thoughtful inquiry. > Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency. > > W. R. Corcoran, Ph.D., P.E. > Nuclear Safety Review Concepts Corporation > 21 Broadleaf Circle > Windsor, CT 06095-1634 > 860-285-8779 > > Subscribe to "The Firebird Forum" TheFirebirdForum- subscribe@ yahoogroups. com<mailto:TheFirebirdForum- subscribe@ yahoogroups. com> > Join the group advancing the practice of root cause analysis/ evaluation Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com<mailto:Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com> > > ****Internet Email Confidentiality Footer**** > > Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it. > ____________ _________ _________ __ > http://news. yahoo.com/ s/ap/20091119/ ap_on_re_ us/us_katrina_ flood_lawsuit > ____________ _________ _________ __ > Negligence ruling in Katrina floods may cost feds > By CAIN BURDEAU, Associated Press Writer Cain Burdeau, Associated Press Writer 1 hr 40 mins ago > > NEW ORLEANS - The federal government could be vulnerable to billions of dollars in claims after a judge ruled that the Army Corps of Engineers' failure to properly maintain a navigation channel led to massive flooding in Hurricane Katrina. > > U.S. District Judge Stanwood Duval on Wednesday awarded seven plaintiffs $720,000, but the government could eventually be forced to pay much more. The ruling should give more than 100,000 other individuals, businesses and government entities a better shot at claiming damages. > > Duval sided with six residents and one business who argued the Army Corps' shoddy oversight of the Mississippi River-Gulf Outlet led to the flooding of New Orleans' Lower 9th Ward and neighboring St. Bernard Parish. He said, however, the corps couldn't be held liable for the flooding of eastern New Orleans, where two of the plaintiffs lived. > The ruling is also emotionally resonant for south Louisiana. Many in New Orleans have argued that the flooding in the aftermath of Katrina, which struck the region Aug. 29, 2005, was a manmade disaster caused by the Army Corps' failure to maintain the levee system protecting the city. > > "Total devastation could possibly have been avoided if something had been done," said Tanya Smith, one of the plaintiffs. "A lot of this stuff was preventable and they turned a deaf ear to it." > > The 36-year-old registered nurse anesthetist lived in Chalmette close to the channel when Katrina hit. She was awarded $317,000 in property damages, the most of any of the plaintiffs. > > Duval referred to the corps' approach to maintaining the channel as "monumental negligence." > > Joe Bruno, one of the lead lawyers for the plaintiffs, said the ruling underscored the Army Corps' long history of not properly protecting the New Orleans region. > > "It's high time we look at the way these guys do business and do a full re-evaluation of the way it does business," Bruno said. > > He said he expected the government to appeal. > > The corps referred calls seeking comment to the Justice Department. Spokesman Charles Miller said the government would review the judge's ruling before making any decision on how to proceed. > > During trial testimony, government lawyers and experts argued the levee system was overwhelmed by the massive storm, and levee breaches couldn't solely be blamed on the shipping channel dug in the 1960s as a short-cut between the Gulf of Mexico and New Orleans. > > The corps had also unsuccessfully argued that it is immune from liability because the channel is part of New Orleans' flood control system. > > In his 156-page ruling, Duval said he was "utterly convinced" that the corps' failure to shore up the channel "doomed the channel to grow to two to three times its design width" and that "created a more forceful frontal wave attack on the levee" that protected St. Bernard and the Lower 9th Ward. > > "The Corps had an opportunity to take a myriad of actions to alleviate this deterioration or rehabilitate this deterioration and failed to do so," Duval said. "Clearly the expression 'talk is cheap' applies here." > > Ahead of Duval's ruling, experts had said it would likely have consequences for the way the Army Corps does business nationwide. > > Pierce O'Donnell, another lead plaintiffs lawyer, said the ruling was the "first time ever the Army Corps has been held liable for damages for a major catastrophe that it caused." > The plaintiffs lawyers would like Congress to set up a compensation fund to speed up payments to the thousands of others whose claims must still be heard in court. > > At a one-month trial in May, experts clashed over the causes of flooding and the channel's contribution to it. > > Government experts argued the levees and floodwalls would have failed regardless of whether the channel had been dug. > > By contrast, the plaintiffs' team of experts said the outlet became a "hurricane highway" that funneled storm surge into New Orleans. They said that without the channel, the flooding would have been minimal. > > The lawsuit was the first major case against the federal government over Katrina flooding to go to trial. A decision rested with Duval because a jury cannot try a case against the federal government. >

