Bill C., First, why are you asking us to share "actual event investigation" reports generated by software? My experience is that potential sources, including...
Failure to detect/alleviate adverse pre-existing conditions and/or behaviors contributes to those factors essential to the event set-up and/or deteriorating...
Alyce.Carlson@...
Jun 1, 2005 2:56 pm
2329
Alyce, Thanks for your rewording of Bill C.'s "theorem". There are not many of us who seek perfection in the use of our language. Would you mind discussing...
How about this? Failure to detect and alleviate adverse pre-existing conditions contributes to those factors essential to the set-up of the consequences. Terry...
Terry, Evidently you agree with Alyce that the failures to detect and alleviate are not themselves essential factors. Bill C. has stated the opposite is a ...
I'm not sure that we're off that much. In order to prevent an undesired consequence, some preventive factor or barrier needs to exist between the condition...
Mike, Thanks. This reply was one of your finest. There is great need for a journalists' guide to reporting adverse events. Your thoughts should be part of it. ...
Terry, If the barrier failed and the consequence happened, wasn't the failure to detect and alleviate the pre-existing weakness of the barrier an essential ...
First, when you say, "detect/alleviate", how do you read the forward slash? If the reader interpreted it to mean "or", wouldn't that erroneously suggest that...
Carlson, Alyce
Alyce.Carlson@...
Jun 3, 2005 7:38 pm
2336
Bob, Dean Gano has, as I recall, a good explanation of this issue in his book. (I don't have access to my copy at the moment.) My recollection is that he uses...
Terry and all, Please feel free to express the theorem in words that appeal to you and/or your management. The nugget is that "The fatal flaw is to not look...
For TOC fans: The limiting constraint is the capability of the system to find its own constraints. I agree with your statement. That is why the TOC thinking...
Jim, At the outset, I would suggest that one basic tenet, observed by most folks in this group, is that there is never only one "root cause". Another is that...
We here at Exelon have a system called the 101 Club. The system rewards those inviduals who went above and beyond their regular expectations giving 101%...
As moderator, allow me to give the old "Preservation Hall" pitch: The more you put in, the more you get back. What can you contribute: a.. Questions b.....
I have a few questions: 1. Is the 101 Club implemented at all Exelon locations? 2. If not, why not? 3. How long has it been in existence? 4. What's the...
Jim, Bill S., and all, Thanks to Jim and Bill for the root cause dialogue. Would you be so kind as to ask two of your in-laws what they think that a person...
Bill S., ... Second, Bill C. inserted "and/or behaviors", and you have included it without objection. I think of a "behavior" as an irremediable action or...
Bill S., One of the values of interim progress reports is that the readers can tell the RCA Team where the RCAT is off base. This avoids having the team wait...
Ludwig, Agreed. I strongly recommend not categorizing before the initial draft is finished. After that, looking at categories can help the root cause analysis...
Terry, At the risk of "piling on" I support Bill Salot. If the latent causes are found before the consequences management has the opportunity to do exactly...
Jim, Thanks for sticking your neck out. Whenever I do I get set straight by other members. I recall reading a description of the Flixborough event and...
Jim, To answer your question: Spend some time checking out the items on the web site and the spillover sites. Answer the key question: "What's wrong with this...
Jim, Sounds like a great idea. Is this just for problem finder-reporters? Take care, Bill Corcoran W. R. Corcoran, Ph.D., P.E. NSRC Corporation 21 Broadleaf...
If a person feels the need to classify early on maybe they can go very high level to start. May I suggest: 1. People, 2. Process, and/or 3. Technology? Mike...
Bill S., I'm sorry to have allowed that impression. There are lots of problems with it. I won't be able to go into detail for a week or so because of other...
Understood, but what about human nature? Some people just have to categorize things no matter what and no matter where in the process. So why not give them...
... Yes, it is. ... N/A. ... Almost 7 months now. ... Not gathered to date. Certainly not in any formalized fashion. The word on the street is that it is...
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