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

From: bobnelms

To: rootcauseconference@yahoogroups.com

Sent: Sunday, January 27, 2002 7:24 PM

Subject: RE: [rootcauseconference] Hostile Witness - Epilogue

Bill S:

 

I’ll be out of touch for a few days, so I thought I’d respond before I leave – just briefly.  Bill, as far as I’m concerned, the bottom line to all this is trust.  I suppose we all gain the trust of our fellow human beings in our own personal ways.  For some reason, people open-up to me and tell me things that they wouldn’t usually tell others.  I’ve learned how to listen – truly listen.  People “pick up” on when a person is merely doing their job (filling in a blank form), or when a person is sincerely listening and really trying to understand.  BTW, it’s very difficult to really listen to someone and engage in a deep dialogue when it’s anything but one on one.  Three on one feels like a firing squad to most people – almost the opposite to what’s needed for most people to open-up and really share.

 

It’s really kind of easy for me (and really for all of us).  When we’re talking to a fellow human being, all we need to do is treat him/her as we’d want to be treated – “do unto others as you’d have them do unto you” is the way I’ve been hearing it for most of my life.  When an RCA feels like a criminal inquisition, I know how I’d feel if I were one of the interviewees.  That’s really all there is to it.

 

Oh, on the question of “facts.”  Anything anyone tells me is told to me for a reason – that’s how I see it.  If a person tells me he’s got too much to do, why would he tell me that unless he thought he had too much to do?  If he is intentionally lying to me, well I’ll find that out also if I interview enough people.  Then I’ll want to know why people feel they must lie at his place.  When I interview someone, aside from a very HUMAN being, I know I’m interviewing a “sponge” of sorts.  We humans absorb things – perceptions, signals, training, gees – all kinds of things.  When something goes wrong, I want to know what’s been absorbed.  Whether someone signs his name on a piece of paper or not – I really want to know how they FEEL about things (as well as what sensory evidence they’ve absorbed) – feelings are all based on prior signals and circumstances that people have absorbed.  In other words Bill, as I see it, EVERYTHING a person says is “facts.”  Or NOTHING a person say is facts.  Because either one or the other must be true, I choose to treat what people tell me in the former way.

 

I feel like you’re going down the wrong path on this one, friend.  Big time.

 

Bob Nelms

 

Helping You Learn from Things that Go Wrong

Without Hurting People in the Process

 

e-mail: bobnelms@...

web site:www.failsafe-network.com

 

-----Original Message-----
From: sentto-2441878-2343-1012085827-bobnelms=compuserve.com@... [mailto:sentto-2441878-2343-1012085827-bobnelms=compuserve.com@...]On Behalf Of wjsalot
Sent: Saturday, January 26, 2002 5:37 PM
To: rootcauseconference@yahoogroups.com
Subject: Re: [rootcauseconference] Hostile Witness - Epilogue

 

Bob,

 

You said, " It’s always been understood in all the investigations I’ve ever been involved with that the NAME of the interviewee is never attached to the information he’s yielded".

 

I have got to comment on that because we do the opposite!

 

Our reasoning is that our investigations, insofar as possible, must be based on documentable facts.  Frequently, some of the evidence comes solely from interviews.  We document those interviews by having each interviewee review the transcript, correct any errors, and SIGN it.

 

We realize this does not ASSURE that the transcripts are factual, but it does minimize distortions and add credibility.  Anonymity does the opposite.

 

We disagree with the assumption that this approach will cause facts to be withheld.  If an interviewee wants to hide something, he/she will try to do so under any circumstance, and anonymous interviews will facilitate it!  On the other hand, if the interviewees are treated as sole sources of key information, it gives them official credit for their input.  It also prevents the investigators from editorializing interviewee statements.

 

For similar reasons, we do not encourage one-on-one interviews.  Instead we try to have the entire investigating team present during interviews.  This is usually practical because our investigating teams seldom have more than 3 to 5 members.

 

Bob, the primary issue between our polar opposite approaches lies in the identification of what you call "latent" causes.  If we are bent on finding such causes by having folks "get things off their chest", we can always do that "off the record" under EITHER approach.  But we must remember the "things" we are told "off the record" are personal opinions that are seldom, if ever, SPECIFIC to the incident being investigated.  If those "things" include a "cancer", that "cancer" must be substantiated and, at some point, put "on the record" before the management or client is likely to take any action.  If it is a "cancer", the interviewee should WANT it "on the record".

 

As you say, "Watch out for breaches in confidence".  I would add, "Beware of anonymous sources".

 

Something tells me we will be choosing up sides on this one.

 

Bill Salot INTP 72    

 

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

From:

bobnelms

To: rootcauseconference@yahoogroups.com

Sent: Thursday, January 17, 2002 5:49 PM

Subject: RE: [rootcauseconference] Hostile Witness - Epilogue

 

Bernie, Bill C, and all:

 

Interesting comments about confidentiality.  This is how I see it – It’s always been understood in all the investigations I’ve ever been involved with that the NAME of the interviewee is never attached to the information he’s yielded.  We usually try not to make a big deal about it by talking about it or by stating it as policy unless it becomes necessary.

 

But, for example, when we’re doing our evidence reviews the “people evidence” gatherer presents his findings WITHOUT saying “who said what.”

 

This might not be too important when you’re talking about PHYSICAL causes, but it becomes extremely important when it comes to discussing LATENT causes.  I agree with Bill C that people LOVE to get things off their chest.  But if they picture all they say being stated in front of a team WITH THEIR NAMES ATTACHED, well just put yourself in their shoes – they clam up.

 

Getting to Bernies specific question, I do think it’s a breach of confidence to go the witnesses supervisor with anything connected to the interview process.  You do that one time, and the word will get out, and that’ll be the end of the trust you’ll have, both as a person and as an investigative process.  I know of more than one person with reputations for doing just this  -- that have happened 10 or more years ago, where the person still is not trusted AND the investigative process is held in suspicion.

 

Watch out for breaches in confidence.  Their confidence in you might be your most important investigative asset.

 

Bob Nelms

 

Root Cause LIVE

www.rootcauselive.com

bobnelms@...

 

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

From: wjsalot

To: rootcauseconference@yahoogroups.com

Sent: Saturday, January 26, 2002 9:51 PM

Subject: Re: [rootcauseconference] Help Sought

Bill C.,

 

You said: "Several people I talked with on the issue of leading safety indicators said that they used first aid cases as a leading indicator of OSHA Recordables, but had no feel for the correlation. One manager said that he was skeptical about first aid cases because an unknown fraction of his workers would self-treat or no-treat and would not report the first aid case if it was likely that it could be glossed over."

 

Bill C., I asked a Safety Engineer at my plant site for statistics that might confirm or refute whether first aid cases are leading indicators of OSHA Recordables.

 

The first cut was as follows:

 

 Period          1st Aid            OSHA

1991-92        Decrease        Decrease                                  

1992-93        Decrease        Decrease

1993-94        Decrease        Decrease

1994-95        Decrease        Decrease

1995-96         Increase         Increase       

1996-97        Decrease        Decrease

1997-98         Increase         Increase

1998-99        DECREASE    INCREASE

1999-00        Decrease        Decrease

2000-01        Decrease        Decrease

 

On an ANNUAL basis, the two data sets generally (9 out 0f 10 times) moved in tandem, neither leading the other.

 

The second cut was as follows:

 

  2001            1st Aid            OSHA

Jan-Feb        Decrease         Increase       

Feb-Mar        Increase         Decrease

Mar-Apr        Decrease         Increase

Apr-May       Increase           Increase

May-Jun       Decrease         Decrease

Jun-July         Increase        No Change

July-Aug        Increase         Increase

Aug-Sep       Decrease        Decrease

Sep-Oct        Decrease        Increase

Oct-Nov        Decrease        Decrease

Nov-Dec         Increase        Decrease

 

On a MONTHLY basis, for the year 2001 only, the first aid cases led the OSHAs:

- by 0 months 4 out of a possible 11 times,

- by 1 month 5 out of a possible 10 times,

- by 2 months 5 out of a possible 9 times,

- by 3 months 4 out of a possible 8 times,

- by 4 months 1 out of a possible 7 times,

- by 5 months 4 out of a possible 6 times,

- by 6 months 1 out of a possible 5 times,

- by 7 months 3 out of a possible 4 times,

- by 8 months 1 out of a possible 3 times,

- by 9 months 1 out of a possible 2 times,

- by 10 months 1 out of a possible 1 time.

 

I don't see any reasonable leading indicator correlation in the above monthly data , nor in similar comparisons of bimonthly data, nor in similar comparisons of quarterly data.  I am satisfied that digging out more data is not justified, and that first aid cases are NOT leading indicators of OSHA recordables.

 

Now I am wondering why we should keep track of first aid cases at all.  Help!

 

Bill Salot INTP 72 

 

 

 ----- Original Message -----

From: Dr. Bill Corcoran at NSRC

To: rootcauseconference@yahoogroups.com

Sent: Sunday, January 13, 2002 4:31 AM

Subject: Re: [rootcauseconference] Help Sought

Bill S.

 

The concept of a "minor near miss" is fascinating. How does one distinguish between a minor near miss and , e.g., a major near miss?

 

In the finance industry some of the leading indicators of economic activity are new building permits, new mortgage applications, births, and the like. They are of the nature of "pipeline readings", i.e., something happening now implies that something else will happen later. E.g., if a baby is born today all goods and services to support the baby will be purchased later at predictable stages.

 

Several people I talked with on the issue of leading safety indicators said that they used first aid cases as a leading indicator of OSHA Recordables, but had no feel for the correlation. One manager said that he was skeptical about first aid cases because an unknown fraction of his workers would self-treat or no-treat and would not report the first aid case if it was likely that it could be glossed over.

 

Other correspondents said that they used safety activity as indicators, but uniformly did not think that safety activity was a legitimate leading indicator. Safety activity is safety meetings, tailboards, safety audits, safety hazard reports, safety fairs, and the like.

 

One would like to have a leading indicator that would tell us that safety performance is deteriorating before the injury rate is beyond the goal so that corrective actions could be taken to head off the problem.

 

Any further thoughts would be appreciated.

 

 

Best Regards,

 

Bill Corcoran

 

W. R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
Mission: Saving lives, pain,assets, and careers through thoughtful inquiry.

 

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

From: Paul Preuss

To: rootcauseconference@yahoogroups.com

Sent: Saturday, January 26, 2002 10:23 AM

Subject: Re: [rootcauseconference] Definition of Root Cause

Bill - Thanks for taking the time to respond to my inquiry and "root cause" vs. casual inquiry.  It is helpful.

I have delayed my response because of other pressing matters and the need to reflect on what you wrote.

I really am not trying to get too complex - but am partially hung up on the idea that we have used the term "root cause"

in New York state educational planning and see it as confusing to broaden the terminology.  I think it simpler to

broaden the concept - as you have done in your posting. 

 

I wonder if there ever was (or is) a pure "root cause".   In the sinking of a boat - the captain radioed for help

but the lone coastguardsman on duty was away from the radio getting coffee and thought the call was just a

radio check.  The bodies were found the next day.  In checking the radio tape the call for help was found.  The

coastguardsman's lack of response was the initial cause focused upon.  But later details revealed that that shift

was a 12 hour solo shift - no breaks and no backup.  A momentary lapse should have been expected under

such conditions - one then asks why such a schedule - perhaps budgetary or staffing issues?  One then needs

to ask why are there budgetary restraints and staffing problems and one goes deeper and deeper without finding

a "root cause" that has no underlying cause. 