Thanks 1.0E+6 to Ira Rimson. Take care, Bill Corcoran Mission: Saving lives, pain, assets, and careers through thoughtful inquiry. Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency. W. R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation 21 Broadleaf Circle Windsor, CT 06095-1634 860-285-8779   Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com Join the group advancing the practice of root cause analysis/ evaluation  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com   ****Internet Email Confidentiality Footer****   Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it. --- On Tue, 11/17/09, Ira Rimson <irimson02@...> wrote: From: Ira Rimson <irimson02@...> Subject: Fw: Made in China! To: "Ericson, Clifton" <cliftonericson@...>, BATTERMAN@..., "Benner, Ludi" <lbjrus@...>, "Corcoran, Bill" <William.R.Corcoran@...>, "Corrie, Steve" <ravensworth@...>, "Dorsett, Robert" <rdd@...>, "Eakin, John" <jeakin@...>, "Evans, David" <de@...>, "Francis, Bob" <bfrancis11@...>, "Goldman, David" <goldmand@...>, "Marvin, Dick" <richard.marvin@...>, "McDowell, Jean" <j.mcdowell@...>, "Negroni, Christine" <christine.negroni@...>, "Newman, Dick" <dicknewman@...>, "Dan Poynter" <DanPoynter@...>, "Raefsky, Manny" <manrraef@...>, "Ste! wart, Jim" <stewji@...>, "Wood, Richard" <woodrh@...> Date: Tuesday, November 17, 2009, 5:35 PM Here's one for the System Safety Eff-Up File:     ----- Original Message ----- Sent: Tuesday, November 17, 2009 3:11 PM Subject: Fwd: Made in China!       Made in China! YES, IT IS A 12 STORY BUILDING IN CHINA. LYING ON THE GROUND.     (1) An underground garage was being dug on the south side, to a depth of 4.6 meters. (2) The excavated dirt was being piled up on the north side, to a height of 10 meters. (3) The building experienced uneven lateral pressure from south and north. (4) This resulted in a lateral pressure of 3,000 tonnes, which was greater than what the pilings could tolerate. Thus the building toppled over in the southerly direction.   First, the apartment building was constructed.   Then the plan called for an underground garage to be dug out. The excavated soil was piled up on the other side of the building.   Heavy rains resulted in water seeping into the ground.   The building began to shift and the hollow concrete pilings were snapped due to the uneven lateral pressures. The building began to tilt.   And thus was born the eighth wonder of the world.       If the buildings were closer together there would also have been a domino effect.               ZE="83936" ID="15" SRC="aoladp://MA24471058-0082/image017.jpg">

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-------------- Original message from bruce.hart@...: --------------

 

Bill,
Is there a way to copy the attachments to my hard drive so that I don't have to keep going back to the email or establish internet connectivity to Yahoo?
I have tried copying into power point and word without success.
Thanks,
B.

DR WILLIAM CORCORAN <William.R.Corcoran@1959.USNA.com> Sent by: Root_Cause_State_of_the_Practice@yahoogroups.com 11/18/2009 08:19 AM Please respond to Root_Cause_State_of_the_Practice@yahoogroups.com

To Root_Cause_State_of_the_Practice@yahoogroups.com cc Subject [Root_Cause_State_of_the_Practice] It is not enough for engineers to know how to work the thing; they must know how the thing works. [15 Attachments]

 
[Attachment(s) from DR WILLIAM CORCORAN included below]

Thanks 1.0E+6 to Ira Rimson. Take care, Bill Corcoran Mission: Saving lives, pain, assets, and careers through thoughtful inquiry. Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency. W. R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts Corporation 21 Broadleaf Circle Windsor, CT 06095-1634 860-285-8779 Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com Join the group advancing the practice of root cause analysis/ evaluation  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com   ****Internet Email Confidentiality Footer****   Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it. --- On Tue, 11/17/09, Ira Rimson <irimson02@comcast.net> wrote: From: Ira Rimson <irimson02@comcast.net> Subject: Fw: Made in China! To: "Ericson, Clifton" <cliftonericson@verizon.net>, BATTERMAN@aol.com, "Benner, Ludi" <lbjrus@gmail.com>, "Corcoran, Bill" <William.R.Corcoran@1959.USNA.com>, "Corrie, Steve" <ravensworth@cox.net>, "Dorsett, Robert" <rdd@dorsett.us>, "Eakin, John" <jeakin@airsafety.com>, "Evans, David" <de@nolan-law.com>, "Francis, Bob" <bfrancis11@comcast.net>, "Goldman, David" <goldmand@mindspring.com>, "Marvin, Dick" <richard.marvin@prccal.com>, "McDowell, Jean" <j.mcdowell@mcdowellowens.com>, "Negroni, Christine" <christine.negroni@gmail.com>, "Newman, Dick" <dicknewman@Xsetp.org>, "Dan Poynter" <DanPoynter@ParaPublishing.com>, "Raefsky, Manny" <manrraef@cox.net>, "Ste! wart, Jim" <stewji@rogers.com>, "Wood, Richard" <woodrh@....com> Date: Tuesday, November 17, 2009, 5:35 PM Here's one for the System Safety Eff-Up File:     ----- Original Message ----- Sent: Tuesday, November 17, 2009 3:11 PM Subject: Fwd: Made in China!       Made in China! YES, IT IS A 12 STORY BUILDING IN CHINA. LYING ON THE GROUND.     (1) An underground garage was being dug on the south side, to a depth of 4.6 meters. (2) The excavated dirt was being piled up on the north side, to a height of 10 meters. (3) The building experienced uneven lateral pressure from south and north. (4) This resulted in a lateral pressure of 3,000 tonnes, which was greater than what the pilings could tolerate. Thus the building toppled over in the southerly direction.   First, the apartment building was constructed.   Then the plan called for an underground garage to be dug out. The excavated soil was piled up on the other side of the building.   Heavy rains resulted in water seeping into the ground.   The building began to shift and the hollow concrete pilings were snapped due to the uneven lateral pressures. The building began to tilt.   And thus was born the eighth wonder of the world.       If the buildings were closer together there would also have been a domino effect.               ZE="83936" ID="15" SRC="aoladp://MA24471058-0082/image017.jpg">

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