"There are no new accidents-only new people having the same old accidents." Ken Phillips Search and Rescue Coordinator Grand Canyon National Park, Arizona Best...
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Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 5, 2002 9:38 pm
Compile all the costs associated with accidents and near-misses and display them for employees and managers. Best Regards, Bill Corcoran W. R. Corcoran, Ph.D.,...
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Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 6, 2002 12:08 pm
Colleagues, I was reminded by a web service that on this date in 1987, the British car ferry "The Herald of Free Enterprise" capsized off Zeebrugge, Belgium,...
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kimwilliamsrootcause
kimwilliamsr...
Mar 6, 2002 1:53 pm
Now I'm frustrated with this site. Why is no one "talking"? It shows 19 members and all the posts I see are items moved from another group because they're...
138
Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 6, 2002 6:05 pm
Bill W., I'm with you. Five years ago I used to recommend the E&CF Chart. I stopped recommending it for many of the same reasons you cited, plus I got tired of...
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Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 6, 2002 6:32 pm
Kim, I empathize with you. Last summer I was asked to help an organization with applying RCA to environmental problems. As part of that effort I asked to...
140
Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 6, 2002 11:18 pm
Jim, This is a classic mix-up. The symptoms of a leak were mixed up with the symptoms of an imbalance. Mix-ups can be done without computers. Some years ago a...
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Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 7, 2002 12:47 am
Mike, Mix-ups are difficult to deal with. This is partly because organizations don't want to admit vulnerability. If I'm not clear enough give me a call on...
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Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 8, 2002 5:26 pm
Bill W., I looked at your mindmap of the ski accident. It's got all the right stuff. Can you change the display configuration? (I'm serious) Why do you think...
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Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 8, 2002 9:18 pm
Bill W., Your Why Staircase Tree on the ski accident done with MindManager looks a lot better than the one done with MindMap. I wonder if anyone out there has...
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Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 9, 2002 2:51 pm
Bob Nelms, I love Bill Salot's idea. I think the first step is to dialogue on the taxonomy of the Root Cause State-of-the-Practice. Bill S. gave one version,...
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Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 9, 2002 4:02 pm
Paul, Thanks. I, too, am using VISIO to make a Why Staircase Tree of the ski strangulation. I am using the Organization Chart Wizard, which , in turn uses an...
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Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 10, 2002 1:32 pm
Bob, My long term goal/wish is for private sector and government to do better (much, much better) at learning from adverse experience. This will greatly reduce...
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Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 10, 2002 5:38 pm
Bob, I do the Why Staircase Trees on a white board, photograph them and either paste them into the RCAR and RCASS (RCA Slideshow) or process the information...
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Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 10, 2002 5:43 pm
Bob, I also do the Missed Opportunity Matrices (MOM's) on a white board, photograph them and either paste them into the RCAR and RCASS (RCA Slideshow) or...
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Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 11, 2002 11:03 am
Bob, I have also photographed easel pads (flip charts), but with less success, for the reasons you mentioned. White board "art" can be refined as it is...
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jim gallman
jgallma1
Mar 11, 2002 2:16 pm
With regards to the question of which tool to use for a RCA. I find the question breaks down to a better focus on what you are trying to accomplish. In terms...
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Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 11, 2002 4:08 pm
Bill S., Thanks for the question. In some organizations they use root cause analysis on non-lost-time injuries and on other low consequence issues that are...
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Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 12, 2002 12:13 pm
Jim, Thanks for the fascinating post. The consequences of the incident were mild, but the significance was high. I hope that authorities assigned resources...
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Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 12, 2002 2:53 pm
Mark, Good points. It is a good idea to ask oneself what the operator can possibly know before writing the alarm response procedure. I'm going to post part of...
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Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 13, 2002 11:51 am
Larry, The zoom is in the camera. It is a two-year old Canon Cyber-shot Digital Still Camera DSC--S70. It downloads via a USB connection. Yep, the flash was...
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Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 13, 2002 4:24 pm
Greg, You are beginning to sound like Peter Senge. That's good. (He wrote an interesting book called "The Fifth Discipline".) After achieving a common current...
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Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 13, 2002 7:28 pm
Bill W. Thinking about teams differing provokes some thinking. What could they disagree on? Consequences (actual): This can be checked out. Consequences...
167
Duffy, Greg
duffy4rca
Mar 14, 2002 1:46 pm
Bill, I recently taught an RCA course for an outside-nuclear indusrty and as part of the course I make members do exercises as teams. In this last course, one...
168
Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 14, 2002 3:32 pm
Greg, Have you tried investigating the consequences, not the event? It brings different weaknesses to light. Try it. You'll like it. Best Regards, Bill...
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Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 14, 2002 3:37 pm
Larry, Thanks for the nice words. Those questions are the heart of "The Phoenix Approach". They are in three categories: 1. Impact: Consequences and...
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Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 14, 2002 5:40 pm
Bill S., File it under "Painting Bull's-eyes Around Bullet Holes", which is one of my favorite hobbies. :<) Best Regards, Bill Corcoran W. R. Corcoran, Ph.D.,...
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Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 14, 2002 6:32 pm
Larry, May I offer a crucial quibble? ____________________________________________________________________________ __ You said : " Assertion: If the cause (of...
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Duffy, Greg
duffy4rca
Mar 14, 2002 7:24 pm
Please provide additional information. The event was the approval and distribution of a procedure that had a technical error. The consequences were the need...
173
Dr. Bill Corcoran at ...
Phoenix_Fire...
Mar 14, 2002 7:50 pm
Larry, You said: "You may want to do a RCA on this problem; i.e. "Many of the RCAs that come to the review committee are poor quality." And then put in place ...