 

I think the issue is - where in the cycle of causes do we have the leverage to prevent - or at least improve prevention?

 

Once again - thanks for your helpful response.  

 

Paul Preuss

ppreuss@...  

 

 

 

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

From: Paul Preuss

To: rootcauseconference@yahoogroups.com

Sent: Saturday, January 26, 2002 9:57 AM

Subject: Re: [rootcauseconference] Using Ourselves as Guinea Pigs

Bob - in response to your message of 1/25 about "helping ourselves see what we haven't seen before" and your question:

"Has anyone on this forum really changed the way they see
or think about anything?  And if so, WHY?  What made you change?"

 

In the early 1990's I "saw" systems for the first time in the words of Russell Ackoff.  At a conference in Boston he

intoned - "Systems are not the sum of their parts - they are the product of their interactions."  It was as if a bomb

(light bulb?) had gone off in my head.  For years I had been aware of the whole of my system and the need to keep

it in balance - in this case a high school - but I had been working on the improvement of parts - not the system as

a whole.  Ackoff's words changed my life forever. 

 

Since I am a graduate of liberal arts colleges and universities I have been taught that nothing is black or white but

rather shades of gray.  So - it is not that I think that well functioning and appropriate parts are bad - it is just that my

emphasis has changed to the white space - the linkages - between and among them. 

 

As I a reminder - I keep a small plastic box of watch parts on my desk.  All of the parts are perfect - but the watch

does not perform as it does not exist - there are no linkages.  The watch on my wrist has the same parts but performs

very well - because of how the parts are linked.

 

So - yes - I have changed dramatically - the result of a few words presented at a conference at just the right moment.

 

Paul Preuss

ppreuss@...

 

 

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Joe,

Thanks for your thoughtful input. It struck a chord with me.

Many of the adverse events I see involve failure to bring available
knowledge to bear at the point where decisions are made. In most cases, I
don't see any prior effort to find out what people know and how they will
get the information they need to do the job safely.

The questions I don't see asked are:
1. What is the scope of the job and how will we assure that it is not
changed?
2. What are the hazards involved in this job?
3. What safety barriers are protecting against these hazards?
4. How will we know if the barriers are ineffective or inadequate?
5. What contingency actions will we take in case of ineffective or
inadequate barriers?

I have never seen a job go awry when those five questions were asked.

Best Regards,

Bill Corcoran

W. R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
Mission: Saving lives, pain,assets, and careers through thoughtful inquiry.

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firebird.one@...
----- Original Message -----
From: <joe0499@...>
To: <rootcauseconference@yahoogroups.com>
Sent: Friday, January 25, 2002 10:25 PM
Subject: Re: [rootcauseconference] Using Ourselves as Guinea Pigs


> I just joined this club after listening to Bob give a presetation this
past
> week. His seminar was on Mini RCA...I came away excited and ready to go
out
> and try some of this new knowledge I learned.. I gave a very short talk on
> the subject at a meeting the next day explaining to my manager what I
thought
> our #1 latency would probably be for many of the problems we encountered
in
> out Company.  "We assume that all individuals know what to do when we send
> them out to do a job" Did we show them how to do it? Did we communicate
with
> them and ask if they had ever performed this task? Did we communicate the
> value that the specific task was worth? Did we listen to the individual's
> concerns about performing the specific task? Or do we just keep performing
> the same task over and over again hoping someday somebody will finally get
it
> right.....Why?????Why????? Why?????? Because we as management believe
> everyone is talented in the same way and if one maintainer knows how to do
it
> they all do!!!!! No need to take time to train or ask questions ,everyone
> knows what I want and everyone knows how to make that specific repair.
> Wrong!!!! And what is the maintainer thinking? " they must not care about
> really fixing this problem because they keep sending me out,and I don't
know
> how to correct it" or " They never took the time to train me so it must
not
> be important" or "Nobody else can fix it so why should I ? Hopefully , our
> organization will wake up and starting asking the question why????
>          I know I got away from the subject matter but just wanted to let
you
> know I not shy !
>
>
> Visit the the Root Cause LIVE clicking:
>
> www.rootcauselive.com
>
> To change conference email options, go to:
http://www.yahoogroups.com/group/rootcauseconference/join
>
> To unsubscribe from this group, send an email to:
rootcauseconference-unsubscribe@yahoogroups.com
>
>
> Your use of Yahoo! Groups is subject to http://docs.yahoo.com/info/terms/
>
>
>

I don't want to speak for Professor Lindley, but rather to state what it
means to me in my professional area, root cause organizational learning.

Accident consequences, i.e., the 'payout' of risk, always arise from the
simultaneous existence of mutually incompatible behaviors and/or conditions.

The simultaneity is crucial. One important class of risk control measures is
to control when behaviors occur and when conditions exist. E.g., air traffic
control is directed at preventing 'conflicts', i.e., multiple aircraft
simultaneously attempting to occupy the same air space.


Best Regards,

Bill Corcoran

W. R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
Mission: Saving lives, pain,assets, and careers through thoughtful inquiry.

Check out our e-group  at
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/

For a complimentary subscription to our e-newsletter on root cause,
organizational learning, and safety send a message to
firebird.one@...
----- Original Message -----
From: "Ranta Jukka" <jukka.ranta@...>
To: "Mailing List for Risk Professionals" <riskanal@...>
Sent: Monday, January 21, 2002 3:54 AM
Subject: [riskanal] Re: Risk Discussion


From: Thomas Lindley
"Outcomes depend on specific conditions, now, here, not some conditions or
other, some place, some time, etc.  If the conditions are not present it
cannot
occur.  If they are not present in the next five years then it cannot occur
in
the next five years."

Does this view mean that e.g. a pedestrian walking on the street is not at
risk
of being hit by a car, except for only those quick seconds when he actually
is
hit? Surely there are physical conditions under which a car hit can not
happen,
but the important question is how sure I can be that those conditions are
met,
and if, then when?. This brings us back to the realm of personal knowledge
and
personal uncertainty, and the discovery that there is no absolute risk that
could be objectively detected or measured from the nature, like weight or
temperature. We can count the number of accidents in certain conditions in
the
past, but quantifying the future risk (or probability) for some individuals
or
populations is not so straightforward. Quantifications of risk depend on
personal beliefs backed up by different experience, knowledge, assumptions
and
data (not only data). This fits perfectly with the Bayesian interpretation
of
probability as a measure of subjective uncertainty. I have seen no
discussion
here about the definitions or assumptions of probability although they are
implicitly under all conceptions of risk. Yet, I'm not sure whether the
discussion on probability would lead to any agreement, but at least we would
then know what probabilistic paradigm is behind each statement or point of
view,
and we could then judge these against the rules of that paradigm. I finish
with
two quotes by  Leonard J. Savage and Barry Gower. The former is a famous
statistician and the latter has written a book on the history of "scientific
method":

"It is not that paradigms are under-determined by facts; it is rather that
there are no paradigm-independent facts we can use to justify the adoption
of
one rather than another." (Barry Gower).

"It is unanimously agreed that statistics depends on somehow on probability.
But, as to what probability is and how it is connected with statistics,
there
has seldom been such complete disagreement and breakdown of communication
since
the Tower of Babel." (L.J.Savage).

You can write "risk" in place of "statistics" above, if you like.


Jukka Ranta, PhD
Department of Risk Assessment
National Veterinary and Food Research Institute
P.O.Box 45, FIN-00581 Helsinki, Finland
E-mail: jukka.ranta@...


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

From: Mark Venable

To: rootcauseconference@yahoogroups.com

Sent: Friday, January 18, 2002 3:28 PM

Subject: Re: [rootcauseconference] Medical Gas Mix-up

From what I read, the mixup was not found until after the 2nd fatality.  The first fatality was considered to have been a normal outcome of the medical procedure on a severely ill, elderly patient.

 

I wonder if we can expect the hospital to require physical inspections of their gas hookups when they apparently don't routinely investigate all of the deaths that occur during surgery.

 

I expect major litigation on this one. 

 

regards

 

Mark Venable  47 ENTP

SynerMetrics llc

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

From: Salot, William

To: 'rootcauseconference@yahoogroups.com'

Sent: Friday, January 18, 2002 12:54 PM

Subject: RE: [rootcauseconference] Example from the process industry

Friends,

In an attempt to catch up with the medical profession, here is a mixup with,
near miss consequences, that has been internetted to petroleum and chemical
processing folks.  To materials engineers, F9 is a designation for a metal
alloy composition.  To one gasket manufacturer, F9 is a designation for a
date of manufacture.  You can guess what happened.  I don't much like the
corrective action that was taken.  That action is described at the end of
the story.

Bill Salot INTP 72
-----Original Message-----

Subject: FW: Ring Joint Stamping

The attached memo from Lamons Gasket is in response to a near miss incident

we (CITCO) had at 736 Coker where two carbon steel ring gaskets were
discovered in a

9%Chrome piping system. The gaskets had suffered severe corrosion damage

(75% through thickness in places) after only a 2 year run. Investigation

revealed that the gasket stamping used by Lamons resulted in the material

being incorrectly identified in the field as 9%Chrome (date stamp was "F9"

for June, 1999). We requested that Lamons revise their stamping system to

prevent future gaskets from being incorrectly identified in the future, and

they have agreed to revise their QC stamping procedure.

Two 20" ring gaskets were removed from the 736 Coker as part of preparations

to isolate the fractionator tower (T-101). The gaskets are located at the

fractionator tower nozzle and a blind flange immediately upstream from the

nozzle. Major corrosion damage was found on both ring gaskets (see attached

pictures). There are locations on both gaskets where more than 75% of the

gasket thickness is gone. These gaskets were installed in 1999 during the

turnaround following the coke drum fire. The pipe specifications for this

piping (9% Chrome) call for 12% Chrome ring gaskets. We verified the gasket

material today (nuclear material analyzer) and both gaskets are plain carbon

steel.

I called the gasket manufacturer (Lamons) and had the stamped information on

these gaskets verified. The gaskets were correctly stamped as carbon steel

by Lamons, but there was additional information stamped on the gasket that

most likely resulted in it being incorrectly identified in the field as

9%-Chrome. Here is a breakdown of the stamped information on these ring

gaskets:

"LAMONS R93 S-4 F9 702702"

LAMONS: manufacturer

R93: identifies gasket size/rating

S-4: identifies gasket as carbon steel (S - steel; F - chrome alloy; etc.)

F9: identifies month/year that ring was manufactured

702702: heat number of material used for ring

The information "F9" is what you would look for in a 9%-Chrome gasket

material, and is most likely how these carbon steel gaskets were installed.

I have requested that Lamons consider changing the date stamps to make sure

they can't be confused for material identification.

Lamons will be forwarding a detailed explaination of their gasket stamping

later today. I'll forward that information to everyone as soon as it's

received.

This is a MAJOR finding. A failure of either of these gaskets could have

resulted in a major fire at the fractionator tower. The corrosion damage

found indicates that a complete failure of one or both of these gaskets was

in the near future (year or less). We will be checking every gasket in the

overhead vapor piping that was opened during the 1999 turnaround to make

sure all of these gaskets are the correct material. We will also perform

material verification on the new ring gaskets being installed during the

turnaround and will train field personnel on how to interpret the stamped

information on the gaskets.



