Bob and all, I have added TRIZ to my list of methods with links. ... Barrier Analysis Beware of superficial techniques that go by this name. drbillcorcoran...
This is not over yet. Only 3 of the 13 LOC Board members were present, and the Mayor of Knox County was represented by a Knox County employee who is a couple...
What do you think of this one? For those who don't recall, a dose of 400 Rads kills 50% of those who get it within 60 days. (The rest get very sick.) ...
I wouldn't characterize this as a health care facility. This is an industrial irradiator for the sterilization of health care products. What they did was way...
Thanks for the clarification. Do you see it as a near miss fatality? Do you have access to an RCA of it? Take care, Bill Corcoran W. R. Corcoran, Ph.D., P.E. ...
Peggy, Your case is indeed a mystery. In over 30 years of work with electric utilities in generation, transmission, distribution, and (believe-it-or-not) ...
Interesting case. I'm suspicious about the cause being "static" electricity. If static electricity is the cause, what would be required for it to explain the...
Brad, Thanks ever so much. It would be great if we could give Peggy a troubleshooting plan to track this one down. There is likely to be an unseen killer...
Terry, Thanks for weighing in on this one. It reminds me of a power plant incident in which people called it static electricity through three shocks until an...
This should be of interest- How does a pregnant women recieve this type of treatment without either physician or herself being aware of the consequences? This...
Here is something you can use next time you have two or more hypotheses competing for causation of a single effect (consequence or cause). OBTW: I find that I...
Have you run into a Catch-22 in your root cause work? The essence of a Catch-22 is, "If there is a rule that looks like it is in your favor, there is always an...
Does anyone have a good link? Please pass it to me an I'll update the web site. Take care, Bill Corcoran W. R. Corcoran, Ph.D., P.E. Nuclear Safety Review...
http://www.princeton.edu/~hammett/CardTrick/html/magic.html <http://www.princeton.edu/~hammett/CardTrick/html/magic.html> ... From: Dr. Bill Corcoran...
This came from http://www.occupationalhazards.com/articles/13010 Please take a minute and tell me what's wrong with this picture? Take care, Bill Corcoran W....
Thanks ever so much. I fixed the link on the web site. Take care, Bill Corcoran W. R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts 21 Broadleaf Circle ...
1) No attempt to ask the DB employees how come the NRC hasn't helped them prior and current. 2) No education of the employees on the role of the media -where...
Here is a durable definition. Too bad it has to be so long. Evidence: Anything, e.g., document, physical object, audible utterance, that could be used to...
Try putting on the following hat: What events have you encountered in which crucial learning would have been missed by investigating only the event? Here are a...
Vee, You are correct when you say that if the consequences are investigated the event will be 'caught', but not vice versa. You are correct in saying that...
A colleague asked me this question and I found it interesting enough to ask you. When I reviewed the RCAR's I have worked on I never found any attitudes called...
This clears up an earlier posting. Any cause that is not in and of itself sufficient to explain the consequences is a contributing factor (contributing cause)....
I suspect this thread will lead to a littany of definitions in an effort to help us each describe what we mean. In many analyses I have been involved in,...
Excellent points, Bob. Would you then list an attitude or paradigm as a root cause? What would you do to verify them as a root cause? If you verify one of...
Terry et al, Your remarks reminded me of a quote from William James (1842-1910): I have often thought that the best way to define a man's character would be to...
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