Subject: Ring Joint Stamping

Mr. Ellis, the letter of the alphabet that is stamped to represent the Month

of manufacturing for the month of June will change. I was told by Harry

Singh, our QC manager, that the letter "F" will be replaced by the letter

"M". This should avoid any confusion in the future of the month's date of

manufacturing with the type metal selection of the ring gasket. Mr. Singh

told me he would make the changes and forward a copy to me and in turn I

will forward the copy to you.






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Thursday, 22 March, 2001

 

Fatal mix up doctor 'can work again'

Najiyah Hussain died of oxygen starvation

A consultant responsible for a hospital mix up in which a three-year-old girl died should be allowed to continue working, an official report has concluded.

After an investigation, it has been concluded that A&E consultant, Mr Andrew Hobart simply made a mistake.

Mr Hobart is the former chair of the BMA's junior doctors' committee.

Najiyah Hussain, of Manor Park, east London, died after being given laughing gas instead of oxygen.

She was taken to the accident and emergency department at Newham General Hospital in east London after suffering a fit at her home in January.

Mr Hobart had demonstrated genuine remorse for his error and made it clear that he is prepared to learn from his mistake

Newham Healthcare NHS Trust

She had gone into convulsions after receiving a flu jab at her GP practice.

Najiyah was given a mask to help her breathe, but instead of being given oxygen to revive her, she was mistakenly fed the anaesthetic nitrous oxide.

The report says: "This happened when the consultant inadvertently opened the nitrous oxide valve rather than the oxygen valve."

The result was only spotted after eight to ten minutes. As a result Najiyah's brain was starved of oxygen, and she died in intensive care.

Suspended

Mr Hobart was suspended following the tragedy, and Newham Healthcare NHS Trust launched an internal inquiry.

Mr Andrew Hobart: suspended after incident

Detectives from Scotland Yard also quizzed members of staff at the hospital.

The trust panel who interviewed Mr Hobart concluded: "He is appropriately trained, competent and safe to practice within the speciality.

"The panel considered that Mr Hobart had demonstrated genuine remorse for his error and made it clear that he is prepared to learn from his mistake."

They concluded that Mr Hobart, who was suspended following the incident, should undergo a period of supervised experience in the critical care aspects of accident and emergency medicine, intensive care and anaesthesia.

The purpose would be to "re-focus" Mr Hobart's experience and to rebuild his confidence in treating critically ill patients before returning to work.

The official report makes 20 recommendations aimed at preventing a repeat of the mix up.

They include:

• all nitrous oxide be removed from the resuscitation room
• an alarm system be fitted to warn if patients are not receiving enough oxygen

Dr Charles Gutteridge, medical director of the trust, confirmed that Mr Hobart would be returning to work.

He said: "Our view is that he is fully trained, he has a lot of experience. He knew precisely what he needed to do, he just did not get it right at that particular time."

Mr Hobart's mistake was to turn the wrong knob on a piece of equipment called a Boyles machine.

Instead of turning a large white knob to release oxygen, he turned a blue knob, which was half its size, that released a dose of nitrous oxide.

The hospital admitted that the equipment used was 17 years old, but stressed that it was regularly checked and met Department of Health guidelines.

In a statement, Dr Hobart said: "I would like to express my deepest sympathies to the family of Najiyah Hussain and to say how very sorry I am about the death of their daughter."

Najiyah's family lawyer John Bruty said the family had not really had time to digest the report having only received it a short while ago.

However, he said it looked at first glance as though the trust had reviewed the matter very thoroughly and had produced a full and open report.

He said: "The family will now want to receive firm assurances from the Trust that the recommendations of the internal inquiry are put in place as soon as possible."

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

From: Salazar, Michael D(Z81411)

To: 'rootcauseconference@yahoogroups.com'

Sent: Friday, January 18, 2002 9:29 AM

Subject: RE: [rootcauseconference] Medical Gas Mix-up

Bill, thanks for the continued monitoring of this event. I believe that it serves to prove my earlier point. Dissection of this event will turn up many, if not all, of the same drivers that caused the Bethlehem Steel fatalities. The more events reviewed, the more commonalties are revealed. Admittedly, every event has some unique features. I strongly believe that if we eliminated the frequent weaknesses, the others might not come into play. In this case we are starting to form a picture of outdated equipment, not used, that is left in service. Those of us in the nuclear end of the world, have many examples of events caused by equipment abandoned in place, or not properly removed. The COG condensate is present at Beth Steel due to the same factors (my opinion). I imagine the chemical industry has similar stories. So knowing that out moded equipment abandoned in place or improperly taken out of service (so that hazards are removed) causes significant events - why do we collectively fail to learn to take proactive measures against this condition?

Value the Prevention of Events
Michael D. Salazar
z81411@...
Phone:   (623)393-1343
Pager:    (602)658-5884

-----Original Message-----
From: Dr. Bill Corcoran at NSRC [mailto:firebird.one@...]
Sent: Friday, January 18, 2002 6:31 AM
To: rootcauseconference@yahoogroups.com
Subject: Re: [rootcauseconference] Medical Gas Mix-up

Mike,

 

The story is still unfolding. See below the signature lines.

 

Best Regards,

 

Bill Corcoran

 

W. R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
Mission: Saving lives, pain,assets, and careers through thoughtful inquiry.

 

Check out our e-group  at
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/

 

For a complimentary subscription to our e-newsletter on root cause, organizational learning, and safety send a message to firebird.one@...

_____________________________________________________________________________________________________________

 

http://ctnow.com/news/health/hc-nitrous0118.artjan18.story?coll=hc%2Dheadlines%2Dhome

Hospital Failed To Disconnect Obsolete Gas Supply Line

Mistaken Use Of Nitrous Oxide Blamed In Two Deaths

By WILLIAM HATHAWAY
And GARRET CONDON Courant Staff Writers

January 18 2002

The Hospital of St. Raphael in New Haven never disconnected an obsolete supply line that delivered fatal doses of nitrous oxide to two women undergoing cardiac catheterization in the past week, even though the anesthetic gas is rarely, if ever, used during the routine procedure.

Cardiologists and anesthesiologists at several leading hospitals in Connecticut said Thursday they do not use nitrous oxide during angiograms and angioplasty and that most cardiac catheterization labs in the state have no supplies of the gas. The gas sometimes is used in general operating rooms as an anesthetic.

The four-room lab on the first floor of St. Raphael's main building was designed in 1985 to handle a variety of procedures and was supplied with nitrous oxide for that reason. At present, three of the four rooms are used for cardiac catheterizations, and the fourth for electrophysiology - the diagnosis and treatment of heart rhythm problems. Helayne Lightstone, director of public relations at St. Raphael, said that she was not aware of any recent use of nitrous oxide for a catheterization at St. Raphael.

Hospital officials blamed the deaths on an unfortunate convergence of broken equipment, bad design and human error.

Lightstone said she believes the gas nozzles are on the wall behind the operating table. The gas outlet is connected to a flow meter fitted with a pin-index safety system with a specific pattern of pins for each gas.

A working oxygen flow meter cannot be connected to an outlet for another gas. The oxygen flow meter's safety pins are positioned at 12 o'clock and 6 o'clock, while the pins for nitrous oxide are positioned at 12 o'clock and 7 o'clock. St. Raphael officials said that one of the pins on the oxygen flow meter was missing, so that it was possible to fit the defective oxygen device onto the nitrous oxide outlet.

The gas line error was detected after the death Tuesday of Joan Cannon, 68, of Wallingford. Hospital officials said that within minutes of her death, hospital staff realized that the "oxygen" she had been given in an effort to revive her actually was deadly nitrous oxide, which deprives the body of oxygen.

The error also is blamed in the Jan. 11 death of Doris "Dot" Herdman, 72, of Southington, in the same room. At the time, her death was attributed to her age and frailty.

The deaths have triggered federal, state and local investigations and shaken up cardiologists, who fear patients will become needlessly concerned about usually safe and potentially life-saving procedures such as angioplasties and angiograms.

"We cannot allow this tragic event to adversely affect the perception of the state's entire hospital system," said Dr. Joxel Garcia, commissioner of the state Department of Public Health. The state and the U.S. Food and Drug Administration are investigating, as is the New Haven Police Department.

State doctors, meanwhile, struggled to figure out how the deaths could have occurred, given several mechanical and procedural safeguards in place to prevent such tragic mix-ups.

"I don't know what happened, but we're all concerned," said Dr. Francis Kiernan, director of Hartford Hospital's cardiac catheterization lab. "We like to operate in an environment where the possibility of error is minimized. You don't want medical devices in the room that aren't integral to what you are doing."

"[Nitrous oxide] is hardly ever used in a `cath' lab," said Dr. Daniel Diver, chief of cardiology and director of the cardiac catheterization laboratory at St. Francis Hospital and Medical Center. "I don't believe we would have a tank of nitrous oxide in a `cath' lab."

In a typical catheterization, which involves inserting a catheter throughan artery in the groin of the patient and guiding it into the heart to either detect or clear blockages, a patient generally receives a sedative and a painkiller. On occasion a patient might require oxygen, Kiernan said. But none of Hartford Hospital's four "cath" labs has nitrous oxide, he said.

Unlike operating rooms that use general anesthesia, catheterization labs aren't required to have devices that determine the type of gas being given to patients, said Dr. Jeffrey B. Gross, professor of anesthesiology and pharmacology at the University of Connecticut School of Medicine. Gross was chairman of a committee that wrote guidelines governing use of anesthetics by non-anesthesiologists.

The only reason nitrous oxide might be used in a cath lab is to help knock out an anxious patient, or if doctors suspect the patient might suffer from a rare blood pressure condition, Gross and Kiernan said.

But Kiernan said that may only occur once or twice a year among the thousands of procedures performed at his hospital annually.

Anesthesiologists would only be called to a cath lab in case of emergency, Gross said. Any gas tanks used would be clearly color-coded - green for oxygen and blue for nitrous oxide. Connections in the wall also are typically color-coded as a further safeguard, Gross said.

Mix-ups of gases are apparently rare.

An FDA spokeswoman said the agency had one report in 1996 of a non-fatal incident in which a patient mistakenly received nitrous oxide instead of oxygen, but she would not provide details on the cause or location of the accident.

Gross recalled another non-fatal accident in the Philadelphia area that occurred in 1981 involving the mistaken use of nitrous oxide.

In 1965, a 28-year-old mother of three died during a minor gynecological operation at Johnson Memorial Hospital in Stafford Springs because nitrous oxide and oxygen lines were mixed up, prompting a negligence lawsuit.

In July 2001, the FDA issued an alert to hospitals, nursing homes and others who use oxygen delivery systems, cautioning them about gas misconnections. It said that in the past four years, seven deaths and 15 injuries had resulted.

The flow meter used at St. Raphael was made by Precision Medical Inc., based in Northampton, Pa. FDA records show reports of 35 problems and injuries involving Precision Medical oxygen regulators and flow meters since 1995. One such incident, in January 2001, involved a regulator that was improperly attached to a cylinder of nitrogen. More typically, problems involved fires, leaks, incorrect use or faulty gas flow.

At least 600,000 cardiac catheterizations are performed annually in the United States to detect or remove blockages to the heart. More than 4,000 were performed last year at St. Raphael. Kiernan, at Hartford Hospital, said that fewer than 1 percent of the procedures lead to severe complications, including stroke, heart attacks or death.

Courant Staff Writer Hilary Waldman contributed to this story.

Copyright 2002, Hartford Courant

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

From: Salazar, Michael D(Z81411)

To: 'rootcauseconference@yahoogroups.com'

Sent: Thursday, January 17, 2002 6:14 PM

Subject: RE: [rootcauseconference] Medical Gas Mix-up

Not what I would call defense in depth.

-----Original Message-----
From: Phoenix_Firebird_One [mailto:firebird.one@...]
Sent: Thursday, January 17, 2002 3:58 PM
To: rootcauseconference@yahoogroups.com
Subject: [rootcauseconference] Medical Gas Mix-up


http://ctnow.com/news/local/hc-appatient0117.artjan17.story?coll=hc%
2Dheadlines%2Dhome
Error Kills Two Patients
Hospital Of St. Raphael Says Women Got Anesthetic Instead Of Oxygen
By PENELOPE OVERTON
Courant Staff Writer

January 17 2002

NEW HAVEN -- Two women, including one from Southington, died in the
past week at the Hospital of Saint Raphael after receiving nitrous
oxide instead of oxygen during routine heart procedures.

The mistake apparently killed a seriously ill woman in her 70s
Friday and a second woman in her late 60s on Tuesday, said Dr.
Charles Riordan, vice president of medical affairs for the hospital.
Both had coronary artery disease.

They died in the same operating room while undergoing heart
catheterization, Riordan said. The common procedure uses a small,
flexible tube to inject dye into the heart to diagnose problems,
such as blockages or defective valves.

The hospital did not identify the women.

But relatives confirmed the woman who died Friday was Doris "Dot"
Herdman, 72, of Southington. A Stamford native, Herdman moved to
Southington in 1964. She leaves behind a husband, a daughter and
grandchildren.

The hospital didn't question the Friday death because of the
seriousness of the woman's condition and her advanced age. But the
Tuesday death was unexpected and touched off an investigation that
revealed the prior victim.

The medical examiner's office is conducting an autopsy of the second
victim to determine the exact cause of death. Hospital officials
said they expected to learn that both women suffocated on the
operating table.

The hospital is blaming their deaths on a combination of human
error, broken equipment and a poorly designed operating room.
Riordan said that Saint Raphael is cooperating with state and
federal regulators called in to investigate the deaths.

An unidentified hospital worker, most likely a nurse or a
respiratory technician, accidentally plugged an oxygen flowmeter
into a tank of nitrous oxide, a common anesthetic. The nitrous oxide
and oxygen tanks sit side by side, officials said.

Nitrous oxide is a quick-acting and short-lived anesthetic often
used by dentists. The colorless gas is often known as laughing gas
because of the euphoria it quickly produces when inhaled in small
amounts. The drug is often abused. Complications from its abuse can
be life-threatening, including anoxia - a lack of oxygen to the
brain - which can cause permanent damage.

According to information from the Center for Substance Abuse at the
University of Maryland, "A person who remains unconscious and
continues to inhale pure [nitrous oxide] gas is likely to die."

An oxygen flowmeter is a small, $60 device that regulates the flow
of oxygen to the patient. It is equipped with tiny safety prongs
that are designed to prevent it from being inserted into anything
but an oxygen tank, officials said.

Apparently the safety pin had snapped off this particular device,
Riordan said.

Flowmeters are inspected regularly for mechanical failure, but
officials did not know the exact date of the most recent inspection
for that particular flowmeter. They are not inspected daily or even
before each procedure, they said.

The ensuing investigation prompted hospital officials to close down
the cardiac catheterization lab, which did about 4,000 of these
procedures in 2001, and check all flowmeters for defects. None were
found.

The oxygen flowmeter is the signature device of Precision Medical
Inc., a small medical products company based in Northhampton, Pa.
The company did not return phone calls late Wednesday.

The hospital is not identifying the employees involved in the
deaths, but said it doesn't plan to take disciplinary actions
against them. The deaths were due to several problems coalescing at
a single moment, officials said.

The hospital also plans to redesign the operating room where the
women died, Riordan said. Right now it is set up in such a way that
workers cannot see the plug-in receptacle for the oxygen and nitrous
oxide tanks, officials said.

It was always assumed the safety prong would prevent any mix-ups,
they said.

That operating room in the catheterization lab remains closed as the
hospital, state and federal investigators look into the deaths.
Catheterizations have resumed in the other rooms of the cardiac lab.

The state Department of Public Health started its investigation on
Wednesday, said spokeswoman Joan Leavitt. Investigators include two
state employees, a nursing consultant and a building and fire safety
engineer.

If the hospital is at fault, the state could issue the hospital a
certificate of non-compliance, revoke its license or levy fines, she
said. Saint Raphael has two weeks to respond to the state's initial
findings.

The U.S. Food and Drug Administration also began its review on
Wednesday. Spokeswoman Sharon Snider said the investigation will
consist of phone calls to the hospital and the manufacturer,
Precision Medical Inc.

Snider said she didn't know if the FDA had investigated Saint
Raphael or the manufacturer before. Investigation records were not
available Wednesday, she said. Neither the hospital nor manufacturer
had submitted their reports yet.

Some Connecticut cardiologists say that oxygen is not usually
administered in routine cardiac catheterizations and that
such "cath" labs do not usually stock gases such as nitrous oxide.

Dr. Daniel Diver, chief of cardiology and director of the
catheterization lab at Saint Francis Hospital and Medical Center in
Hartford, said it is the hospital clinical engineering departments,
not doctors, that usually inspect flowmeters.

Hospital officials said they have talked with relatives of both
victims.

The hospital's admission of guilt has eliminated the biggest burden
facing the families should they seek compensation, said Bridgeport
malpractice attorney Michael Koskoff.

Courant Staff Writers Hilary Waldman, William Hathaway, Bill Weir,
Kimberly Moy, Jack Dolan and Garret Condon contributed to this
story.
Copyright 2002, Hartford Courant




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In the files section of this group
(Root_Cause_State_of_the_Practice@yahoogroups.com) you will find a
report of the CSB on the subject event.

I was delighted with the detail of the report, especially with the
illustrations, but I was disappointed with the analysis and with the
so-called "root causes". A normal reaction to reading such "root
causes" is to ask, "But why?". It doesn't look like we are at the
bottom of the Why Staircase.

CSB results would be more helpful if they would use some basic root
cause processes. In this case it would have been very useful to have
a Why Staircase Tree beginning with the fatalities and working back
to the way the COG system was designed and managed.

A key occurrence in this event was the decommissioning of the
furnace. This left a large vertical dead leg connected to the
overhead COG pipling. This was sure to cause trouble. A key mistake
was to leave the dead leg in place. The longer it was left in place
the more trouble it would be likely to cause.

The first trouble we know about that it caused (or allowed) was the
crack in the 10-inch valve. This prompted the next error, installing
a slip blind instead of a drainable blind flange and drain assemply.

This guaranteed more trouble because it guaranteed that whenever the
valve was worked there would be a accumulation of condensate above
the slip blind, for which there was no regular way of draining.

Each step in the drama set the stage for the next one. Who is to
identify the point of no likely return?

More later, perhaps.

Best Regards,

Bill Corcoran

W. R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
Mission: Saving lives, pain,assets, and careers through thoughtful
inquiry.

Check out our e-group  at
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/

For a complimentary subscription to our e-newsletter on root cause,
organizational learning, and safety send a message to
firebird.one@...

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

From: Salazar, Michael D(Z81411)

To: 'rootcauseconference@yahoogroups.com'

Sent: Thursday, January 17, 2002 6:14 PM

Subject: RE: [rootcauseconference] Medical Gas Mix-up

Not what I would call defense in depth.

-----Original Message-----
From: Phoenix_Firebird_One [mailto:firebird.one@...]
Sent: Thursday, January 17, 2002 3:58 PM
To: rootcauseconference@yahoogroups.com
Subject: [rootcauseconference] Medical Gas Mix-up


http://ctnow.com/news/local/hc-appatient0117.artjan17.story?coll=hc%
2Dheadlines%2Dhome
Error Kills Two Patients
Hospital Of St. Raphael Says Women Got Anesthetic Instead Of Oxygen
By PENELOPE OVERTON
Courant Staff Writer

January 17 2002

NEW HAVEN -- Two women, including one from Southington, died in the
past week at the Hospital of Saint Raphael after receiving nitrous
oxide instead of oxygen during routine heart procedures.

The mistake apparently killed a seriously ill woman in her 70s
Friday and a second woman in her late 60s on Tuesday, said Dr.
Charles Riordan, vice president of medical affairs for the hospital.
Both had coronary artery disease.

They died in the same operating room while undergoing heart
catheterization, Riordan said. The common procedure uses a small,
flexible tube to inject dye into the heart to diagnose problems,
such as blockages or defective valves.

The hospital did not identify the women.

But relatives confirmed the woman who died Friday was Doris "Dot"
Herdman, 72, of Southington. A Stamford native, Herdman moved to
Southington in 1964. She leaves behind a husband, a daughter and
grandchildren.

The hospital didn't question the Friday death because of the
seriousness of the woman's condition and her advanced age. But the
Tuesday death was unexpected and touched off an investigation that
revealed the prior victim.

The medical examiner's office is conducting an autopsy of the second
victim to determine the exact cause of death. Hospital officials
said they expected to learn that both women suffocated on the
operating table.

The hospital is blaming their deaths on a combination of human
error, broken equipment and a poorly designed operating room.
Riordan said that Saint Raphael is cooperating with state and
federal regulators called in to investigate the deaths.

An unidentified hospital worker, most likely a nurse or a
respiratory technician, accidentally plugged an oxygen flowmeter
into a tank of nitrous oxide, a common anesthetic. The nitrous oxide
and oxygen tanks sit side by side, officials said.

Nitrous oxide is a quick-acting and short-lived anesthetic often
used by dentists. The colorless gas is often known as laughing gas
because of the euphoria it quickly produces when inhaled in small
amounts. The drug is often abused. Complications from its abuse can
be life-threatening, including anoxia - a lack of oxygen to the
brain - which can cause permanent damage.

According to information from the Center for Substance Abuse at the
University of Maryland, "A person who remains unconscious and
continues to inhale pure [nitrous oxide] gas is likely to die."

An oxygen flowmeter is a small, $60 device that regulates the flow
of oxygen to the patient. It is equipped with tiny safety prongs
that are designed to prevent it from being inserted into anything
but an oxygen tank, officials said.

Apparently the safety pin had snapped off this particular device,
Riordan said.

Flowmeters are inspected regularly for mechanical failure, but
officials did not know the exact date of the most recent inspection
for that particular flowmeter. They are not inspected daily or even
before each procedure, they said.

The ensuing investigation prompted hospital officials to close down
the cardiac catheterization lab, which did about 4,000 of these
procedures in 2001, and check all flowmeters for defects. None were
found.

The oxygen flowmeter is the signature device of Precision Medical
Inc., a small medical products company based in Northhampton, Pa.
The company did not return phone calls late Wednesday.

The hospital is not identifying the employees involved in the
deaths, but said it doesn't plan to take disciplinary actions
against them. The deaths were due to several problems coalescing at
a single moment, officials said.

The hospital also plans to redesign the operating room where the
women died, Riordan said. Right now it is set up in such a way that
workers cannot see the plug-in receptacle for the oxygen and nitrous
oxide tanks, officials said.

It was always assumed the safety prong would prevent any mix-ups,
they said.

That operating room in the catheterization lab remains closed as the
hospital, state and federal investigators look into the deaths.
Catheterizations have resumed in the other rooms of the cardiac lab.

The state Department of Public Health started its investigation on
Wednesday, said spokeswoman Joan Leavitt. Investigators include two
state employees, a nursing consultant and a building and fire safety
engineer.

If the hospital is at fault, the state could issue the hospital a
certificate of non-compliance, revoke its license or levy fines, she
said. Saint Raphael has two weeks to respond to the state's initial
findings.

The U.S. Food and Drug Administration also began its review on
Wednesday. Spokeswoman Sharon Snider said the investigation will
consist of phone calls to the hospital and the manufacturer,
Precision Medical Inc.

Snider said she didn't know if the FDA had investigated Saint
Raphael or the manufacturer before. Investigation records were not
available Wednesday, she said. Neither the hospital nor manufacturer
had submitted their reports yet.

Some Connecticut cardiologists say that oxygen is not usually
administered in routine cardiac catheterizations and that
such "cath" labs do not usually stock gases such as nitrous oxide.

Dr. Daniel Diver, chief of cardiology and director of the
catheterization lab at Saint Francis Hospital and Medical Center in
Hartford, said it is the hospital clinical engineering departments,
not doctors, that usually inspect flowmeters.

Hospital officials said they have talked with relatives of both
victims.

The hospital's admission of guilt has eliminated the biggest burden
facing the families should they seek compensation, said Bridgeport
malpractice attorney Michael Koskoff.

Courant Staff Writers Hilary Waldman, William Hathaway, Bill Weir,
Kimberly Moy, Jack Dolan and Garret Condon contributed to this
story.
Copyright 2002, Hartford Courant




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

From: Paul Preuss

To: rootcauseconference@yahoogroups.com

Sent: Tuesday, January 15, 2002 12:47 PM

Subject: [rootcauseconference] Definition of Root Cause

I am in a situation where we have been using the term "root cause" to describe the process of seeking causes

for student academic failure in the context of schools.  Some are having trouble with the term as they hold to

what I consider a rather narrow definition of the process.  They suggest instead some such term as causal

mapping or causal analysis should be used.  I think we have something invest in the term and training and am wondering if others have run in to a similar situation.  Paul

 

Paul G. Preuss, Ed.D.
www.Plan2020.com

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

From: silkobj@...

To: rootcauseconference@yahoogroups.com

Sent: Thursday, January 17, 2002 4:02 PM

Subject: Re: [rootcauseconference] Hostile Witness - Epilogue

I want to thank everyone for your responses to my "Hostile Witness"
question last week.  As usual, you were insightful and helpful.  I was not
a member of this RCAT but very close to it because my role is to manage the
RCAT process and support and consult to the teams.  The witness is a
technical person who was coordinating the project in question.

Here's how the situation played out:

   A day or two before the preliminary briefing, my boss spoke with the
   witness's manager about the witness's behavior during the interviews.
   The manager was not surprised and said he'd been working with the
   witness on controlling his confrontational attitude.  The witness's
   behavior was not a direct result of the investigation but part of his
   personality (albeit exacerbated by the investigation).

   We decided not to invite the witness to the preliminary briefing, just
   the VP and 4 of his managers.  The VP invited one other witness but not
   the hostile witness.  The briefing addressed the most significant
   findings to date and went very well.  It served as a good heads-up to
   these people before the final formal presentation earlier this week.

This leads me to ask a more generic question.  A couple of you suggested
talking to the witness's supervisor, and initially that struck me as
violating interviewee confidentiality.  But as I thought about it, it
became clear this was necessary to hold the witness accountable for his
duty to cooperate.  But what if the team believed a witness was holding
back information or not telling the truth: couldn't that be considered
interview content protected by confidentiality?  Where do you draw the line
between keeping the contents of interviews confidential and holding the
interviewee accountable for his or her duty to be forthright, truthful, and
otherwise cooperative?

-  Bernie

Bernard J. Silkowski, CSP




                                                                                                              
                    silkobj@...                                                                            
                                        To:      rootcauseconference@yahoogroups.com                          
                                        cc:      (bcc: Bernard J. Silkowski/NUS)                              
                                        Subject:      [rootcauseconference] Hostile Witness                   
                    01/08/2002                                                                                
                    11:20 PM                                                                                  
                    Please respond                                                                            
                    to                                                                                        
                    rootcauseconfer                                                                           
                    ence                                                                                      
                                                                                                              
                                                                                                              





As I mentioned previously, our very first root cause analysis teams
(RCAT's) are underway investigating two high risk situations that were
identified before near-misses or any other type of consequence could even
occur.  A key player in one case has been a difficult, defensive, and
hostile witness.  This person had responsibility for the situation in
question but at this point the issues all seem to be system related.
Everyone on the team has been intensively trained in RCA and is performing
his/her duties very professionally.  The team's charter explicitly
prohibits them from considering fault or assigning blame, but this has done
little to assuage this person's attitude.

Next week the team will formally brief our Executive EHS Committee (all
VP's and the sponsor of the RCA) of its findings and recommendations.  But
first, on Thursday of this week, it will brief the management of the
affected group on its preliminary findings.  The VP of this group had
previously given his enthusiastic support to doing an RCA of the incident,
but has suddenly sent signals downplaying the significance of the situation
and questioning why the investigation should take any longer than one day.
One would think the above witness has been talking with him.

The VP and a couple of his directors will attend the preliminary briefing.
Our original intention was to also invite the witness because of his
management role in the situation.  Now we're wondering if we should because
of the dynamics his presence could set up in the room.   In other words, it
might be easier for the VP to see the truth, which is not likely to
implicate the witness at all, without the witness present.  The witness's
presence may make for a more difficult presentation but, on the other hand,
could result in convincing him that no one is out to get him.

Mmmmm . . . I think I may have just answered my own question.  But let me
go on as I'd still like to get your views on this.

Suggestions?  Do you normally invite the key players in the incident to the
preliminary briefing?  Or do you limit attendance to higher level
management?  Do you invite the key players to the final formal
presentation?  Do you even do a preliminary briefing?

- Bernie

Bernard J. Silkowski, CSP



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

From: Kamal El-Sheikh

To: Mailing List for Risk Professionals

Sent: Tuesday, January 15, 2002 4:24 AM

Subject: [riskanal] The risk of zero risk-zero benefit

Actions to remove hazard or exposure may remove benefits. Loss of benefits may introduce new risks. The following incident illustrates the point.

 

Two teenagers were electrocuted by an energized street light in a county in Florida a few years ago. To eliminate the risk of electrocution, the county ordered all streetlights extinguished until they could be rewired. In the evening, a man was struck and killed by a car while crossing the darkened street and a motorist was killed in a two-car collision in the same area. The county action eliminated the risk of electrocution but the loss of benefits from operating traffic lights created new fatality risks.

 

A rational decision should account for the impact of benefit reduction resulting from risk reduction actions. Some US regulations require that a “total hazard” approach be considered in evaluating risk reduction actions.

 

 

Kamal El-Sheikh

RSACS  

(Reliability & Safety Assurance 

 Consulting  Services)

3316 Kuykendall Place
San Jose, CA 95148-2737
Tel: (408)270-0518
Fax: (408)532-6385

 

-----Original Message-----
From: Juderon [mailto:juderon@...]
Sent: Monday, January 14, 2002 8:29 PM
To: Mailing List for Risk Professionals
Subject: [riskanal] Re: riskanal digest: January 13, 2002

 

Dr Ibrahim's original comment was "You can reduce accidents risk to a certain thresholds beyond which, no dollar amount can allow you to further reduce risk. The is no such thing as zero risk."[sic]

 

In this context my statement was that there can be zero risk when dealing with specifics -- of course there is no such thing as zero risk in life in general -- but I've never seen a risk analysis that undertakes such a holistic view in its analysis.

 

What are the risks for a devout hindu getting mad cow disease from eating beef?

What are the risks for a devout Jew or Muslum getting trichomosis from eating pork?

What are the chances of drowning whilst swimming at a beach if you never go to the beach in the first place?

 

If one is talking about life -- of course there are no risks -- if one is talking about individual [potential] hazards -- then risk can be zero if either the hazard is removed or the exposure is removed.

 

My argument wasn't about the risks associated with energy per se, which of course requires a broader risk analysis than simply considering the risks associated with nuclear power plants. I doubt that anyone offered $1,000 to consider the risks associated with eating rice would undertake a comprehensive analysis of alternatives such as [green] potatoes, or taro, or casava, or whatever... that would cost somewhat more.

 

Unless I've misunderstood the definitions of hazard and risk then I can't see how I can be wrong. If I'm wrong -- then please educate me with rational arguments. Simply stating that my argument is circular is irrational as far as I can tell.

 

Regards

Ron

 

 

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

From: hinhaber@...

To: Mailing List for Risk Professionals

Sent: Monday, January 14, 2002 6:38 PM

Subject: [riskanal] Re: riskanal digest: January 13, 2002

 

 

Ron Law wrote:

 

"For example - a few decades ago New Zealand debated the pros and cons of nuclear power stations. Numerous potential risks associated with nuclear reactors were identified and New Zealand reduced these to zero by choosing not to build any nuclear reactors -- end of story is that risks associated with nuclear reactors in New Zealand are zero"

 

But people in New Zealand presumably want something to happen when they put a plug into a wall socket. What types of risks are they exposed to from other sources of energy - coal (air pollution and workers deaths), hydro (dam failues, etc)? Saying that NZ avoided nuclear risks by not having reactors is like saying that a desert country like Saudi Arabia avoided hydro dam failures by not building dams.

 

To choose another analogy - and there are a million - you could say that NZ now avoids Volkswagen Beetle traffic deaths by not having them on the road anymore (assuming they have all disappeared). So what? There are hundreds of other kinds of cars on the road, all causing some traffic deaths.

 

Herbert Inhaber, Ph.D.

President

Risk Concepts

3920 Mohigan Way

Las Vegas Nevada 89119

Phone: 702-894-9095

Fax: 702-894-9095

e-Mail: hinhaber@...

 

>

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This is a response to Dave Hall who said: As to accidents, most are caused
by unthinking actions or unconsidered actions.  Few (percentage wise) are
caused by failures of things.
____________________________________________________________________________
__________________________________-

Dave is headed in the right direction. The ones I have investigated or
reviewed over the past two decades had consequences that were influenced by
four types of factors:

Those that made the situation vulnerable to the accident.
Those that triggered it.
Those that made the consequences as bad as they were. And
Those that kept the consequences from being worse.

In most of the cases, as Dave suggests, there was a failure to bring
available knowledge to bear on one or more key decisions involved in the
event. Examples are: Challenger, Bhopal, Chernobyl, Three Mile Island.

In all of these cases and many more the activities leading to the event were
completely in accord with the existing management culture. It would have
taken ordinary, but out-of-the-box, activity to prevent the accident or to
have its consequences less severe.

Thus the terms "unthinking" and "unconsidered" need to be placed in context.


Best Regards,

Bill Corcoran

W. R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
Mission: Saving lives, pain,assets, and careers through thoughtful inquiry.

Check out our e-group  at
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/

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firebird.one@...
----- Original Message -----
From: " David Hall" <dhall5@...>
To: "Mailing List for Risk Professionals" <riskanal@...>
Sent: Monday, January 14, 2002 9:33 AM
Subject: [riskanal] Re: Accidents


> Risk assessments consider future events and the possible permutations of
those events.  No one can ever understand or predict every future event and
how it will turn out.  The best we can do is try to predict those more
obvious events and determine what potential deviations from the expected
(risks) are most likely to occur given certain conditions.
>
> We can use facts (things that happened in the past) to try and anticipate
future events, however, nothing ever repeats exactly,  So that is why each
risk assessment must be continually updated as new things happen and
unplanned stuff occurs.
>
> As to accidents, most are caused by unthinking actions or unconsidered
actions.  Few (percentage wise) are caused by failures of things.  It is
totally impossible to predict what a specific person will do in a specific
situation, so risk assessments must consider an average.  That is, so many
of these types of accidents will occur over this period of time.  Now, what
has caused these accidents in the past and what should be changed, learned,
etc. to minimize such happenings?  There is a whole procedure here for risk
assessments of potential industrial accidents, potential travel accidents
(how many accidents during this holiday weekend type), etc.  that is based
on history.
>
> I like the quote "It is impossible to make anything idiot-proof, as idiots
are so ingenious!"
>
> Dave Hall
> Risk Manager
>
> -----Original Message-----
> From: AndyJByers@...
> Date: Sun, 13 Jan 2002 05:39:29 EST
> To: "Mailing List for Risk Professionals" <riskanal@...>
> Subject: [riskanal] (no subject)
>
>
> > Dear All,
> >
> > Your thoughts please on the following,
> >        If risk assessments are comprehensive why do accidents still
occur?
> >
> > Regards
> >        Andy Byers
> >
>
> --
>
>
>
> ---
> You are currently subscribed to riskanal as: firebird.one@...
> To unsubscribe send a blank email to leave-riskanal-2987C@...
>

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

From: bobnelms

To: rootcauseconference@yahoogroups.com

Sent: Friday, January 11, 2002 11:25 AM

Subject: RE: [rootcauseconference] Re: Definition of Failure

Bill C:

 

Ok, I understand so far, but let’s get specific to your Why Staircase.  If an incident occurred that cost the client $100,000 AND someone got seriously injured, would you handle them all in the same Tree or would you do it in 2 different trees?

 

Bob Nelms

 

Root Cause LIVE

www.rootcauselive.com

bobnelms@...

 

-----Original Message-----
From: sentto-2441878-2270-1010765280-bobnelms=compuserve.com@... [mailto:sentto-2441878-2270-1010765280-bobnelms=compuserve.com@...]On Behalf Of Dr. Bill Corcoran at NSRC
Sent: Friday, January 11, 2002 11:08 AM
To: rootcauseconference@yahoogroups.com
Subject: Re: [rootcauseconference] Re: Definition of Failure

 

Bob,

 

"The d-words" is just a mnemonic device. There are consequences that don't begin with "d", like injuries, fines, and jail.

 

The point is that from a business and/or human point of view we need to understand what influenced the adverse consequences.

 

I almost always start with the consequence of most concern to the client, but the aggregation of the consequences is important. Most organizations do not aggregate their consequences for a given event, much less all of their adverse events over a period of time. This makes it hard to give corrective measures a fair shake.

 

I have found that the learning from determining the influences on a few consequences covers most of the available learning.

 

Does this help?

 

Best Regards,

 

Bill Corcoran

 

W. R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
Mission: Saving lives, pain,assets, and careers through thoughtful inquiry.

 

Check out our e-group  at
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/

 

For a complimentary subscription to our e-newsletter on root cause, organizational learning, and safety send a message to firebird.one@...

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

From:

crnelms

To: rootcauseconference@yahoogroups.com

Sent: Friday, January 11, 2002 8:41 AM

Subject: [rootcauseconference] Re: Definition of Failure

 

Bill C:

I'm reviewing some of the earlier messages.  They contain a WEALTH of
ideas.  I'd like to ask you a follow-up on this one.

"What belongs at the top of the Why Staircase is the aggregation of 
the consequences. These are the d-words: death, dollars, doses, days
of lost work, days of lost production, damage, disruption, discredit,
delays, defections, dismissals"

I like what you're suggesting here, but I want to make sure I
understand it.  Firstly, these are a LOT of d-words, making for an
expansive investigation.  Secondly, how do you handle each d-word in
terms of your Why Staircase -- do you have a seperate Staircase for
each d-word?

Thanks

Bob Nelms

--- In rootcauseconference@y..., "William R. Corcoran"
<firebird.one@a...> wrote:
> Bob,
>
> What belongs at the top of the Why Staircase is the aggregation of
> the consequences.
>
> These are the d-words: death, dollars, doses, days of lost work,
days
> of lost production, damage, disruption, discredit, delays,
> defections, dismissals,  ...
>
> Three classes of consequences are worth considering: actual (what
you
> really have now), expected (what's in the pipeline and is on the
way)
> and potential (what could have happened, but didn't because of
luck,
> sanctifying grace, or good practice).
>
> It would be nice to be able to have a "currency converter" that
> reduced all of the consequences to a common unit of adversity, but
we
> are not there yet.
>
> If you investigate consequences you will get different answers than
> if you investigate events. I know. I've done both.
>
> You don't need to investigate all of the consequences, just the
ones
> you want to make sure don't happen in the future.
>
> B/r,
>
> Bill Corcoran
> ENTP 64
> ____________________________________________________________________
>
> --- In rootcauseconference@y..., "Bob Nelms (INTJ-53)"
> <bobnelms@c...> wrote:
> > To all:
> >
> > As approach the end of the month, I was reflecting on Kim's
chosen
> > focus area this month -- "defining failure."  I have a lingering
> > question to ask of all of you.  I'll ask it using my vocabulary,
> > hoping that you'll understand what I'm asking:
> >
> > "How do you agree on (or define) the TOP BLOCK in your
> investigative
> > team's WHY TREE?"
> >
> > In other words, how do you decide how expansive (or how limited)
> your
> > investigation will be?  In your response, it would be very
helpful
> to
> > give some examples.
> >
> > Thanks!
> >
> > Bob Nelms



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

From: crnelms

To: rootcauseconference@yahoogroups.com

Sent: Friday, January 11, 2002 8:41 AM

Subject: [rootcauseconference] Re: Definition of Failure

Bill C:

I'm reviewing some of the earlier messages.  They contain a WEALTH of
ideas.  I'd like to ask you a follow-up on this one.

"What belongs at the top of the Why Staircase is the aggregation of 
the consequences. These are the d-words: death, dollars, doses, days
of lost work, days of lost production, damage, disruption, discredit,
delays, defections, dismissals"

I like what you're suggesting here, but I want to make sure I
understand it.  Firstly, these are a LOT of d-words, making for an
expansive investigation.  Secondly, how do you handle each d-word in
terms of your Why Staircase -- do you have a seperate Staircase for
each d-word?

Thanks

Bob Nelms

--- In rootcauseconference@y..., "William R. Corcoran"
<firebird.one@a...> wrote:
> Bob,
>
> What belongs at the top of the Why Staircase is the aggregation of
> the consequences.
>
> These are the d-words: death, dollars, doses, days of lost work,
days
> of lost production, damage, disruption, discredit, delays,
> defections, dismissals,  ...
>
> Three classes of consequences are worth considering: actual (what
you
> really have now), expected (what's in the pipeline and is on the
way)
> and potential (what could have happened, but didn't because of
luck,
> sanctifying grace, or good practice).
>
> It would be nice to be able to have a "currency converter" that
> reduced all of the consequences to a common unit of adversity, but
we
> are not there yet.
>
> If you investigate consequences you will get different answers than
> if you investigate events. I know. I've done both.
>
> You don't need to investigate all of the consequences, just the
ones
> you want to make sure don't happen in the future.
>
> B/r,
>
> Bill Corcoran
> ENTP 64
> ____________________________________________________________________
>
> --- In rootcauseconference@y..., "Bob Nelms (INTJ-53)"
> <bobnelms@c...> wrote:
> > To all:
> >
> > As approach the end of the month, I was reflecting on Kim's
chosen
> > focus area this month -- "defining failure."  I have a lingering
> > question to ask of all of you.  I'll ask it using my vocabulary,
> > hoping that you'll understand what I'm asking:
> >
> > "How do you agree on (or define) the TOP BLOCK in your
> investigative
> > team's WHY TREE?"
> >
> > In other words, how do you decide how expansive (or how limited)
> your
> > investigation will be?  In your response, it would be very
helpful
> to
> > give some examples.
> >
> > Thanks!
> >
> > Bob Nelms



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Bernie,

This is a really great problem. Problems are good because they get your mind
off your troubles.

This situation could be the beginning of the end of RCA in your
organization. How would you like this to turnout and what do you need to do
to have that happen?

If the hostile witness gets away with being hostile to an RCAT that behavior
will be reinforced and the message will go out that managers can stiff-arm
RCAT's!!

This is not good.

If I were you I would talk to my boss soon armed with exhaustive notes on
the actual behavior of the hostile manager. Your boss needs to understand
that this is a watershed event. That does not mean necessarily that your
boss needs to make a big deal out of it. You need ideas and support from
your boss, not direction.

I would also do a lot of brainstorming, e.g., does your company have OD
people that help in conflict resolution? Have managers been rewarded for
stiff-arming EHS, HR, and other powerless staff units?

This posting is just the tip of the iceberg.

Call if you like.

Best Regards,

Bill Corcoran

W. R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
Mission: Saving lives, pain,assets, and careers through thoughtful inquiry.

Check out our e-group  at
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/

For a complimentary subscription to our e-newsletter on root cause,
organizational learning, and safety send a message to
firebird.one@...
----- Original Message -----
From: <silkobj@...>
To: <rootcauseconference@yahoogroups.com>
Sent: Tuesday, January 08, 2002 11:20 PM
Subject: [rootcauseconference] Hostile Witness


> As I mentioned previously, our very first root cause analysis teams
> (RCAT's) are underway investigating two high risk situations that were
> identified before near-misses or any other type of consequence could even
> occur.  A key player in one case has been a difficult, defensive, and
> hostile witness.  This person had responsibility for the situation in
> question but at this point the issues all seem to be system related.
> Everyone on the team has been intensively trained in RCA and is performing
> his/her duties very professionally.  The team's charter explicitly
> prohibits them from considering fault or assigning blame, but this has
done
> little to assuage this person's attitude.
>
> Next week the team will formally brief our Executive EHS Committee (all
> VP's and the sponsor of the RCA) of its findings and recommendations.  But
> first, on Thursday of this week, it will brief the management of the
> affected group on its preliminary findings.  The VP of this group had
> previously given his enthusiastic support to doing an RCA of the incident,
> but has suddenly sent signals downplaying the significance of the
situation
> and questioning why the investigation should take any longer than one day.
> One would think the above witness has been talking with him.
>
> The VP and a couple of his directors will attend the preliminary briefing.
> Our original intention was to also invite the witness because of his
> management role in the situation.  Now we're wondering if we should
because
> of the dynamics his presence could set up in the room.   In other words,
it
> might be easier for the VP to see the truth, which is not likely to
> implicate the witness at all, without the witness present.  The witness's
> presence may make for a more difficult presentation but, on the other
hand,
> could result in convincing him that no one is out to get him.
>
> Mmmmm . . . I think I may have just answered my own question.  But let me
> go on as I'd still like to get your views on this.
>
> Suggestions?  Do you normally invite the key players in the incident to
the
> preliminary briefing?  Or do you limit attendance to higher level
> management?  Do you invite the key players to the final formal
> presentation?  Do you even do a preliminary briefing?
>
> - Bernie
>
> Bernard J. Silkowski, CSP
>
>
>
> Visit the the Root Cause LIVE clicking:
>
> www.rootcauselive.com
>
> To change conference email options, go to:
http://www.yahoogroups.com/group/rootcauseconference/join
>
> To unsubscribe from this group, send an email to:
rootcauseconference-unsubscribe@yahoogroups.com
>
>
> Your use of Yahoo! Groups is subject to http://docs.yahoo.com/info/terms/
>
>

Joe,

That's a great example of solving the problem without paying any mind to
root causes. It's also an example of solutions causing problems.

OBTW: Would it be fair to say that the driver used "out-of-the-box"
thinking? Or was it "out-with-the-box" thinking?

OBTW2: What will keep this from happening again? Who cares?

Best Regards,

Bill Corcoran

W. R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
Mission: Saving lives, pain,assets, and careers through thoughtful inquiry.

Check out our e-group  at
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/

For a complimentary subscription to our e-newsletter on root cause,
organizational learning, and safety send a message to
firebird.one@...
----- Original Message -----
From: "Drago, Joseph" <Joseph.Drago@...>
To: "William R. Corcoran (E-mail)" <firebird.one@...>
Sent: Tuesday, January 08, 2002 3:32 PM
Subject: FW: FED EX BOX


> Bill,
>
> Here is that classic instance where the FedEx driver knew what his/her job
> is and did it!  Because when it positively, absolutely has to be there,
> FedEx delivers!
>
> Glad to hear you had a great time in FL.
>
> Joe
>
> -----Original Message-----
>
> Sent: Tuesday, January 08, 2002 2:30 PM
> To: ALL BUILDING 201 OCCUPANTS (E-mail)
> Subject: FED EX BOX
>
> As most of you are aware, the Fed Ex box located near the walkway at the
> East side of the building was removed before the Holiday Break.  The
reason
> for the removal was that the box had been over-stuffed and the Fed Ex
driver
> was not able to remove the contents when he arrived to make his pick-up.
>
> I was notified today that the box should be returned on January 15th,
> however, Fed Ex said they cannot guarantee the date.  In the meantime, we
> will have to continue using the Fed Ex boxes located at Buildings 208, 360
> and 401.
>
> Fed Ex apologizes for the inconvenience.

Bill S.

That's very helpful.

Have you found that any of the other indicators are "leading indicators" for
OSHA Recordables?

By staff, I mean operators, maintenance workers, engineers and others whose
knowledge of the facility could be a factor in the level of safety achieved.

OBTW: Using the serious First Aid Cases as "near misses" is resourceful. But
some of the near misses that don't even require first aid can be very
significant as well.

Best Regards,

Bill Corcoran

W. R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
Mission: Saving lives, pain,assets, and careers through thoughtful inquiry.

Check out our e-group  at
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/

For a complimentary subscription to our e-newsletter on root cause,
organizational learning, and safety send a message to
firebird.one@...
----- Original Message -----
From: "Salot, William" <william.salot@...>
To: <rootcauseconference@yahoogroups.com>
Sent: Friday, January 04, 2002 9:30 AM
Subject: RE: [rootcauseconference] Help Sought


> Bill C.,
>
> Your non-nuclear questions below cover two areas that do not get a lot of
> attention in our plant.
>
> 1) OSHA recordables and LWDAs (lost workday away) are certainly our
primary
> safety metrics. We also measure and track attendance to required safety
> training/meetings. First aid cases are also tracked. We are just beginning
> to use such things as workers' comp. cases (# and $), safety related work
> tickets' status, and near-miss OSHAs (first aids that were relatively
> serious).  Our CATS (corrective action tracking system) Action Items
status
> is also monitored.
>
> 2) I'm not sure whether you intend "plant staff" to mean plant leaders or
> all plant personnel, and whether you intend "details of the plant itself"
to
> mean mechanical, process, or performance details.  In general, we maintain
> and increase personnel knowledge through orientation, on the job training
> (OJT), job rotation, and a variety of communication tools.  This includes
a
> fairly comprehensive new manager orientation program.
>
> I'm sure you can suggest some improvements.
>
> Bill Salot INTP 72
>
> -----Original Message-----
> From: Phoenix_Firebird_One [mailto:firebird.one@...]
> Sent: Monday, December 17, 2001 7:26 AM
> To: rootcauseconference@yahoogroups.com
> Subject: [rootcauseconference] Help Sought
>
>
> Colleagues,
>
> Can you point me in the right direction for the answers to two
> questions about non-nuclear organizations:
>
> 1) What metrics or indicators do they use to measure the
> effectiveness of safety programs and practices other than the "OSHA
> Recordables"? I am especially interested in leading indicators.
> 2) How do they maintain and increase plant staff knowledge of the
> details of the plant itself?
>
> Any help would be greatly appreciated on-line or off-line.
>
> B/r,
>
> Bill Corcoran
> 860-285-8779
>
>
>
> Visit the the Root Cause LIVE clicking:
>
> www.rootcauselive.com
>
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>
>
>

Rod,

Great example. What you did is often called "Difference Analysis". In
Difference Analysis we compare the problem-free situation to the problem
situation to determine what the differences are and which of the differences
is likely to be part of the causation of the problem.

This would make a superb example of a difference analysis.

As far as you are concerned as an individual customer, you got THE ROOT
CAUSE!! Wow!!

If you were the NHTSB investigating a series of deaths from this problem
(not likely) you would be nowhere near anything that even smells like a root
cause.

If you would like some more commentary on your Ford Ranger triumph just
respond to this posting.

Best Regards,

Bill Corcoran

W. R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
Mission: Saving lives, pain,assets, and careers through thoughtful inquiry.

Check out our e-group  at
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/

For a complimentary subscription to our e-newsletter on root cause,
organizational learning, and safety send a message to
firebird.one@...
----- Original Message -----
From: "Rod Jenkins" <jenkirl@...>
To: <rootcauseconference@yahoogroups.com>
Sent: Sunday, January 06, 2002 11:30 PM
Subject: RE: [rootcauseconference] SIMPLE examples


> Simple examples:
>
> 1.  I had a Ford Ranger pick-up that the tailgate kept
> getting stuck on.  I had "repaired" it many times and
> began carring a screwdriver with me so I could unlatch
> the assembly when it was stuck.  I was at the lumber
> yard and could not lower the tailgate and became
> fustrated to the point I decided to fix it.
>
> I told my wife I was going to fix the tailgate today,
> if it took all day.  I went to the dealership, but
> they didn't have any of the assemblies instock.  The
> partsman said they didn't stock them although they did
> order quite a few.
>
> I headed home to take the tailgate apart and on the
> way home was remembered that I find root cause of
> failures for a living.  I went home and took off the
> cover of the tailgate latch assembly and began to do
> the hand sketch.  While sketching I found the left
> hole in the assembly was not centered, while the right
> hole in the assembly was centered.  I look over how
> the assembly functioned and decided that the
> off-center hole was allowing the latch to slip.  I
> re-drilled the holes and installed a nylon bushing to
> center the assembly.
>
> The tailgate has not failed for over a year.
>
>
>
>
> __________________________________________________
> Do You Yahoo!?
> Send FREE video emails in Yahoo! Mail!
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>
>
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>
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>
>
>

Bob,

This is an excellent opportunity for us to help.

My hopes and wishes for this effort are:
1. We will use all of the features of the e-group: messages, bookmarks,
files, photos, databases, and polls.
2. Many of us will participate.
3. Someone will volunteer to be the "Project Manager" for this.
4. The Project Manager will create a Work Breakdown Structure and ask for
volunteers for each task.
5. One task will be integration of the output of the other tasks.
6. The result will be shared in the files section of this e-group.

I nominate Anand Varadarajan as Project Manager.

I volunteer to be his offline sounding board and mentor.

Best Regards,

Bill Corcoran

W. R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
Mission: Saving lives, pain,assets, and careers through thoughtful inquiry.

Check out our e-group  at
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/

For a complimentary subscription to our e-newsletter on root cause,
organizational learning, and safety send a message to
firebird.one@...
----- Original Message -----
From: "crnelms" <bobnelms@...>
To: <rootcauseconference@yahoogroups.com>
Sent: Wednesday, January 02, 2002 6:33 AM
Subject: [rootcauseconference] Help with some SIMPLE examples


> To all:
>
> Yesterday, I received the following message from one of our members.
> This is a refreshing request!  I hope we can help.
>
> Bob Nelms, Moderator
> ==============================================
>
> Season's greetings,
> I work as a Quality Specialist in a multinational manufacturing firm
> and I would like to get your help in preparing a presentation on the
> fundamental concepts and basics of root cause analysis to share with
> some manufacturing employees.
> I would like to give some down - to - earth examples of root causes
> by creating some scenarios from our day to day life.
> Once the employees are familiar with root causes of even
> insignificant things, they will always go beyond the surface to solve
> the bigger and more expensive problems at work.
> If all the employees learn the basics of RCA, it would make my job
> easier and the company would benefit on the whole as all of us
> oriented towards solving the root cause of all problems.
> I would really appreciate if you or your friends in the root cause
> forum can help me with some basic scenarios and the subsequent root
> cause(s) and the solution
> The reason for this note is with the intention that different people
> have different ideas and when grouped together would benefit all.
>
> Thanks in advance
> Anand Varadarajan
>
>
>
>
> Visit the the Root Cause LIVE clicking:
>
> www.rootcauselive.com
>
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>
>
>

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

From: Salot, William

To: 'rootcauseconference@yahoogroups.com' ; Undisclosed@...

Sent: Monday, December 31, 2001 3:12 PM

Subject: RE: [rootcauseconference] Mix-up: Police officer shot dead during police training exercise

Bill C.

Sure it was a mixup. 

But if you categorized it as something else such as an example of poor
planning or inadequate inspection, wouldn't you still analyze it in the same
way and come up with the same corrective actions?

Bill Salot INTP 72

-----Original Message-----
From: Dr. Bill Corcoran at NSRC [mailto:firebird.one@...]
Sent: Sunday, December 30, 2001 11:20 AM
To: Undisclosed-Recipient:@pimout1-int.prodigy.net;
Subject: [rootcauseconference] Mix-up: Police officer shot dead during
police training exercise


East Providence officer shot dead during police training exercise
By Richard Lewis, Associated Press, 12/27/2001 22:36
EAST PROVIDENCE, R.I. (AP) A veteran police officer was shot and killed
Thursday during a routine training drill that was not supposed to include
live ammunition.

Capt. Alister McGregor was shot by a fellow officer with a rifle as a
12-member SWAT team staged a mock hostage situation on a school bus, said
Police Chief Gary Dias, who called the shooting an accident.

''It's just a tragic accident that should've never happened,'' he said
during news conference Thursday night.

McGregor was a 16-year veteran of the East Providence police force who had
recently been promoted to Captain. He was commander of the SWAT team and had
organized the training exercise that led to his death, Dias said.

Asked why live ammunition was being used in the exercise, Dias said:
''(There) should not have been. We haven't determined that. That's why it
was an accident, obviously.''

He later said a gun may have been introduced into the drill after all the
other weapons had been checked to make they sure they weren't loaded with
live rounds.

The state police and the attorney general's office will investigate by
reconstructing the incident, routine in friendly fire incidents, according
to Deputy Attorney General Jerry Coyne.

The officer who shot McGregor has not been identified by police. Dias said
he is a 5-year veteran who served in the military before joining the force.

He was so distraught over the shooting that he had to be sedated and
hospitalized, Dias said. He was later released.

''I can't even imagine the feelings that he's experiencing,'' the chief
said.

The shooting occurred shortly after 1:30 p.m. in a parking lot on Commercial
Way that is owned by Laidlaw Education Services, a school bus company that
leases the space to the police department for training.

Andrew Montreuil, 25, of Swansea, Mass., a salesman at a nearby auto
dealership, said he was returning from his lunch break with an assistant and
was across the street from the mock hostage standoff when he heard three
quick gunshots.

''We were like 'What's going on?' I didn't know what to think,'' Montreuil
said.

Minutes later, several police cruisers and an ambulance sped by in the
direction of the bus company parking lot.

''They came from everywhere,'' Montreuil said.

After, police blocked off access to the street, located behind a strip of
car dealerships in an industrial section of the city. Two fire engines, an
ambulance and several police cruisers were on the scene, and officers from
the Seekonk, Mass., police department directed traffic along the busy route.

Around 5 p.m. the body was removed from the bus and placed in a white van by
the state medical examiner's office.

Dias said the SWAT team officers were all seasoned veterans and such drills
are staged at least once per month. Most have a military background, he
added.

''Hopefully, you have the safeguards in place to prevent these accidents,
but nothing is foolproof,'' he said.

Dias called McGregor ''a good person'' and ''the best there is.''

He said McGregor distinguished himself and rose quickly through the ranks.
He leaves behind a wife and five children and was working toward a master's
degree at Roger Williams University. He was a graduate of East Providence
High School.

''Everyone is just emotionally drained right now,'' Dias said.



____________________________________________________________________________
_____________________
Subject: Mix-up: East Providence officer shot dead during police training
exercise


Colleagues,

The mix-up in this case was that a loaded weapon was introduced into a
group
of unloaded exercise weapons.

Best Regards,

Bill Corcoran

W. R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
Mission: Saving lives, pain,assets, and careers through thoughtful inquiry.




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Bill S.,

Thanks.

As for recommendations to go with the Lessons to be Learned (LTBL), I have
poor experience with multiple recommendations emanating from RCA's. Most
managers I have worked for didn't want to fix their organization's culture.
They just wanted to avoid accidents with the same organizational culture.

The most important outcome of an RCA is for people to change their behaviors
and this involves changing the way they think.

Most organizations have a tendency to try "The Oregon Trail Approach": Stay
in the same ruts, but make the wheels bigger so you can still make headway.

Every Lesson to be Learned (LTBL) has an implicit recommendation to change
behavior and thinking.

My most successful RCA work was with an organization that did not have a
corrective action tracking system. None of their RCA's included specific
actionable recommendations, but they did include detailed LTBL. And what was
probably more important, they put together elaborate carefully crafted
slideshows that they gave to everyone in their division. This shined a
spotlight on the ruts so people could chose to get out of them or to be
aware that everyone else sees their huge wheels.

Will their be an Installment 2? Probably, but not today.

Happy New Year.

Best Regards,

Bill Corcoran

W. R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
Mission: Saving lives, pain,assets, and careers through thoughtful inquiry.

Check out our e-group  at
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/

For a complimentary subscription to our e-newsletter on root cause,
organizational learning, and safety send a message to
firebird.one@...
----- Original Message -----
From: "Salot, William" <william.salot@...>
To: <rootcauseconference@yahoogroups.com>
Cc: "State-of-the-Practice Root Cause"
<Root_Cause_State_of_the_Practice@yahoogroups.com>
Sent: Monday, December 31, 2001 11:59 AM
Subject: RE: [rootcauseconference] Lessons to be Learned, Installment 1


> Bill C.
>
> I'm beginning to understand the composition of your Lessons to be Learned.
> Now if I include some pertinent Lessons to be Learned in my next
> investigation report, wouldn't it be important to attach a recommendation
to
> each one?  Otherwise the Lessons to be Learned may evaporate or go
> unrecognized by their primary targets.
>
>  Will there be an installment 2 ?
>
> Bill Salot INTP 72
>
> -----Original Message-----
> From: Dr. Bill Corcoran at NSRC [mailto:firebird.one@...]
> Sent: Wednesday, December 26, 2001 7:28 AM
> To: rootcauseconference@yahoogroups.com
> Cc: State-of-the-Practice Root Cause
> Subject: Re: [rootcauseconference] Lessons to be Learned, Installment 1
>
>
> Bill S.
>
> Thanks for your feedback on Lessons to be Learned (LTBL), Installment 1.
>
> You raise an interesting point as to the uniqueness of LTBL.
>
> I congratulate you on your mental discomfort, because such discomfort is
> often fruitful while comfort is, well, comforting. Comfort supports a
false
> sense of security and discomfort supports alertness. Now to your point:
>
> It would be nice to be able to state that the listed LTBL form a complete
> and unique set. However:
>
> When I get into the details of the behaviors and conditions that influence
> the consequences I always find that there were multiple ordinary
> opportunities for multiple ordinary individuals to have averted the event
or
> to have made its consequences much less severe by doing ordinary things
> ordinarily well.
>
> I occasionally find some insightful lightning bolt, but mostly the
insights
> are BFO's (Blinding Flashes of the Obvious).
>
> The LTBL are related to the missed opportunities and the underlying
> cognitive models that influenced the dysfunctional behaviors and
conditions.
> For a given individual the most important LTBL relate to how that
individual
> could change their thinking and behavior to avert or limit consequences in
> future similar situations.
>
> I have been humbled enough by having other people look at my list of LTBL,
> and saying, "You left out X.", to believe that there are many ways to
avert
> and limit particular consequences. The best we can do is to provide a
proper
> subset of the LTBL.
>
> After your message I will begin putting a statement in my RCA's saying
that
> the list of LTBL is the RCAT's carefully considered opinion of the most
> important LTBL. I will probably not craft my introductory remarks in such
a
> way as to assert that the list of LTBL is complete or uniquely superior.
>
> Example: There was a fire at a remote and difficult-to-reach location at a
> nuclear power plant. Because of the location, the fire brigade had to
reach
> and cross the roof of a large building. They donned their turn-out gear
> before traveling to the fire scene. When they got there the were so
> exhausted from climbing in heavy protective clothing that some members
were
> afraid of heart problems.
>
> Needless to say, there were many LTBL involving the state of exhaustion of
> the fire brigade.
>
>
> Best Regards,
>
> Bill Corcoran
>
> W. R. Corcoran, Ph.D., P.E.
> Nuclear Safety Review Concepts
> 21 Broadleaf Circle
> Windsor, CT 06095-1634
> 860-285-8779
> Mission: Saving lives, pain,assets, and careers through thoughtful
inquiry.
>
>
>
> Visit the the Root Cause LIVE clicking:
>
> www.rootcauselive.com
>
> To change conference email options, go to:
http://www.yahoogroups.com/group/rootcauseconference/join
>
> To unsubscribe from this group, send an email to:
rootcauseconference-unsubscribe@yahoogroups.com
>
>
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>
>
>

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

From: wjsalot

To: rootcauseconference@yahoogroups.com

Cc: State-of-the-Practice Root Cause

Sent: Tuesday, December 25, 2001 4:57 PM

Subject: Re: [rootcauseconference] Lessons to be Learned, Installment 1

Happy Christmas to all.

 

Bill C.

 

I look forward to next year and another installment of your comments on "Lessons to be Learned".

 

Here is my feedback on Installment 1:

 

One of the things I seek is a practical definition of "Lessons to be Learned", so that I will feel more comfortable when I include some in an investigation report.

 

But you said: "When we write down the lessons to be learned we are really writing down one proper subset of the lessons to be learned from the event. Other people might well legitimately write down a different set."

 

That makes me more confused than comfortable.  I don't want to define "Lessons to be Learned" as anything the investigation team says they are.  I don't want to be telling folks that these are the lessons that the team learned, and they think you should learn, but, if you don't agree with ours, you can ignore them and generate your own.  Isn't there a better, more specific definition that will justify generating such information?

 

We have a safety engineer who has a collection of catchy safety maxims, such as:  "Avoid pinch points",  "Be aware of your surroundings", "Accidents can happen at any time", etc.  He likes to attach one or more of these sayings to locally publicized descriptions of accidents that have just happened.  Do they qualify as "Lessons to be Learned"?  Are they worthy of inclusion in an investigation report?  Personally, I don't think they are specific enough to be of much value in an investigation report.

 

Assuming a consensus is reached on including some "Lessons to be Learned" in an investigation report, the next question is how can we most effectively teach those lessons to the personnel who will benefit most?

 

I hope the group considers these questions to be practical and of general interest. 

 

And to all a good night.

 

Bill Salot INTP 72  

 

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

From: Dr. Bill Corcoran at NSRC

To: rootcauseconference@yahoogroups.com

Cc: State-of-the-Practice Root Cause

Sent: Monday, December 17, 2001 8:34 AM

Subject: [rootcauseconference] Lessons to be Learned, Installment 1

Colleagues,

 

This is the first of a series of responses to Bill Salot's "dilemma", which gets to the heart of why we do RCA at all.

 

Even before the grounding of the Ark, people seemed to know intuitively that consequences come from behaviors and conditions.RCA is done to identify behaviors and conditions that can be cost-effectively amended to obtain better future consequences.

 

Behaviors, in part, come from learning. In fact, an outside observer cannot tell that learning has taken place until the observer can see a different behavior under the same set of circumstances.

 

One way of encouraging people to change their behavior is to present them with insights from an investigation. These are the "lessons to be learned".

 

The lesson has not been learned until behavior is changed. Before that it is a "lesson to be learned".

 

Learning is an individual phenomenon.

 

Different people will go through the same experience or hear the same story and learn different things from it.

 

When we write down the lessons to be learned we are really writing down one proper subset of the lessons to be learned from the event. Other people might well legitimately write down a different set.

 

This is a start.

 

Best Regards,

 

Bill Corcoran

 

W. R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
Mission: Saving lives, pain,assets, and careers through thoughtful inquiry.

Visit the the Root Cause LIVE clicking:

www.rootcauselive.com

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

From: Steverman, Jack C

To: 'Dr. Bill Corcoran at NSRC'

Sent: Monday, December 17, 2001 9:49 AM

Subject: RE: The Firebird Forum: Safety 101

Bill,

 

Thanks for putting this together. Each Firebird Forum gets me changing my thoughts in a positive way. On this one I'm struggling with Principles 5 & 6. If Management and individuals are accountable for their own safety how, then is Management accountable for all behaviors and conditions? I might be splitting hairs here but I think that Management is responsible for the safety of employees and the public and Management is made up of employees. To me, this means that "Management" (the organization) needs to provide the tools (processes, procedures and equipment) that allows individuals to perform their tasks in a safe manner and to assure that the tools are properly used.  

 

It t may be that my definitions of accountability and responsibility are too confining and I'll have to rethink those concepts.

 

Thanks again and have a happy and safe holiday season.

 

Jack

-----Original Message-----
From: Dr. Bill Corcoran at NSRC [mailto:corcoran.nsrc@...]
Sent: Sunday, December 16, 2001 5:42 PM
To: Undisclosed-Recipient:@pimout1-int.prodigy.net;
Subject: The Firebird Forum: Safety 101

 

Colleagues,

 

From time to time, it helps to get back to the basics of safety thinking. This article states the most helpful few safety principles and discusses each briefly. Each safety principle implies accountabilities for individual contributors and for personnel in supervisory and management positions.  The purposes of this article are to introduce safety principles to professionals who have not previously been exposed to them as such and to initiate a dialogue on what the most helpful safety principles are.

 

Your comments, suggestions, and differing professional opinions are needed to refine the attached article for your future use.

 

Have a safe and happy Holidays and thank you for your support over the last year.

 

Best Regards,

 

Bill Corcoran

 

W. R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
Mission: Saving lives, pain,assets, and careers through thoughtful inquiry.

 

Check out our e-group  at
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/



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